Provider not eligibleEnrollment inactiveOrdering or referring failure
Provider or Supplier Not Eligible to Bill
The billing, rendering, ordering, referring, attending, or supplier enrollment facts do not support payment for the claim and service date.
First checks
- 1Identify which provider role failed.
- 2Check enrollment and effective dates for the service location.
- 3Compare NPI and name exactly with payer records.
Resolution path
- 01Correct a claim-role or identifier error.
- 02Resolve enrollment through PECOS or the payer before rebilling when possible.
- 03Request retrospective review only under applicable rules.
- 04Do not shift a provider-enrollment failure to the patient without a valid basis.
Evidence packet
- Enrollment approval
- NPPES and PECOS data
- Reassignment and location records
- Licensure or accreditation where applicable
Prevent the next denial
Monitor enrollment, revalidation, reassignment, location, taxonomy, licensure, and ordering eligibility before services are scheduled and billed.
Official sources
Use the current payer notice, contract, code set, policy, and filing instructions. This guide is educational and does not determine patient liability or appeal rights for an individual claim.