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Enrollment Deadline for Medicare and Medicaid Service Providers

July 29, 2010

Pursuant to an Interim Final Rule (“IFR”) published on May 5 by the Centers for Medicare and Medicaid Services (“CMS”) to comply with the Patient Protection and Affordable Care Act ("PPACA"), all providers and suppliers who qualify for a National Provider Identifier (“NPI”) must provide the NPI on any enrollment applications to Medicare and Medicaid. Physicians are also required to list the legal name and NPI of the referring or ordering physician on their claim for payment under Medicaid and Medicare. The IFR requires that all referring or ordering physicians that order and refer covered items and services for Medicare beneficiaries after July 1, 2010 be enrolled in Medicare through the Medicare enrollment database known as the Provider Enrollment, Chain and Ownership Systems ("PECOS") or have a valid opt-out record with PECOS including physicians who refer or order durable medical equipment, prosthetics, orthotics and supplies ("DMEPOS" ) and home health, laboratory or imaging services. It also requires Medicare providers or suppliers that enrolled in PECOS prior to receiving an NPI to provide such NPI information if not already in PECOS records. The IFR further implements the PPACA in that it adds requirements for the maintenance of documentation by providers and suppliers participating in Medicare in certain health care services deemed to be high risk of waste and abuse such as providers or suppliers of DMEPOS, home health, laboratory, imaging or services. The IFR requires both the provider furnishing Part B services and the ordering provider or supplier of Part B services to maintain documentation of orders or referrals for 7 years and such documentation must include the legal name and NPI of the referring physician or eligible professional ordering or referring the service. Additionally, the IFR directs that Medicaid provider agreements include NPIs. The IFR regulations were effective starting on July 6, 2010. For a link to the complete IFR, click here. In a recent press release issued by CMS on June 30th however, CMS has indicated that it is not automatically rejecting Medicare claims for providers who have attempted to enroll in PECOS and have not had PECOS enrollment applications approved by this July 6, 2010 deadline. For a link to the CMS press release, click here.
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