Interim Final Rule Implements Health Care Law Provisions

An interim final rule with comment period (IFC), which the Centers for Medicare & Medicaid Services (CMS) published in the Federal Register on May 5, implements provisions in the Patient Protection and Affordable Care Act (Health Reform law). The provisions serve to promote quality health care and eliminate fraud and abuse in high-risk areas by enforcing stricter provider enrollment and claims submission requirements.

The IFC establishes health reform law provisions that affect durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS), home health, and laboratory services.

To summarize, effective July 6, the IFC requires:

A. The inclusion of a National Provider Identifier (NPI) on all Medicare and Medicaid enrollment applications and claims.

Qualifying providers and suppliers must include their NPI in all Medicare and Medicaid enrollment applications and in all paper and electronic claims for payment submitted under Medicare and Medicaid.

CMS began requiring providers and suppliers to report their NPIs in their Medicare enrollment applications in May 2006. Beginning May 23, 2008, CMS began requiring its enrolled fee-for-service (FFS) providers and suppliers to use NPIs in their paper and electronic claims submitted to Medicare and Medicaid. This IFC establishes a new requirement for all Medicaid providers and suppliers to submit their NPIs on Medicaid provider agreements to state agencies as well.

B. The ordering or referring supplier to be identified by legal name and NPI in the claim submitted by the DMEPOS supplier.

The ordering supplier for DMEPOS items covered under Medicare Part B must be a physician or other eligible professional with an approved enrollment record in the Provider Enrollment, Chain, and Ownership System (PECOS) and be identified in the claim by his or her legal name and own NPI. This requirement also applies to Part A/B home health services and Part B claims for covered services of laboratories, imaging suppliers, and specialists (some exceptions apply).

C. Physicians, other providers, and suppliers to maintain and provide access to documentation on referrals to programs at high risk of waste and abuse.

Immediate Action Required

Providers and suppliers who enrolled in Medicare more than six years ago and who have not updated their enrollment information in the past six years will need to resubmit an enrollment application to Medicare to be added to the enrollment record in PECOS.

Speak Up and Be Heard

Comments on this IFC will be accepted through July 6, 5 p.m. ET. See the interim final rule (fr05my10R) for commenting instructions.


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