A valid NPI and the eligible provider's name as it appears in PECOS. In CMS's words: "The claim must have a valid NPI and the eligible provider's name as it appears in PECOS." This applies to ordered items and services like DMEPOS, clinical lab services and imaging, and to certified home health services. CMS also says only individual (Type 1) NPIs can be used to order or certify.
Which claims this covers
CMS describes two roles:
"Providers order non-physician patient items or services, like DMEPOS, clinical lab services, or imaging services" (CMS, MLN9658742)
"Providers certify patient home health services" (CMS, MLN9658742)
The three conditions for ordering and certifying providers
Per CMS, eligible ordering and certifying providers must:
- "Have an individual NPI"
- "Be enrolled in Medicare in either an approved or opt-out status"
- "Be an eligible specialty type to order or certify"
Individual NPIs only (Type 1)
"Medicare allows only Type 1 NPIs to solely order items or certify services." (CMS, MLN9658742)
"Organizational NPIs don't qualify, and you can't use them to order or certify." (CMS, MLN9658742)
Order-only enrollment: CMS-855O
CMS describes a form for providers who only order or certify:
"Physicians and other eligible NPPs use this form to enroll in Medicare solely to order or certify items or services for Medicare patients." (CMS, MLN9658742, on form CMS-855O)
"Those who enroll as eligible providers using CMS-855O can't bill Medicare" (CMS, MLN9658742)
When the ordering or certifying provider is missing
"If claims lack a valid individual NPI, MACs deny them if they're from:" (CMS)
CMS's list covers clinical labs, imaging centers, DMEPOS suppliers, and certain Part A home health agencies and hospices.
"If you bill a service that needs an eligible provider and they aren't on the claim, the MAC will deny the claim." (CMS)
Source for this section: CMS, MLN9658742 (Dec 2025).
One MAC's job aid: enter it the way PECOS has it
One DME MAC's job aid (CGS, Jurisdiction C) says:
"Be sure to enter the name and NPI exactly as it appears in the PECOS records." (CGS, DME MAC Jurisdiction C)
That's one MAC's guidance, so check your own MAC.
Desk checklist
This is a checklist built from the CMS lines above, not extra CMS text:
- Individual (Type 1) NPI for the ordering or certifying provider, not an organizational NPI.
- Enrolled or opted out: the provider is enrolled in Medicare "in either an approved or opt-out status."
- Eligible specialty type to order or certify.
- Name matches PECOS on the claim.
- Check the source and your MAC for anything specific to your claims.
FAQ
What does Medicare require for the ordering or certifying provider on a claim?
CMS says, "The claim must have a valid NPI and the eligible provider's name as it appears in PECOS."
Can an organizational NPI be used to order or certify?
No. CMS says, "Organizational NPIs don't qualify, and you can't use them to order or certify."
What conditions does an ordering or certifying provider have to meet?
CMS lists three: "Have an individual NPI"; "Be enrolled in Medicare in either an approved or opt-out status"; and "Be an eligible specialty type to order or certify".
What is the CMS-855O for?
CMS says, "Physicians and other eligible NPPs use this form to enroll in Medicare solely to order or certify items or services for Medicare patients."
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RxRev is not affiliated with CMS or CGS.
Sources: CMS, MLN9658742, Medicare Provider Enrollment (MLN booklet, December 2025). CGS Medicare (DME MAC Jurisdiction C), Ordering/Referring Provider Denial Job Aid (one MAC's guidance; check your own MAC). All quotes above are from these pages.