Oct. 29, 2007: By this date, all carriers, A/B Medicare administrative contractors (MACs), and durable medical equipment MACs will be rejecting claims where the national provider identifier (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.
Jan. 1, 2008: As of this date, 837-I electronic claims and UB-04 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.
The Centers for Medicare and Medicaid Services (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 standard paper 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 coordination-of-benefits crossover claims at this time.
Reminders regarding claims processing
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 provider identifier number (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 the National Plan and Provider Enumeration System (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 nonphysician practitioners have formed or by physicians and nonphysician practitioners who bill Medicare directly.
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. Pay attention to the informational edits prior to Oct. 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
At the beginning of October, CMS issued a notice that referred to institutional claims. It is further clarifying that effective Jan. 1, 2008, 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 Jan. 1. (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 May 23, 2008, if you choose.
Reminder for residents at teaching hospitals and academic medical centers
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.
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. Medicare will require the NPI on paper claims; be sure to begin the testing process now even if you bill paper.
Audiocast to be held Oct. 31
The Workgroup for Electronic Data Interchange will host an NPI audiocast on Oct. 31. Visit the WEDI web site to learn more. Please note that there is a cost to participate in WEDI events.
