Medicare - Ordering & Referring Provider Not Eligible Denial
- This denial states that referring or ordering provider is not eligible to bill the service as provider is not enrolled in Medicare.
- To check Medicare enrollment of provider, refer PECOS website - https://opedge.com/Pecos
- On the website, enter the provider's first, and last name and state or enter the NPI number then click on the search button.
- If the provider is enrolled in Medicare then it will show a Green correct tick mark stating the Provider is PECOS enrolled or a Red cross mark stating the Provider is NOT PECOS enrolled according to the latest file provided by CMS.
- For the same denial reason from other insurance, you can refer to the same website if it follows Medicare guidelines.
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in PECOS provider are showing in green, but we are still receiving denial related to provider not enrolled with medicare
ReplyDeleteIf referring provider is showing in green on PECOS and you have still received denial for referring provider not enrolled with Medicare then you can place a call to Medicare and verify PECOS details. Hopefully, they will ask you to reopen or resubmit the claim.
DeleteThanks for sharing your knowledge....
ReplyDeleteThank you!
DeleteWhat about medicaid
ReplyDeleteMedicaid guidelines differ by state. On referring provider's enrollment denial from Medicaid, you will need to check the provider's enrollment with a specific state Medicaid.
DeleteThe claim was denied by Medicaid because the provider’s group, Mental Health Connections was not linked to the provider’s profile at the time of submission in June 2025. The group was later added on July 28, 2025. what should be the scenario in this claim
ReplyDeleteIf the group has become active for the date of service (DOS), the claim can be resubmitted. However, if the group is still inactive for the DOS, the claim should be written off accordingly.
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