National Provider Identifier Updates
NPI: Get It. Share It. Use It.
On May 23, 2007, the NPI replaced health care provider identifiers that were in use in HIPAA standard transactions. MAG is keeping you informed of the updates from the Centers for Medicare & Medicaid Services regarding the new identifier. Please follow the links below for more information.
04.04.08 MAG Alert: Begin Testing NOW for NPI-Only Deadline
CMS is concerned that the percentage of Medicare claims with NPI-only is not growing fast enough. The next milestone – May 23 – requires providers to take the next step so they do not risk disruption in cash flow. Begin billing with NPI-only now to test how the May 23-switch will impact you.
CMS encourages all health care providers to ensure they understand the readiness of other health plans with which they interact, especially if those health plans may be primary or secondary to Medicare. Medicare will only accept/send NPI-only transactions beginning May 23rd and providers from other plans need to understand what will happen if they are unable to send/receive NPI-only transactions.
Read More from NPI Update
03.25.08 NPI-Only Deadline is in Less than Two Months
As of May 23, 2008, the NPI will be required for all HIPAA standard transactions. This means:
- For all primary and secondary provider fields, only the NPI will be accepted and sent on all HIPAA electronic transactions (837I, 837P, NCPDP, DDE, 276/277, 270/271 and 835), paper claims (UB-04 and CMS-1500) and SPR remittance advice.
- The reporting of Medicare legacy identifiers in any primary or secondary provider fields will result in the rejection of the transaction.
REMINDER: Test NPI-Only Now!
Now that the NPI is required on all Medicare claims in the primary provider fields, if your claims are being successfully processed with NPI/legacy pairs (and most are) now is the time to begin testing claims using the NPI alone. If the Medicare NPI Crosswalk cannot match your NPI to your Medicare legacy number, the claim with an NPI-only will reject. CMS recommends that you should do this test now!
If the claim is processed and you are paid, continue to increase the volume of claims sent with only your NPI. If the claims reject, go into your NPPES record and validate that the information you are sending on the claim is consistent with the information in NPPES. If it is different, make the updates in NPPES and resend a small batch of claims three to four days later. If your claims are still rejecting, you may need to update your Medicare enrollment information to correct this problem. Call the Customer Service Representative at your Medicare carrier, FI, or A/B MAC enrollment staff or your DME MAC to discuss your situation and, if necessary, have it investigated. Have a copy of your NPPES record or your NPI Registry record available. The contractor telephone numbers are likely to be quite busy, so don't wait.
Doing this testing now will allow time for any needed corrections prior to May 23, 2008, the date when only the NPI will be accepted in all provider fields.
03.12.08 MM5890 - Additional Information on Reporting an NPI for Ordering/Referring and Attending/Operating/Other/Service Facility for Medicare Claims
Effective with claims received on or after May 23, Medicare will not pay for referred or ordered services or items; unless the fields for the name and NPI of the ordering, referring and attending, operating, other, or service facility providers are completed on the claims.
03.05.08 Preparing for Full NPI Implementation in May
With May 23 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 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 deadline when claims must include the NPI only.
03.01.08 March 1 is Milestone for NPI
Effective today, 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!
CMS expects that, as of 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.
Read More about NPI Implementation
02.19.08 Critical NPI Date Approaching for Medicare Blling
Beginning March 1, all Medicare claims must contain a National Provider Identifier. You may submit claims with a legacy number and an NPI or just an NPI, but no longer will Medicare accept claims with just the legacy number. Physicians who bill Medicare and are being paid for claims submitted with both an NPI and a legacy number are strongly urged to test their ability to get paid using just their NPI. To test this, they should submit one or two claims as soon as possible. This step is critical to ensuring that their claims will be processed without interruption beginning March 1.
02.15.08 Are you using the latest Cahaba GBA's EDI application?
CMS now requires that an NPI appear on an EDI application before it can be processed. Cahaba GBA has updated the Medicare Part B EDI application to reflect this change.
Please use this application to change vendors or billing services/clearing houses, or to set up providers initially for electronic claims filing and/or electronic remittance advice. EDI applications received without an NPI will be returned to the provider to be corrected. This will delay getting the provider set up to file electronic claims or to receive electronic remittances. If you have any questions, please contact Cahaba GBA EDI Services at 866.582.3253.
Download Updated EDI Application
01.29.08 Important Information for Medicare Providers: Medicare's Key Dates
There are two key dates remaining for 2008 in Medicare's NPI implementation plan. There is also some confusion as to the difference between the implementation steps for March 1 and May 23.
