CMS releases rule on Medicare and Medicaid enrollment and claims

Today the Centers for Medicare & Medicaid Services(CMS) released an interim final rule that implements several Patient Protection and Affordable Care Act (PPACA) provisions, which impact Medicare and Medicaid enrollment and claims. The rule requires providers with a National Provider Identifier (NPI) to include it on their Medicare and Medicaid enrollment applications and claims. Medicare Part B claims for suppliers that furnish covered, ordered Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), laboratory, imaging, or specialist services must identify the ordering/referring supplier by legal name and NPI on the claim. Additionally, the ordering/referring supplier must be a physician or an eligible professional with an approved enrollment record in the Provider Enrollment Chain and Ownership System (PECOS). Claims that do not meet these requirements will be rejected by Medicare contractors. Part A claims for Part A and B covered home health items or services must meet these same requirements and must be ordered by physicians. These requirements are effective July 6, 2010.

This requirement that ordering/referring providers be in the PECOS enrollment database drastically changes the existing Jan. 3, 2011 deadline that CMS established for these providers to have accurate, up-to-date enrollment records in PECOS. In addition, Medicare providers are also now required to maintain documentation, including the ordering/referring physician’s NPI for seven years on any covered, ordered DMEPOS, laboratory, imaging or specialist services that the provider furnishes.