HF4831

Purpose

• To require provider-based clinics to obtain and use a unique National Provider Identifier (NPI) for all reimbursement claims.
• To ensure that all-payer claims data includes the provider-based clinic’s unique NPI.
• To amend Minnesota law (62U.04) and codify the new requirements in Minnesota Statutes chapter 62J.

Main Provisions

• Define key terms to clarify scope, including National Provider Identifier (NPI), provider-based clinic, health care clearinghouse, and all-payer claims data.
• Require provider-based clinics to apply for, obtain, and use a unique NPI on every claim for services provided at the clinic.
• The provider-based clinic’s unique NPI must be different from and distinct from the hospital’s NPI.
• The unique NPI must be included on all reimbursement or payment claims for services from the provider-based clinic, regardless of who files the claim (e.g., hospital central office or other intermediaries).
• Update all-payer data reporting to ensure that data submitted about provider-based clinics includes this unique NPI, separate from the hospital’s NPI.

Definitions and Key Concepts

• Provider-based clinic: an off-campus clinic or clinic site located at least 250 yards from the main hospital buildings (or as CMS determines) that is owned by a hospital licensed under chapter 144 or by a health system operating one or more hospitals, and primarily provides diagnostic and therapeutic care (history, exams, health status assessments, treatment monitoring). Clinics that exclusively provide laboratory, X-ray testing, therapy, pharmacy, or educational services are not considered provider-based clinics.
• National Provider Identifier (NPI): the standard unique health identifier for health care providers, issued under federal rules.
• Health care clearinghouse: as defined by federal regulations.
• All-payer claims data: data used to capture claims information across multiple payers.

Data Submission and Compliance

• All data submitted under the referenced section relating to a provider-based clinic must include the provider-based clinic’s unique NPI.
• The provider-based clinic’s NPI must be used on all reimbursement-related claims, regardless of whether the claim is filed directly by the clinic, a hospital central office, a health care clearinghouse, or another intermediary.

Significant Changes to Existing Law

• Adds a new subdivision to Minnesota Statutes 62J.825 establishing the unique NPI requirement for provider-based clinics and defining the clinic as a specific off-campus site with distinct criteria.
• Amends Minnesota Statutes 62U.04 by adding a subdivision requiring that all-payer data related to provider-based clinics include the clinic’s unique NPI, distinct from the hospital’s NPI.
• Establishes a framework for separating billing identifiers between provider-based clinics and hospitals to ensure clear, separate reimbursement and data reporting.

Relevant Terms - National Provider Identifier (NPI) - provider-based clinic - unique NPI - all-payer claims data - hospital NPI - off-campus clinic - Centers for Medicare and Medicaid Services (CMS) - health care clearinghouse - Minnesota Statutes 62U.04 - Minnesota Statutes chapter 62J - reimbursement claims - data submission - provider-based clinic’s unique NPI