Medicare Enrollment of Ordering/Referring Providers
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USPS Mailing Address
WPS GHA
Medicare Provider Enrollment
P.O. Box 8248
Madison, WI 53708-8248
Overnight Delivery
WPS GHA
Medicare Provider Enrollment
1717 W. Broadway
Madison, WI 53713-1834
(866) 234-7331
8:00 AM - 5:00 PM ET, Monday - Friday
USPS Mailing Address
WPS GHA
Medicare Provider Enrollment
P.O. Box 8248
Madison, WI 53708-8248
Overnight Delivery
WPS GHA
Medicare Provider Enrollment
1717 W. Broadway
Madison, WI 53713-1834
(866) 518-3285
7:00 AM - 5:00 PM CT, Monday - Friday
USPS Mailing Address
WPS GHA
Medicare Provider Enrollment
P.O. Box 8248
Madison, WI 53708-8248
Overnight Delivery
WPS GHA
Medicare Provider Enrollment
1717 W. Broadway
Madison, WI 53713-1834
(866) 234-7331
8:00 AM - 5:00 PM ET, Monday - Friday
USPS Mailing Address
WPS GHA
Medicare Provider Enrollment
P.O. Box 8248
Madison, WI 53708-8248
Overnight Delivery
WPS GHA
Medicare Provider Enrollment
1717 W. Broadway
Madison, WI 53713-1834
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Mail audit materials:
WPS GHA
ATTN: Audit Supervisor
P.O. Box 8696
Madison, WI 53708-8696
When using a delivery service:
WPS GHA
ATTN: Audit Supervisor
1717 W. Broadway
Madison, WI 53713-1834
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ATTN: Audit Supervisor
P.O. Box 14172
Madison, WI 53708-0172
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ATTN: Audit Supervisor
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Madison, WI 53713-1834
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Medicare Enrollment of Ordering/Referring Providers
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Medicare claims resulting from an order or a referral must contain the National Provider Identifier (NPI) and the name of the ordering/referring provider. CMS requires Medicare contractors to verify the Medicare claim’s ordering/referring provider meets one of the following criteria:
- The provider has an approved enrollment record in the Provider Enrollment, Chain and Ownership System (PECOS), or
- The provider opted out of Medicare and is of a specialty eligible to order and refer.
This applies to all claims requiring an ordering/referring provider, including claims:
- To WPS Government Health Administrators for diagnostic tests and other services
- To the durable medical equipment Medicare Administrative Contractors (DMEMACs) for durable medical equipment, prosthetics and orthotics, and supplies (DMEPOS)
- For home health agency services
The following physicians and non-physician practitioners may be ordering/referring providers on Medicare claims:
- Doctors of medicine or osteopathy
- Doctors of dental surgery and dental medicine
- Doctors of podiatric medicine
- Doctors of optometry (DMEPOS, laboratory, and x-ray services only)
- Physician assistants
- Clinical nurse specialists
- Nurse practitioners
- Clinical psychologists
- Certified nurse midwives
- Clinical social workers
Note: Doctors of medicine (MD), osteopathy (DO), or podiatric medicine (DPM) are the only referring providers for Home Health Agency (HHA) services.
Providers must enroll or opt out of Medicare to order/refer services. Providers not doing these actions cannot be an ordering/referring provider on a claim. Information regarding opting out of Medicare is available on our website.
Enrollment for the Sole Purpose of Being an Ordering/Referring Provider - CMS 8550
- Professionals eligible to order and refer who do not submit Medicare claims may enroll for the sole purpose of ordering/referring items or services for Medicare beneficiaries. These include:
- Employees of the Department of Veterans Affairs (DVA)
- Department of Defense (DOD) TRICARE program
- Public Health Service (PHS)
- Employees of federally qualified health centers (FQHCs)
- Employees of rural health clinics (RHCs)
- Employees of critical access hospitals
- Other providers, including dentists and pediatricians, may also enroll on this basis irrespective of their employer
These providers may apply for this type of enrollment by:
- Using Internet-based PECOS, which transmits enrollment applications to WPS GHA via the Internet
- Submitting the CMS 855O paper enrollment form, "Medicare Enrollment Application for Eligible Ordering and Referring Physicians and Non-Physician Practitioners"
Note: Do not submit the CMS 855R forms for reassignment of benefits as there are no payable benefits with this type of Medicare enrollment.
Non-physician practitioners submitting the CMS 855O enrollment application must include:
- A copy of their diploma
- A copy of their academic transcript if the diploma itself does not document that they meet the academic requirement for their specialty
- A copy of the certification issued by the appropriate certifying body for their specialty, if applicable
- Any additional documentation appropriate to their specialty, such as two years of post-degree supervised clinical experience for clinical social workers
- A copy of the provider's license
Physicians in internship, residency, or fellowship programs may enroll for the sole purpose of being ordering/referring providers when:
- He/she is licensed
- He/she is an unlicensed physician and the State provides a provisional license
- He/she is an unlicensed physician and the State otherwise permits interns and residents to order and refer services
When an unlicensed intern or resident does not meet these criteria, enter the teaching, admitting, or attending physician's name and NPI on the claim as the ordering/referring provider.
When an ordering/referring professional later wants to obtain Medicare billing privileges, he or she must apply for enrollment by completing a CMS 855I enrollment form. If applicable, include a CMS 855R enrollment form to reassign benefits.
The following resources provide additional information for the Medicare enrollment of ordering/referring providers:
- The CMS Ordering & Referring Information web page
- Medicare Enrollment Guidelines for Ordering/Referring Providers
Upload required documentation when submitting an Internet-based application. Mail paper Medicare enrollment applications, Certification Statements, and supporting documentation to the appropriate address:
Regular Mail | Overnight Delivery Mailing Address |
---|---|
WPS Government Health Administrators Medicare Provider Enrollment P.O. Box 8248 Madison, WI 53708-8248 |
WPS Government Health Administrators Medicare Provider Enrollment 1717 W. Broadway Madison, WI 53713-1834 |
global-tags: Featured Guides and Resources,Provider Enrollment,J8B,J5B,Order/Refer
Need help?
Contact Us About Provider Enrollment
(866) 518-3285
7:00 AM - 5:00 PM CT, Monday - Friday
USPS Mailing Address
WPS GHA
Medicare Provider Enrollment
P.O. Box 8248
Madison, WI 53708-8248
Overnight Delivery
WPS GHA
Medicare Provider Enrollment
1717 W. Broadway
Madison, WI 53713-1834
(866) 234-7331
8:00 AM - 5:00 PM ET, Monday - Friday
USPS Mailing Address
WPS GHA
Medicare Provider Enrollment
P.O. Box 8248
Madison, WI 53708-8248
Overnight Delivery
WPS GHA
Medicare Provider Enrollment
1717 W. Broadway
Madison, WI 53713-1834
(866) 518-3285
7:00 AM - 5:00 PM CT, Monday - Friday
USPS Mailing Address
WPS GHA
Medicare Provider Enrollment
P.O. Box 8248
Madison, WI 53708-8248
Overnight Delivery
WPS GHA
Medicare Provider Enrollment
1717 W. Broadway
Madison, WI 53713-1834
(866) 234-7331
8:00 AM - 5:00 PM ET, Monday - Friday
USPS Mailing Address
WPS GHA
Medicare Provider Enrollment
P.O. Box 8248
Madison, WI 53708-8248
Overnight Delivery
WPS GHA
Medicare Provider Enrollment
1717 W. Broadway
Madison, WI 53713-1834
.
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