New DME NPI Requirements for providers

Dear durable medical equipment provider:

The Centers for Medicare & Medicaid Services (CMS) require that ordering and referring
provider information be included on claim submissions, including claims for durable medical equipment (DME).

Beginning August 1, 2020, CareOregon/Health Share, Jackson Care Connect, Columbia Pacific CCO and CareOregon Advantage will deny DME claims that have missing or invalid National Provider Identifier (NPI). This change will apply to all Medicaid and Medicare claims.

Per CMS regulations, only physicians and certain types of non-physician practitioners are eligible to order or refer for services. This includes:

  • Doctor of medicine or osteopathy
  • Doctor of dental medicine
  • Doctor dental surgery
  • Doctor podiatric medicine
  • Doctor optometry
  • Physician assistant
  • Certified clinical nurse specialist
  • Nurse practitioner
  • Clinical psychologist
  • Interns, residents and fellows
  • Certified nurse midwife
  • Clinical social worker

Providers should be aware of the limitations applied by CMS, which include but are not limited to:

  • Chiropractors are not eligible to order or refer supplies or services for Medicare beneficiaries. All services ordered or referred by a chiropractor will be denied.
  • Home Health Agency (HHA) services may only be ordered or referred by a doctor of medicine (MD), doctor of osteopathy (DO), or doctor of podiatric medicine (DPM). Claims for HHA services ordered by any other practitioner specialty will be denied.
  • Optometrists may only order and refer DMEPOS products/services — and laboratory and
    X-ray services — payable under Medicare Part B.

There are multiple CMS articles pertaining to these ordering/referring NPI requirements. For additional information, please refer to CMS’s MLN Matters site at cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles and cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1305.pdf.

  • CR 6417 offers background and discusses who can refer/order.
  • CR 6696 discusses ordering/referring providers who are not enrolled in Medicare.
  • CR 7097 announces that physicians and non-physicians need to enroll in Medicare
    to order/refer.

Please contact Customer Service at 800-224-4840 if you have questions.

Sincerely,

Danielle Barzaga

Provider Services Manager, CareOregon



Click here to download the letter.