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January 14, 2016

Reminder – Ordering Physician and CMS-1500 Claim Form

Joint DME MAC Publication

Recently the Durable Medical Equipment Medicare Administrative Contractors (DME MAC) have noted an increase in Comprehensive Error Rate Testing (CERT) program denials when the name and national provider identifier (NPI) of the referring provider, listed in Block 17 and Block 17b of the CMS-1500 claim form do not match the name and NPI of the physician who completed the order. Title XVIII §1833(q) of the Social Security Act requires the referring/ordering physician information be submitted on a Medicare claim when the billing provider/supplier has received a referral or order for the referred/ordered service(s) or item.

This type of error can occur as the result of Medicare beneficiaries who are under the care of multiple physicians or the death, reassignment or retirement of their primary care provider, resulting in a change in providers. Suppliers are strongly encouraged to check their documentation from referring physicians or other healthcare practitioners and ensure that the information listed in Block 17 and Block 17b on the CMS-1500 form for the referring provider matches the information on the order for any item of durable medical equipment, orthotics, prosthetics or supplies (DMEPOS).

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