CMS Issues Final Rule Requiring Providers To Obtain National Provider Identifier Number

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By Steve Teske  

All providers and suppliers who qualify for a National Provider Identifier (NPI) will be required to include the NPI on any enrollment applications to Medicare and Medicaid, as well as on any payment claims, according to a final rule issued by the Centers for Medicare & Medicaid Services April 24.

CMS said the rule will save Medicare about $1.6 billion over 10 years.

The rule also requires physicians and other professionals who are permitted to order and certify covered items and services for Medicare beneficiaries to be enrolled in Medicare. In addition, it mandates document retention and provision requirements on providers and suppliers that order and certify items and services for Medicare beneficiaries.

CMS may revoke a provider's enrollment in federal health care programs for up to a year for failing to meet the documentation requirements. The agency said most providers that want to enroll in Medicare and Medicaid already have an NPI.


CMS said the rule would give it and states the ability to link provider claims to the ordering or certifying physician or eligible professional and to check for suspicious ordering activity.  



The NPI is a 10-digit number that identifies health care providers. The National Plan and Provider Enumeration System collects identifying information on health care providers and assigns each a unique NPI. CMS published an interim final rule on the NPI requirement in May 2010 (84 HCDR, 5/4/10).

The regulation, which is scheduled for publication in the April 27 Federal Register, is effective June 26.

Combating Fraud.

“Thanks to the [Patient Protection and] Affordable Care Act, we are expanding our work to combat fraud,” CMS Deputy Administrator for Program Integrity Peter Budetti said in a press release. “This rule will save money for taxpayers and ensure people with Medicare get high-quality care.”

CMS said it based its Medicare savings estimate on a decrease in the use of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS), imaging services, clinical laboratory services, and home health care because a small number of patients will go to physicians without enrollment numbers and thus will not get referrals to these services.

Some provider claims without proper documentation, including some fraudulent claims, could be denied as a result of the rule, but the agency said it does not have “a basis for quantifying the value of such claims.”

CMS said the rule will give it and states the ability to link provider claims to the ordering or certifying physician or eligible professional and to check for suspicious ordering activity.

The regulation implements Section 1128J(e) of the Social Security Act, added by the Patient Protection and Affordable Care Act, which requires that all providers and suppliers eligible for an NPI include it on all applications and payment claims for federal health care programs.

'Reasonable Policy,' Group Says.

William A. Dombi, vice president for law at the National Association for Home Care & Hospice, told BNA April 24 the rule appears “to be well done and workable.”

”CMS is setting out a reasonable policy that will allow for physicians to qualify if they are enrolled in [the Provider Enrollment, Chain, and Ownership System] or another format of Medicare enrollment,” he said.

“Further, they indicate that there will be no adverse actions on claims until after they issue a notice that the automated edit is going to be turned on,” Dombi added. “This should mean that providers can anticipate that any remaining bugs in the system will have been worked out before the edit goes live.”

By Steve Teske  

The final rule is at

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