Attending Providers on Institutional Claims

Effective September 1, 2019, all institutional claims submitted to Maryland Medicaid must include the NPI of an attending physician who is enrolled and in an active status as a Maryland Medicaid Provider.


Impacted Billing Providers

  • Provider types subject to the Attending Provider requirements include:
  • Hospitals (PT 01, 03, 04, 05, 06, 07)
  • Home Health Agencies (PT 41)
  • Intermediate Care Facilities — Addiction (PT 55)
  • Intermediate Care Facilities – Intellectual Disabilities (PT 56)
  • Nursing Facilities (PT 57)
  • Dialysis Facilities (PT 61)
  • Residential Treatment Centers (PT 88)

Hospice providers (PT 71) are not currently included. Medicaid will determine a future date to apply these attending provider requirements to hospice claims.

Background

The Affordable Care Act and federal regulations require the State Medicaid Agency to enroll ordering and referring providers. The Centers for Medicare and Medicaid Services (CMS) interprets this enrollment requirement to include attending physicians supervising care in institutional settings, including hospitals, nursing facilities and residential treatment centers.  For such services, the attending physician serves as the ORP provider, and must be enrolled with the state Medicaid program for the service to be reimbursed by Medicaid.

Requirements

Claims with dates of service beginning on or after September 1, 2019 will be denied if they do not meet all of the following criteria:
  • The attending NPI should be inserted within field 76 on the UB-04. Click here for example. 
  • The attending provider NPI field must be filled with a valid 10-digit number.
  • The attending provider NPI must belong to a provider who is actively enrolled in the Maryland Medicaid program.
  • The attending provider NPI must be a Type 1 (Individual) NPI belonging to an individual practitioner. A Type 2 (Organizational) NPI belonging to a professional group or facility is not permitted in the attending field.