From the Contributor’s Corner: PPACA & National Provider Identifiers

Health Wolters Kluwer Law & Business will periodically feature posts from outside contributors who are members of our Advisory Board. Today’s post comes from Ericka L. Adler.

On April 27, 2012, the Centers for Medicaid and Medicaid services (“CMS”) issued a Final rule (77 FR 25284)  (24 CFR parts 424 and 431) addressing provisions of the Patient Protection and Affordable Care Act (PPACA)  (P.L. 111-148) that:

  • (a) require providers of medical or other items or services and suppliers that qualify for a National Provider Identifier (“NPI”) to include the NPI on all applications to enroll in the Medicare and Medicaid programs and on all claims for payment submitted under the Medicare and Medicaid programs;
  • (b) require physicians and other professionals who are permitted to order and certify covered items and services for Medicare beneficiaries to be enrolled in Medicare; and
  • (c) mandate document retention requirements for providers and suppliers that order and certify items and services for Medicare beneficiaries.

The Final rule will be effective June 26, 2012.

 The Final rule replaces an Interim rule and comment period (75 FR 24437)  published May 5, 2010, which implemented several provisions of PPACA regarding provider and supplier enrollment, ordering and referring and documentation requirements. Notable changes in the Final rule from the Interim rule include the following:

1. The Final rule clarifies that opted-out physicians and non-physician practitioners are not required to submit an enrollment application for any reason, including to order and certify.

2. Language in the Final rule revised to clarify the particular NPIs that are required on each claim.

3. July 6, 2010 will remain the effective date for inclusion of the NPI on all Medicaid claims and submission of NPIs pursuant to the Medicaid Provider Agreements for new providers, despite numerous comments on this topic. The Final rule did clarify that existing providers will only be required to submit NPIs upon the next date that a change must be made to their Provider Agreement or upon the date of revalidation.

4. In a significant change from the Interim rule, in which CMS indicated they would reject, not deny, claims from providers and suppliers that did not comply with ordering and certifying requirements, the Final rule provides that CMS will deny all such claims to provide suppliers, providers and beneficiaries with appeal rights. CMS will not activate the automated edits that would cause a claim not to be paid for lack of an approved enrollment record in Medicare or a valid opt-out status without providing adequate notice.

5. Residents enrolled in an accredited graduate medical education program in a state that licenses or otherwise enables such individuals to practice or order items or services, will be permitted under the Final rule to enroll in Medicare so as to order and certify. In states that do not license or otherwise permit such individuals to practice or order and certify services, the teaching physician’s full legal name and NPI must be included on the claim as the person who ordered or certified the services.

6. The Final rule clarifies exactly the items and services that will be covered by the and deletes the language that referred to “ordered or referred covered Part B items and services (excluding home health services described in Section 4.2.4507(b) and Part B drugs).” Instead the Final rule added language that designates the covered items and services as including items of DMEPOS, clinical laboratory, imaging, and home health services. Specialist services were removed from this portion of the Final rule.

7. With regard to home health services, physicians who order/certify must be listed on claims for payment, as opposed to those who just order. Additionally, the Final rule clarified that document maintenance, and affording access to documentation, applies to orders and certifications and that documents must be retained from the date of service, rather from the date of the order or certification.

In issuing the Final rule, CMS emphasized that the main objectives of the Final rule remains constant in that providers and suppliers must provide their NPI as part of their enrollment and on any claims for payment, along with the NPI of any other provider or supplier listed on the claim form. CMS stressed that the Final rule is intended to finalize conditions of payment for ordered items and services and does not address broader payment policy questions.

 Ericka L. Adler is a partner at the firm of Kamensky Rubinstein Hochman & Delott, LLP.  Her primary practice focus is in the areas of regulatory and transactional health care law and she has substantial experience structuring sophisticated health care ventures and advising clients regarding compliance with federal and state health care laws and regulations. Ms. Adler lectures to and advises physicians, providers and other health care specialists nationally regarding regulatory health care issues, day to day practice management, physician contract matters and other business issues that impact healthcare. Ms. Adler has a J.D. and an LL.M in health care law from the Health Law Institute at the DePaul University College of Law.  You can reach her at and can follow her on Twitter at @krhdhealthlaw.