March 1, 2008 Implementation Steps
- Medicare FFS 837P and CMS-1500 claims must include an NPI in the primary provider fields on the claim (i.e., the billing, pay-to, and rendering provider fields).
- You may continue to submit NPI/legacy pairs in these fields or submit only your NPI on the claim. You may not submit claims containing only a legacy identifier in the primary provider fields.
- Failure to submit an NPI in the primary provider fields will result in your claim being rejected or returned as unprocessable.
- Until further notice, you may continue to include legacy identifiers only for the secondary provider fields.
Key Point: Claims with only legacy identifiers in the primary provider fields will be rejected.
May 23, 2008 Implementation Steps
- In keeping with the Contingency Guidance issued on April 2, 2007, CMS will lift its NPI contingency plan, meaning that only the NPI will be accepted and sent on all HIPAA electronic transactions (837I, 837P, NCPDP, 276/277, 270/271 and 835), paper claims and SPR remittance advice. (Note that this date is one day earlier than that mandated by the National Enforcement Policy)
- 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.
Key Point: If the claim contains a legacy identifier in any field, it will be rejected.
01.29.08 Industry-Wide Enforcement of the NPI Compliance Date
The compliance date for the NPI for all HIPAA covered entities except small health plans was May 23, 2007. (Small health plans have until May 23, 2008 to comply.) Last year CMS announced that, through May 23, 2008, it would not impose penalties on covered entities that deploy contingency plans to facilitate the compliance of their trading partners. On May 24, 2008, CMS will lift its enforcement-leniency policy. Complaints will be investigated as they are today, but penalties will be a legitimate resolution if the entity does not demonstrate compliance or corrective action. CMS will continue to employ a complaint-driven approach to enforcement. For example, if a complaint is received alleging a failure to comply with the NPI requirements, CMS will contact the entity to secure evidence of compliance and the contingency plan that had been in place. If violations are identified, enforcement actions will take place.
This notice does not prohibit covered entities from lifting contingency plans prior to May 24, 2008.
In sum, no later than May 24, 2008, all covered entities are expected to be using the NPI in a compliant manner, and all contingency plans should be lifted.
01.29.08 NPPES and the NPI Enumerator: Misconceptions & Facts
In conversations and correspondence with health care providers, health plans, and others within the health care industry, it is very clear that there are misconceptions concerning the National Plan and Provider Enumeration System (NPPES) and the NPI Enumerator.
View Misconceptions & Facts
12.21.07 Reminder: NPI Requirement on Medicare Electronic and Paper Institutional Claims Begins January 1st!
Effective 01.01.08, 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 01.01.08. (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 05.23.08, if you choose.
Urgent: Test Your Claims Now! After you have submitted claims containing both NPIs and legacy identifiers and those claims have been paid, Medicare urges you to send a small batch of claims now with only the NPI in the primary provider fields. If the results are positive, begin increasing the number of claims in the batch.
(Reminder: For institutional claims, the primary provider fields are the Billing and Pay-to Provider fields. For professional claims, the primary provider fields are the Billing, Pay-to, and Rendering Provider fields. If the Pay-to Provider is the same as the Billing Provider, the Pay-to Provider does not need to be identified.)
11.27.07 Important NPI Compliance Dates for Medicare Providers
As of Oct. 29, 2007, all Medicare contractors have lifted the bypass logic and are editing against the Medicare crosswalk. As a result, claims that include non-matching NPIs and legacy identifiers are now being rejected. The following table is a review of the next set of dates which are crucial for compliance with the NPI regulations.
Jan. 1, 2008
- 837I 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.
March 1, 2008
- Medicare FFS 837P and CMS-1500 claims must include an NPI in the primary fields on the claim (i.e., the billing, pay-to, and rendering fields).
- You may continue to submit NPI/legacy pairs in these fields or submit only your NPI on the claim. You may not submit claims containing only a legacy identifier in the primary fields.
- Failure to submit an NPI in the primary fields will result in your claim being rejected or returned as unprocessable.
- Until further notice, you may continue to include legacy identifiers only for the provider secondary fields.
May 1, 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 and sent 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 also will stop sending legacy identifiers on COB crossover claims at this time.
11.26.07 NPI Registry Now Available for Medicare Providers
The NPI Registry enables you to search for a provider's NPPES information. All information produced by the NPI Registry is provided in accordance with the NPPES Data Dissemination Notice. You may run simple queries to retrieve this read-only data. For example, users may search for a provider by the NPI or Legal Business Name. There is no charge to use the NPI Registry.
View NPI Registry
11.13.07 Important NPI Information for Medicare Providers
As it gets closer to May 23, 2008, be sure to pay attention to information from Medicare and other health plans regarding NPI implementation timelines.
