Note: This article was revised on December 18, 2007, to add DME MACs as affected providers. In addition, references to CR5328, CR5416 and CR4169 at the end of the article were removed. These CRs were incorrect. All other information remains unchanged.

Provider Types Affected
Physicians and providers who bill Medicare carriers, fiscal intermediaries (FI), Durable Medical Equipment Medicare Administrative Contractors (DME MAC) and Part A/B MACs for claims for services provided 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 an NPI. For Medicare purposes, this means that submission of an NPI for an ordering/referring provider is mandatory effective May 23, 2008. Legacy numbers cannot 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 23, 2008, that number must be an 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 (PIN) or unique physician identification numbers (UPIN), cannot be reported on any claims sent to Medicare on or after May 23, 2008.
• Physicians 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).

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, DME 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, DME 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.

News Flash - Flu Season is upon us! Begin now to take advantage of each office visit as an opportunity to talk with your patients about the flu virus and their risks for complications associated with the flu. (Medicare provides coverage of the flu vaccine without any out-of-pocket costs to the Medicare patient. No deductible or copayment/coinsurance applies.) Remember - Influenza vaccination is a covered Part B benefit. Note that influenza vaccine is NOT a Part D covered drug. For information about Medicare’s coverage of flu vaccine and its administration, please go to http://www.cms.hhs.gov/MLNProducts/Downloads/flu_products.pdf on the CMS Web site. Get Your Flu Shot. – Not the Flu.

Posted: 12/27/2007