CMS changes provider enrollment, ordering and referral documentation requirements

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The Centers for Medicare and Medicaid Services (CMS) last week released provisions of the Patient Protection and Affordable Care Act requiring all providers of medical or other items or services and suppliers that qualify for a National Provider Identifier (NPI) to include their NPI number on all enrollment applications and on all claims submitted under the Medicare and Medicaid programs.

The Federal Register notice--which includes a request for public comment--also requires physicians and eligible professionals to order and refer covered items and services for Medicare beneficiaries to be enrolled in Medicare. The changes also call for medical providers participating in the Medicare program to provide documentation on referrals to programs at high risk of waste and abuse, to include durable medical equipment, prosthetics, orthotics and supplies, home health services and other items or services specified by the Secretary of Health and Human Services (HHS), Kathleen Sebelius.

According to CMS, the changes will consist of the following:

  • Inclusion of NPIs on all Medicare enrollment applications and claims--In addition to medical providers, this requirement also applies to Medicaid providers when submitting Medicaid provider agreements. Claims that are submitted by a provider without an NPI number of the aforementioned provider will be rejected.
  • Ordering or referring physician enrollment requirements--Referring physicians must be identified by name and NPI number on claims submitted for services provided to Medicare beneficiaries by the suppliers of laboratory, imaging, and specialist services. The rule does exempt residents and interns. However, an attending physician needs to be identified on the claim when a service is ordered or referred.┬áThese requirements will become effective on July 1.
  • Requirements to maintain and provide access to documentation of referrals--Providers are expected to maintain the ordering documentation for seven years from the date of service and must grant access to this documentation upon the request of a Medicare contractor provider.

Public comment regarding the Medicare provider enrollment and ordering and referring regulations final rule must be received no later than 5 pm on July 6, according to CMS.