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February 7, 2014

Claim Denials and Rejections: Ordering/Referring Edits

Phase 2 ordering/referring edits were implemented on January 6, 2014. These edits affect submitted claims as follows:

  • Claims without a valid ordering/referring NPI for the following services will be denied: claims from clinical laboratories for ordered tests and claims from imaging centers for ordered imaging procedures. These claims are identified on your Remittance Advice (RA) with remark codes CO-16 or CO-183, along with N264, N265, N575, and MA13.
  • Other claims that require valid ordering/referring NPI will be rejected. This includes: clinical lab tests billed by other than clinical laboratories; imaging and interpretation of imaging from other than imaging centers; and claims that include charges for drugs. These claims are identified on your Remittance Advice (RA) with remark codes CO-16 and/or N265, N276, and MA13.

Claims Denied or Rejected in Error

While most claims that have been denied or rejected based on these edits were processed correctly, some claims were not.

  • Affected claims involve ordering/referring providers that had both an active and inactive NPI number and were processed between January 6-24, 2014.
  • If the inactive NPI is finalized on a later date than the active NPI, claims with that ordering/referring provider's information were either denied or rejected, as noted above, in error.
  • This issue was corrected on January 24, 2014.

If you have claims you believe were denied or rejected in error, please call our Provider Contact Center at 866.276.9558. We will verify whether the claim in question was denied or rejected in error and will request that the claim be reopened on your behalf if it was impacted by this error. We sincerely apologize for the inconvenience.

Tips for Claim Submission

Please note that many of the claims subject to these edits were denied/rejected correctly. The following tips will assist you in preventing these denials and rejections:

  • Submit the ordering/referring practitioner's first and last name, as they appear on the CMS ordering/referring file.
  • DO NOT submit:
    • Professional designations (such as M.D.) or Jr., Sr., etc.
    • Nicknames which differ from the name listed in the CMS ordering/referring file (e.g., Stan instead of Stanley)
    • Middle initials


  • Find the list of physicians and practitioners eligible to order and refer services and that have valid enrollment records in PECOS on this CMS Web pageExternal Website (under Downloads)
  • For more information on ordering/referring edits, including background information, refer to CMS MLN Matters article SE1305External PDF, "Full Implementation of Edits on the Ordering/Referring Providers in Medicare Part B, DME, and Part A Home Health Agency (HHA) Claims (Change Requests 6417, 6421, 6696, and 6856)"

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