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The NPI
Important Information for Medicare FFS Providers
March 1 Milestone
Effective March 1, 2008, all 837P and CMS-1500 claims must have an NPI or NPI/legacy pair in the required primary provider fields. Failure to include an NPI will cause the claim to reject!
Background
One of the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA, Title II) required the Department of Health and Human Services (HHS) to establish unique national identifiers for providers. The purpose of these provisions is to improve the efficiency and effectiveness of the electronic transmission of health information. On March 1, 2008, Medicare claims submitted by physicians and other practitioners, laboratories, ambulance company suppliers, DMEPOS suppliers and others that bill Medicare are required to include the new National Provider Identifier (NPI).
Providers must use this information when they submit their claims to Medicare carriers, A/B Medicare Administrative Carriers (MACs), and DME MACs when they use certain electronic and paper Medicare claims (specifically the X12N 837P electronic claim and the CMS-1500 paper claims).
Hospitals, skilled nursing facilities, home health care agencies and other such institutional providers were required to begin using their NPI beginning on January 1, 2008.
The deadlines for submitting Medicare claims using the NPI are necessary to help the Centers for Medicare & Medicaid Services (CMS), the Medicare contractors and health care providers prepare for the final May 23, 2008 deadline for full NPI compliance. While the final NPI Rule required compliance on May 23, 2007, CMS stated in the NPI National Contingency Guidance that it will not take enforcement action against covered entities that deploy contingency plans through May 23, 2008, provided that conditions in the Guidance were met.
CMS is anticipating that some providers will experience some problems with claims submitted after March 1 – problems could arise in the following situations:
- The provider does not have an NPI T
- he provider does not submit their NPI on their claim
- The provider has already received an NPI, but the NPI is not consistent with the provider’s enrollment information received by the contractor.
Providers whose claims are rejected and returned to them should immediately contact their contractor before resubmitting that claim or submitting new claims for services provided to Medicare beneficiaries. Contact information for the Medicare contractors can be found at www.cms.hhs.gov/MLNGenInfo/ under “Downloads.” The file is named, “Provider Call Center Toll-Free Numbers Directory.”
The March 1, 2008, Deadline
Expectations for March 1:
- A small portion of claims will continue to be submitted without an NPI. These claims will be rejected. Providers have had over two years to acquire and test their NPI.
- Some rejections may occur because a contractor has not completed processing a provider’s enrollment application, submitted by the provider to fix inconsistencies between a provider’s NPI and Medicare’s provider enrollment files.
Medicare Risk Mitigation
CMS and the Medicare contractors are taking aggressive steps to ensure that providers will be paid for treating Medicare beneficiaries after March 1.
Medicare contractors are enhancing their toll-free phone lines by expanding the number of people available to answer calls. Throughout the month of February, CMS has intensified its planning efforts to assist contractors to prepare for the March 1 implementation date. In February 2008, CMS held a training session with contractor call centers and CMS regional office staff to ensure they are able to address provider inquiries on NPI issues.
Daily calls with the carriers, A/B MACs, and DME MACS are scheduled to monitor the status of successful and rejected claims, inquiries, enrollment backlog status, and other relevant information.
Each contractor has created a NPI Coordination Team to quickly identify and resolve claims processing issues related to the submission of the NPI or NPI-Legacy combination, expedite the processing of enrollment applications, and address other issues that may arise.
CMS has implemented temporary measures to allow the Medicare contractors time to address some of the backlog issues, but at some contractors, more work is needed.
Current Claims Process as of March 1
Currently, most Medicare providers (and their claims clearinghouse vendors) are submitting claims that include their new NPI. For those providers who don’t have an NPI, they are submitting claims using their legacy provider numbers. When the claim is submitted, Medicare’s computer systems will check to confirm that the claim includes an NPI. If there is no NPI, the claim will be rejected and the provider will receive an error message pointing to the lack of an NPI. If the provider has an NPI, the provider should make sure that the number is on the claim and resubmit the claim. If at that point the claim is again rejected, the provider should immediately contact the Medicare contractor to ensure that all provider records are correct before resubmitting the claim.
Contact information for the Medicare contractors can be found at www.cms.hhs.gov/MLNGenInfo/ under “Downloads.” The file is named, “Provider Call Center Toll-Free Numbers Directory.”
Medicare contractors expect to be able to handle all incoming calls, but some callers may experience extended hold times. CMS is urging providers to be patient – their issues will be addressed.
The Future – May 23, 2008
With May 23, 2008 less than three months away, CMS and the Medicare health care providers must make sure they are ready for full NPI implementation. Providers must be certain their NPI information and Medicare enrollment information is accurate and up-to-date before that date. Further, if providers’ claims are being successfully processed with NPI/legacy pairs (and most are) now is the time for them to begin testing claims using only the NPI. Providers should start with small volumes of these NPI-only claims and gradually increase their submissions. Doing this testing now will allow time for any needed corrections prior to the May 23, 2008, deadline when claims must include the NPI only.
What to do if your 837P and CMS-1500 Claims are Rejected
- Check your record in the National Plan and Provider Enumeration System (NPPES)
o Validate that the legacy identifier sent on the claim is reported in the provider/supplier’s NPI Registry record. If the legacy identifier is not there, instruct the provider/supplier to add it.
o Validate that the Legal Business Name (if the provider/supplier is an organization) or the Legal Name (if the provider/supplier is an individual or a sole proprietorship) is correct.
o Validate that the correct Entity type was selected by the provider/supplier when applying for the NPI. Individuals obtain an NPI as Entity Type 1. Organizations obtain an NPI as Entity Type 2 NPI.
(Note: If you enumerated through the EFI alternative, you should use the NPI Registry to check the content of the NPPES file. Make sure to have the Customer Service Representative at your Medicare contractor verify your TIN/EIN as the NPI Registry does not list this information.)
- If these claims are still rejecting, call your Medicare Contractor
o Have a copy of the NPPES record in hand. A copy of the NPPES record can be obtained online at https://nppes.cms.hhs.gov . The Employer Identification Number or Social Security Number will not be shown on this print out.
o Have the claim reject number and message
o Be prepared to give the following information:
1. Legal Business Name of the Organization
2. Contractor Tracking Number (if known)
3. Approximate date (month/year) when the 855 enrollment application was submitted
4. Provider/Supplier Tax Identification Number or Social Security Number (SSN)
5. National Provider Identifier (NPI)
6. Medicare legacy Identifier
7. Practice location on claim (i.e. where is the practice located (e.g. 100 Main St. New Orleans, LA)
8. Contact Information where Provider/Supplier can be reached if further discussion is needed
Need More Information?
Still 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.
Note: All current and past CMS NPI communications are available by clicking "CMS Communications" in the left column of the www.cms.hhs.gov/NationalProvIdentStand CMS webpage.
