October 27, 2007
The NPI is here. The NPI is now. Are you using it?
Key Dates for Medicare, Clarification Regarding NPI Requirement on Medicare Institutional Claims & More
As we get closer to May 23, 2008, be sure to pay attention to information from Medicare and other health plans regarding NPI implementation timelines.
Important Message for Residents at Teaching Hospitals and Academic Medical Centers: Why get your NPI now?
- If the hospitals' residents want to enroll in Medicare, you will need to obtain NPIs before applying (enrolling) as a Medicare provider.
- Other health plans may require you to obtain NPIs as a condition of enrollment.
- If you prescribe medication, the pharmacies may need to know your NPI before dispensing the medications and submitting claims to health plans.
- If you order or refer services, your NPI may be required on the claims from providers who actually furnished the services.
- Future employers may require you to obtain NPIs as a condition of employment.
Important Information for Medicare Providers
Summary of Key Medicare Dates:
October 29, 2007 - By this date, all carriers, A/B MACs and DME MACs will be rejecting claims where the NPI/legacy identifier combination used in claims cannot be validated against the NPI crosswalk. Informational edits will no longer be issued once this happens, but will be replaced by reject reports that will assist providers in determining why the claim is being rejected.
January 1, 2008 - As of this date, 837I electronic claims and UB04 paper claims without an NPI in fields identifying the primary provider (billing and pay-to) will be rejected. Legacy identifiers paired with NPIs in the primary provider fields on the claim will still be acceptable as will legacy-only numbers in secondary provider fields (see clarification below).
CMS has not yet announced the date by which an NPI will be required for primary provider fields on 837 professional electronic claims and 1500 paper claims processed by carriers, A/B MACs and DME MACs. This will occur prior to May 23, 2008; a specific date will be announced once available.
May 23, 2008 - In keeping with the Contingency Guidance issued on April 3, 2007, CMS will lift its NPI contingency plan, meaning that only the NPI will be accepted on all HIPAA electronic transactions (837I, 837P, NCPDP, 276/277, 270/271 and 835), paper claims and SPR remittance advice. This also includes all secondary provider fields on the 837P and 837I. The reporting of legacy identifiers will result in the rejection of the transaction. CMS will also stop sending legacy identifiers on COB crossover claims at this time.
Common Claims Problems/Errors Causing Rejections
The following problems/errors are due to providers billing with incompatible NPI/legacy pairs:
- The type of NPI you use (Entity Type 1 or Entity Type 2) must match your Medicare enrollment PIN (individual or organization). When compatible NPI/legacy pairs are submitted on a claim, there is a much higher success rate for finding a match on the NPI crosswalk, thus further ensuring timely and accurate processing of your claim.
- Those who are enrolled with Medicare as individuals but obtained an Organization (Entity type 2) NPI through NPPES (or vice versa) need to ensure their enrollment records are correct and their NPIs were obtained appropriately.
- On professional claims (837P and CMS-1500), the NPI/PIN combination should identify the Billing, Pay-to, and Rendering Provider (the Pay-to Provider is identified only if it is different from the Billing Provider). This includes claims that are submitted by corporations that physicians and non-physician practitioners have formed or by physicians and non-physician practitioners who bill Medicare directly. For more information, please refer to MLN Matters article SE0744 at http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0744.pdf on the CMS website.
Other problems identified include:
- Providers are not taking proactive action based on the Part B informational edits and reject reports, despite extensive outreach and educational activities designed to make providers aware of the need to take action. Don't let this happen to you. Pay attention to the informational edits prior to October 30 and the reject messages thereafter.
- CMS has received reports of clearinghouses and billing services that may be stripping the NPI from the claim and later adding the NPI back on the remittance advice. Make sure this is not unknowingly happening to your claims. If you suspect that your clearinghouse or billing service is stripping your NPI from claims, please contact your contractor to confirm that an NPI was not received.
Clarification: NPI Requirement on Medicare Institutional Claims for 1/1/08
At the beginning of October, CMS issued a notice that referred to institutional claims. We are further clarifying that effective 1/1/08, NPIs will be required to identify the primary providers (the Billing and Pay-to Providers) in Medicare electronic and paper institutional claims (i.e. 837I and UB-04 claims). You may continue to use the legacy identifier in these fields as long as you also use the NPI in these fields. This means that 837I and UB-04 claims with ONLY legacy identifiers in the Billing and Pay-to Provider fields will be rejected starting on 1/1/08. (Pay-to Provider is identified only if it is different from the Billing Provider.)
You may continue to use only legacy identifiers for the secondary provider fields in the 837I and UB-04 claims, until 5/23/08, if you choose.
Test Your Claims Now!
Medicare encourages submitters to send a small number of claims using NPIs only (no legacy identifiers). If no claims are rejected, the submitter may gradually increase the volume. And remember, Medicare will require the NPI on paper claims – be sure to begin the testing process now even if you bill paper!
Upcoming WEDI NPI Audiocast on Using the NPI Registry and the NPPES Downloadable File
The Workgroup for Electronic Data Interchange will host an NPI audiocast on October 31st. Visit http://www.wedi.org/npioi/index.shtml on the WEDI website to learn more. Please note that there is a cost to participate in WEDI events.
Still Confused?
Not sure what an NPI is and how you can get it, share it and use it? As always, more information and education on the NPI can be found through the CMS NPI page www.cms.hhs.gov/NationalProvIdentStand on the CMS website. Providers can apply for an NPI online at https://nppes.cms.hhs.gov or can call the NPI enumerator to request a paper application at 1-800-465-3203. Having trouble viewing any of the URLs in this message? If so, try to cut and paste any URL in this message into your web browser to view the intended information.
Getting an NPI is free - not having one can be costly.
