When does Medicare require the referring doctor's name on electronically filed claims?
Sunday, March 21st, 2010 at
5:08 pm
I’ve run into problems when calling referring doctors’ offices for their NPI numbers, which are necessary if the referring doctor’s name is on the claim. Is the name of the referring doctor ALWAYS necessary on electronically-filed Medicare claims? Some offices don’t even know what one is!
Filed under: Retirement Planning
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The referring doctor must be listed when the services preformed are because of a referral.
Example: A primary doctor referred a patient to 10 Physical Therapy sessions for low back pain. An NPI and Referring Doc name must be listed.
If the same patient goes to the Physical Therapist and requests treatment himself because his back hurts, no NPI is needed.
Effective January 1, 1992, a physician or supplier that bills Medicare for a service or item must show the name and UPIN (or NPI) of the ordering/referring physician on the claim form, if that service or item was the result of an order or referral from a physician. If the ordering physician is also the performing physician, the physician must enter his/her name and assigned UPIN as the ordering physician. If the ordering/referring physician is not assigned a UPIN, the biller may use a surrogate UPIN, e.g., until an application for a UPIN is processed and a UPIN assigned. (See ยง14.9.2.)
You can search the NPI directory and get the numbers yourself (most of the time) on this site: https://nppes.cms.hhs.gov/NPPES/NPIRegistryHome.do
NO
Yes it is necessary. If you need an NPI number you can go to the NPI registry. If there is a medical provider that has not registered for one, you will have trouble so you may want to steer clear of using their services. Most offices have you sign a financial responsibility form stating you will be responsible for what is not covered by insurance.