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Medicare Enrollment and Claims Processing

Creation/Revision Date: June 30, 2010

Updated June 30, 2010 

Understanding the July 6 Date by which all Physicians Who Refer or Order Must be Enrolled in Medicare


New Medicare enrollment deadline for referring/ordering physicians. This includes any physician who has not submitted an updated enrollment application to Medicare in the past 6 years or has had a change to their enrollment information (i.e., change of address) during this time but has not reported the change. All physicians must list the legal name and NPI of the physician or provider who referred/ordered to them on their claims. This change stems from Section 6405 of the new health system reform law known as Patient Protection and Affordable Care Act (PPACA). 


Compliance deadline is July 6, 2010. Physicians are very concerned that if the referring/ordering physician listed on their claim was not enrolled in PECOS by this date that the physician or provider who accepted the referral could see their claims rejected. Due to significant AMA advocacy, Centers for Medicare and Medicaid Services (CMS) announced on June 30th, that claims that list the name and NPI of a referring / ordering physician who is not yet enrolled in PECOS will NOT see their claims reject beginning on this date. CMS will provide more information about when they will begin rejecting claims in the near future. We continue to urge them not to reject any for at least 6 more months. For more information we recommend physicians review the CMS June 30th press release found at: 


Physicians or health care providers who refer or order the following services for Medicare patients to other physicians or health care providers:

1) Durable medical equipment, prosthetics, and supplies (DMEPOS);
2) Home health;
3) Specialist services (not yet defined by CMS);
4) Laboratory; or
5) Imaging services.

: Any physician/provider including those who do not traditionally bill Medicare (i.e., dentists, pediatricians, and physicians employed by VA/DOD/Public Health Service)

EXCLUDES: Physicians who have opted-out of Medicare. Physicians are encouraged to call their Medicare contractor to determine whether the 
contractor has them officially listed as opted out.


Prior to the passage of the new health system reform law, CMS announced that all physicians / providers who order and refer services to other health care providers must be enrolled by January 3, 2011. CMS originally was going to require these same physicians / providers to be enrolled by the end of 2009, however, the AMA was successful in securing an extra year to become enrolled. 

But, the new law required physicians who order and refer DMEPOS and home health to be enrolled by July 2010. The law does permit CMS to allow physicians who order/refer other Part B services to be enrolled later but CMS decided instead to require them all to be enrolled in PECOS by July 6. 

Due to the significant number of problems physicians have had with enrollment over the past few years and the lack of appropriate contractor resources to handle the volume of enrollment applications, the AMA voiced its serious objections to CMS concerning the impact this could have on claims processing and the time needed for al referring / ordering physicians to become enrolled. 

The AMA recommends physicians check with their Medicare contractors, medical societies and the AMA on any future information associated with this 
policy since CMS expects to publish a final rule with more details in July.


Renal Physicians Association

1700 Rockville Pike
Suite 220
Rockville, MD 20852

Phone: 301-468-3515
Fax: 301-468-3511

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