View Summary of Key NPI Dates
11.02.07 Requirement to Update Information in the National Plan and Provider Enumeration System (NPPES)
Health care providers who are covered entities under HIPAA are required by the National Provider Identifier (NPI) Final Rule to update their NPPES data. The Final Rule [at (162.410(a)(4)] states that covered health care providers must notify the NPPES of changes in their required NPPES data elements within 30 days of the changes. Failure to provide updated information may be considered an act of non-compliance with the NPI regulation, and a complaint may be filed against covered health care providers who do not comply with this provision, or any other provisions of the rule.
Read More NPI Updates
10.12.07 Important NPI and Enrollment Information for Physicians and Non-Physician Practitioners
By October 31, 2007, all Medicare carriers (and A/B MACs that service providers who formerly billed carriers) will be rejecting Part B claims if they are unable to "match" a NPI and a PIN combination submitted on a claim to an NPI/PIN combination in the Medicare NPI crosswalk. The NPI/PIN combination may be used to identify the Billing, Pay-to, or Rendering Provider (the Pay-to Provider is identified only if it is different from the Billing Provider). This applies to 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.
10.12.07 What to Do if Claims Are Rejected
Read Cahaba GBA's Tips
10.12.07 Medicare Fee-For-Service (FFS) National Provider Identifier (NPI) Final Implementation
MM5728 –Medicare Fee-For-Service (FFS) National Provider Identifier (NPI) Final Implementation This article is based on CR5728, which describes the policy change brought about as a result of the Health Insurance Portability and Accountability Act (HIPAA) of 1996, that requires issuance of a unique national provider identifier (NPI) to each physician, supplier, and other provider of health care who conducts HIPAA standard electronic transactions. Once CMS ends its’ NPI contingency, the legacy number will NOT be permitted on any inbound electronic and outbound electronic transaction (there are exceptions to the 835 remittance advice (see CR5452)). Medicare contractors will begin rejecting claims, electronic, including direct data entry, that contain legacy provider numbers for any primary provider instead of or in addition to the NPI number.
Read More
10.10.07 NPI Vs. Legacy IDs Editing Begins October 15
Since October 2, 2006, providers have been encouraged to submit both the NPI and Medicare legacy identifier (PIN) on their claims. During this timeframe providers were not penalized for invalid NPI/legacy ID combinations.
Effective October 15, Cahaba GBA Part B, will begin editing the NPI/legacy ID combinations for validity against the NPI crosswalk file. Where a match cannot be located on the crosswalk, claims will be rejected or returned to the provider.
When the claim is returned, a provider should first verify that the correct NPI was submitted. If correct, you will need to verify that your legacy identifier (PIN or NSC) number corresponds with the information on file with the National Plan and Provider Enumeration System (NPPES). NPPES data may be checked on line at https://nppes.cms.hhs.gov.
If your NPPES information is correct and you have included and matched ALL Medicare legacy identifiers with a corresponding NPI in NPPES, but you are experiencing provider identifier problems with your claims that contain an NPI, you may need to submit a Medicare enrollment application (i.e., the CMS-855). If you have any questions, please contact the Provider Contact Center for Georgia at: 1.877.567.7271.
Cahaba GBA suggests that submitters send a small batch of claims with an NPI only to validate the legacy selected to match with the NPI is correct. The CMS has been told that some submitters do not have this capability, but it would be a helpful tool to detect problems early without effecting cash flow.
09.14.07 Starting Oct. 1, Medicare Policy Allows for Missed Appointment Charges
Beginning October 1, the Center for Medicaid and Medicare Services policy is to allow physicians and suppliers to charge Medicare beneficiaries for missed appointments. Medicare itself does not pay for missed appointments, so charges should not be billed to Medicare.
Providers may not charge only Medicare patients for missed appointments; they must also charge non-Medicare patients. Additionally, the charge for missed appointments must be the same for all patients (Medicare and non-Medicare).
09.11.07 AMA and MGMA Wants CMS to Turn Off NPI Edits
As of September 4, Medicare has started to "turn on" the edits that previously allowed carriers to correct billing or pay-to provider information submitted on Medicare claims submitted by group practices, which may cause a significant administrative burden for the physician practice. The AMA along with MGMA is aggressively advocating for the Centers for Medicare and Medicaid Services to reverse this policy.
