As reported in the HCA’s Update last week, CMS published in the Federal Register “Medicare and Medicaid Programs: Changes in Provider and Supplier Enrollment, Ordering and Referring, and Documentation Requirements; and Changes in Provider Agreement.”
This final rule finalizes several provisions of the Affordable Care Act implemented in the May 5, 2010 interim final rule with comment period. It requires all providers of medical or other items or services and suppliers that qualify for a National Provider Identifier (NPI) to include their NPI on all applications to enroll in the Medicare and Medicaid programs and on all claims for payment submitted under the Medicare and Medicaid programs. In addition, it requires physicians and other professionals who are permitted to order and certify covered items and services for Medicare beneficiaries to be enrolled in Medicare.
To receive payment for home health services, any Medicare-enrolled Home Health Agency must file claims containing the name and National Provider Identifier (NPI) of the physician who ordered the service.
The ordering physician must be enrolled in PECOS. The NPI used must be for an individual physician (cannot be a group or organizational NPI) and the individual physician must be of a specialist type that is eligible to order; Doctors of Medicine or Osteopathy, Doctors of Podiatric Medicine
Failure to meet the requirements mentioned above will result in denied claims once the automatic edits are activated. The Medicare Learning Network’s “Medicare Enrollment Guidelines for Ordering/Referring Providers” is an excellent fact sheet if you need more information
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