Bulletin: February 01, 2006

Medicare expectations on determination of subparts

By: Corporate Compliance Officer

CMS has published an interesting paper outlining their NPI requirements for determination of subparts by Medicare providers. The following are a few key points from the paper:

• Enrolled Medicare providers and suppliers that are covered entities must obtain NPIs. Subpart determinations must mirror Medicare enrollment.
• Medicare providers must take any federal statutes or regulations into account to ensure that, if Medicare providers are uniquely identified now by using Medicare identifiers in HIPAA standard transactions, they obtain NPIs so they can continue to be uniquely identified.
• A subpart that conducts any of the HIPAA standard transactions separately from the covered organization provider of which it is a part must have its own unique NPI.
• Regardless of how an enrolled provider determines subparts and obtains NPIs, Medicare payment may be made only to an enrolled provider.
• If a provider designates subparts other than those who are enrolled Medicare providers, and those subparts obtain their own NPIs and use them in standard transactions, those NPIs will not identify enrolled Medicare providers and Medicare is not required to enroll them. (Medicare does not have to enroll a subpart in the Medicare program just because a provider decided to obtain an NPI for a subpart that wasn't already enrolled in Medicare.)
• Medicare will ensure that the NPIs it receives in standard transactions are valid. The check-digit algorithm will determine the validity. Valid NPIs, like the PIN numbers used today, must be "known" to Medicare.

The entire paper is available for downloading from the CMS Web site.