42 CFR 424.507 - Ordering and referring covered items and services for Medicare beneficiaries.
§ 424.507
Ordering and referring covered items and services for Medicare beneficiaries.
(a) Conditions for payment of claims for ordered or referred covered Part B items and services (excluding home health services described in
(1) Part B provider and supplier claims.
To receive payment for ordered or referred covered Part B items and services (excluding home health services described in § 424.507(b), and Part B drugs), a provider's or supplier's must meet all of the following requirements:
(i)
The Part B items and services must have been ordered or referred by a physician or, when permitted, an eligible professional (as defined in § 424.506(a) of this part ).
(ii)
The claim from the Part B provider or supplier must contain the legal name and the National Provider Identifier (NPI) of the physician or the eligible professional (as defined in § 424.506(a) of this part) who ordered or referred.
(iii)
The physician or the eligible professional who ordered or referred must have an approved enrollment record or a valid opt-out record in the Provider Enrollment, Chain and Ownership System (PECOS).
(iv)
If the items or services were ordered or referred by a resident or an intern, the claim must identify the teaching physician as the ordering or referring supplier. The claim must identify the teaching physician by his or her legal name and NPI and he or she must have an approved enrollment record or a valid opt-out record in PECOS.
(2) Part B beneficiary claims.
To receive payment for ordered or referred covered Part B items and services (excluding home health services described in § 424.507(b), and Part B drugs), a beneficiary's claim must meet all of the following requirements:
(i)
The Part B items and services must have been ordered or referred by a physician or, when permitted, an eligible professional (as defined in § 424.506(a) of this part ).
(ii)
The claim must contain the legal name of the physician or the eligible professional (as defined in § 424.506(a) of this part) who ordered or referred.
(iii)
The physician or the eligible professional who ordered or referred must have an approved enrollment record or a valid opt-out record in the Provider Enrollment, Chain and Ownership System (PECOS).
(iv)
If the items or services were ordered or referred by a resident or an intern, the claim must identify the teaching physician as the ordering or referring supplier. The claim must identify the teaching physician by his or her legal name and he or she must have an approved enrollment record or a valid opt-out record in PECOS.
(b)
Conditions for payment of claims for ordered covered home health services. (1) Home health provider claims. To receive payment for ordered, covered Part A or Part B home health services, a provider's home health services claim must meet all of the following requirements:
(ii)
The claim from the provider of home health services must contain the legal name and the National Provider Identifier (NPI) of the ordering physician;
(iii)
The ordering physician must have an approved enrollment record or a valid opt-out record in the Provider Enrollment, Chain, and Ownership System (PECOS); and
(iv)
If the services were ordered by a resident or an intern, the claim must identify the teaching physician as the ordering or referring physician. The claim must identify the teaching physician by his or her legal name and NPI and he or she must have an approved enrollment record or a valid opt-out record in PECOS.
(2) Home health beneficiary claims.
To receive payment for ordered covered Part A or Part B home health services, a beneficiary's home health services claim must meet all of the following requirements:
(ii)
The claim from the provider of home health services must contain the legal name of the ordering physician.
(iii)
The ordering physician must have an approved enrollment record or a valid opt-out record in the Provider Enrollment, Chain, and Ownership System (PECOS).
(iv)
If the services were ordered by a resident or an intern, the claim must identify the teaching physician as the ordering or referring physician. The claim must identify the teaching physician by his or her legal name and he or she must have an approved enrollment record or a valid opt-out record in PECOS.
(c)
A Medicare contractor will reject a claim from a provider or a supplier for covered services described in paragraphs (a) and (b) of this section if the claim does not meet the requirements of paragraph (a)(1) and (b)(1) of this section, respectively.
(d)
A Medicare contractor may deny a claim from a Medicare beneficiary for covered items or services described in paragraphs (a) and (b) of this section if the claim does not meet the requirements of paragraphs (a)(2) and (b)(2) of this section, respectively.
[75 FR 24448, May 5, 2010]
Title 42 published on 2012-10-01
The following are only the Rules published in the Federal Register after the published date of Title 42.
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Title 42 published on 2012-10-01
The following are ALL rules, proposed rules, and notices (chronologically) published in the Federal Register relating to 42 CFR 424 after this date.
