Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.Medicare guidance says This chapter specifies the resources and procedures Medicare fee-for-service contractors must use to establish and maintain provider and supplier enrollment in the Medicare program. These procedures apply to A/B MACs (A & B) and the National Supplier Clearinghouse (NSC), unless contract specifications state otherwise. No provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program. Further, it is essential that each provider and supplier enroll with the appropriate Medicare fee-for-service contractor. You can find this guidance in the Medicare Program Integrity Manual, Chapter 15 -Medicare Enrollment, Section 15.1 -Introduction to Provider Enrollment.Medicare guidance says This section is designed to provide Medicare enrollment information for providers, physicians, non-physician practitioners, and other suppliers. Please review the downloadable fact sheets below to learn more about Medicare provider and supplier enrollment. You can find this guidance in the CMS.gov, Medicare Provider-Supplier Enrollment.Medicare guidance says Medicare Enrollment for Institutional Providers Institutional providers must enroll in the Medicare Program to get paid for covered services they furnish to Medicare beneficiaries. This booklet shows institutional providers how to determine whether they are eligible to enroll in the Medicare Program and howto enroll. Who Are Institutional Providers? Institutional providers are listed on the Medicare Enrollment Application: Institutional Providers (Form CMS-855A). Institutional providers include: Community Mental Health Centers (CMHCs), Comprehensive Outpatient Rehabilitation Facilities (CORFs), Critical Access Hospitals (CAHs), End-Stage Renal Disease (ESRD) Facilities, Federally Qualified Health Centers (FQHCs), Histocompatibility Laboratories, Home Health Agencies (HHAs), Hospice Organizations, Hospitals,Indian Health Service (IHS) Facilities, Organ Procurement Organizations, Outpatient Physical Therapy/Occupational Therapy/Speech Pathology Services, Religious Non-Medical Health Care Institutions, Rural Health Clinics (RHCs), Skilled Nursing Facilities (SNFs). If your institutional provider type is not listed above, contact the provider enrollment services division of your Medicare Administrative Contractor (MAC) before submitting a Medicare enrollment application. Refer to the Medicare Fee-For-Service Provider Enrollment Contact List for enrollment services contact information for each State's MAC. You can find this guidance in the MLN Matters Number ICN 903783 January 2019.Medicare guidance says NPI: What You Need to Know An NPI is a unique identification number for covered health care providers, created to improve the efficiency and effectiveness of electronic transmission of health information. What an NPI Doesn't Do Obtaining and NPI will not: Change or replace your current Medicare enrollment or certification process, Enroll you in a health plan, Ensure you are licensed or credentialed, Guarantee payment by a health plan, Require you to conduct HIPAA transactions. You can find this guidance in the Medicare Learning Network 909434 December 2016, NPI: What You Need to Know.