National Government Services, Inc. Medicare Monthly Review Part A and B
A Combined Part A and Part B Newsletter

MMR-2007 12AB, December 2007

MLN Matters Number: MM674 Related Change Request Number: 5674

How to Handle the National Provider Identifier (NPI) for Ordering/Referring and Attending/Operating/Other/Service Facility for Medicare Claims

Provider Types Affected
Physicians and providers who bill Medicare carriers, fiscal intermediaries (FI) and Medicare Administrative Contractors (A/B M C) for claims for service provide to Medicare beneficiaries  

What Providers Need to Know
Be cognizant of the fact that in accordance with the NPI final rule, when an identifier is reported on a claim for ordering/referring/attending provider, operating/other/service facility provider or for any provider that is not a billing, pay-to or rendering provider, that identifier must be in NPI. For Medicare purpose this means that submission of an NPI for an ordering/referring provider is mandatory effective May 23, 2008. Legacy numbers can not be reported on any claims sent to Medicare on or after May 23, 2008.

Medicare has always required that a provider identifier be reported for ordering/referring providers. Effective May 3, 2008, that number must be a NPI, regardless of whether that referring or ordering provider participates in the Medicare program or not or is a covered entity

Key Points

• Medicare will not pay for referred/ordered services or items unless the name and NPI number of the referring/ordering/attending/operating/other/service facility provider is on the claim.
• It is the responsibility of the claim/bill submitter to obtain the ordering/referring/attending/operating/other/service facility NPI for health care providers.
• Providers whose business is largely based upon provision of services or items referred/ordered by other providers must be careful furnishing such services/items unless they first obtain the NPI of the referring/ordering individual. If they furnish services/items and do not obtain that person’s NPI prior to billing Medicare, their claim will be denied.
• If the NPI is not directly furnished by the ordering/referring provider at the time of the order, the provider expected to furnish the services or items should contact that provider for his/her NPI prior to delivery of the services/items.
• Providers who have not obtained an NPI by May 23, 2008, are not permitted to refer/order services or items for Medicare beneficiaries.
• Legacy numbers, such as provider identification numbers (PINs) or unique physician identification numbers (UPINs), cannot be reported on any claims sent to Medicare on or after May 23, 2008.
• Physicians (MD and DO) and the following non physician practitioners are the only types of providers allowed to refer/order services or items for beneficiaries:
• Nurse practitioners (NP);
• Clinical nurse specialists (CNS);
• Physician assistants (PA); and
• Certified nurse midwives (CNM).
• Established NPI business requirements for beneficiary submitted (CR 5328), deceased physician (CR 5416), adjustments (CR 5416), beneficiary submitted (CR 4169), flu claims (CR 4169), foreign claims (CR 4169) and pandemic flu claims (CR 4169) remain as written.

Background
This article is based on Change Request (CR) 5674. Please note that the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandate the adoption of a standard unique health identifier for each health care provider. The (NPI) Final Rule, published on January 23, 2004, establishes the NPI as this standard. All health care providers covered under HIPAA must comply with the requirements of the NPI final rule (45 CFR Part 162, CMS-045-F). All entities covered under HIPAA must comply with the requirements of the NPI Final Rule.

Additional Information
If you have questions, please contact your Medicare A/B MAC, FI, or carrier at their toll-free number which may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site.

You may see the official instruction (CR5674) issued to your Medicare A/B MAC, FI, or carrier by going to http://www.cms.hhs.gov/Transmittals/downloads/R225PI.pdf on the CMS Web site.

Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.