Read Letter Sent to CMS
09.04.07 National Plan and Provider Enumeration System FOIA-Disclosable Data Becomes Available
NPPES health care provider data that is disclosable under the Freedom of Information Act (FOIA) will now be disclosed to the public by the Centers for Medicare & Medicaid Services (CMS). In accordance with the e-FOIA Amendments, CMS is disclosing this data via the Internet. Data is available in two forms:
- A query-only database, known as the NPI Registry
- A downloadable file
The NPI Registry became operational on September 4 and the downloadable file will be ready approximately one week later. CMS has posted several documents to help providers understand what the downloadable file looks like, including a "Read Me" file, Header File, and Code Value document for the downloadable file.
View NPPES Downloadable File
09.07.07 AMA Alert: Medicare starting to reject claims with NPI discrepancies
The AMA is alerting physicians that Medicare must be able to match a physician's appropriate PIN to his or her correct National Provider Identifier (NPI)-and may reject claims if a match can't be made. Prior to Sept. 4, most Medicare carriers permitted claims to process through their computer systems even if an appropriate match between the physician's NPI number and their old legacy billing number(s) couldn't be made. However, as of Sept. 4, Medicare has started to "turn on" the edits that previously allowed these claims to process.
The AMA strongly encourages physicians to immediately check with their billing office to determine what, if any, error reason codes have been returned over the summer. These codes could indicate an NPI mismatch in the Medicare system. And, physicians who use a clearinghouse should check to ensure that the NPI or these reason codes are not being stripped off of their claims.
NOTE: Medicare must be able to match single, incorporated physicians-those who have an LLC or other incorporated business arrangement. These physicians must have two NPIs-one for themselves and one for their corporation. In some cases Medicare may have originally assigned these physicians one PIN rather than the two that are now needed to match a physician to his or her correct NPI number. In these cases, re-enrollment in Medicare is required. In addition, physicians in large group practices who may have multiple Medicare PINs could also experience claims interruptions if there are matching problems.
The AMA is aggressively advocating for the Centers for Medicare and Medicaid Services to alleviate the significant administrative burden these developments will place on physician practices. The AMA is also working to get physicians more time to re-enroll in Medicare so they can obtain the appropriate PIN and avert claims processing interruptions.
09.04.07 Invalid NPI/legacy Combinations will be Rejected Starting Oct. 15
Since October 2, 2006, providers have been encouraged to submit both the NPI and Medicare legacy identifier (PIN) on their claims. During this timeframe providers were not penalized for invalid NPI/legacy ID combinations.
Effective October 15, 2007, Cahaba GBA Part B, will begin editing the NPI/legacy ID combinations for validity against the NPI crosswalk file. Where a match cannot be located on the crosswalk, claims will be rejected or returned to the provider.
When the claim is returned, a provider should first verify that the correct NPI was submitted. If correct, you will need to verify that your legacy identifier (PIN or NSC) number corresponds with the information on file with the National Plan and Provider Enumeration System (NPPES).
If your NPPES information is correct and you have included and matched ALL Medicare legacy identifiers with a corresponding NPI in NPPES, but you are experiencing provider identifier problems with your claims that contain an NPI, you may need to submit a Medicare enrollment application (i.e., the CMS-855). If you have any questions, please contact the Provider Contact Center servicing your state at:
- Alabama: 866.539.5598
- Georgia: 877.567.7271
- Mississippi: 866.419.9454
Check Your NPPES Data Online
09.03.07 Systems will begin to reject claims with improper NPIs
Starting September 3, Medicare carriers and DME MACs will begin transitioning their systems to start rejecting claims when the NPI and Legacy Provider Identifier cannot be found on the Medicare Crosswalk.
Since May 29, Medicare Fiscal Intermediaries, as well as Part B CIGNA Idaho and Tennessee, have been validating NPIs and Legacy Provider Identifier pairs submitted on claims against the Medicare NPI Crosswalk. Between the period of September 3 and October 29, all other Part B carriers and DME MACS will begin to turn on edits to validate the NPI/Legacy pairs submitted on claims. If the pair is not found on the Medicare NPI crosswalk, the claim will reject. Contractors have been instructed to inform providers at a minimum of 7 days prior to turning on the edits to validate the NPI/Legacy pairs against the Crosswalk.
If you are receiving informational edits today, CMS strongly urges you to validate that the NPPES has ALL of the NPI and legacy numbers you intend to use on claims and for billing purposes. If NPPES is correct, and you continue to receive information edits, you should ask your contractor to validate the provider information in their system. If the contractor information is not correct, you may be instructed to submit an enrollment form or CMS-855. Please include ALL of your NPI/Legacy numbers in NPPES AND all of your NPIs that are to be used in place of your legacy on the CMS-855. If the information is different in the two systems, there is a very good chance your claim will reject.
Verify NPPES Data
08.01.07 NPI Registry Delayed Until September 4
The NPI Registry, a query-only database, which was expected to be operational starting August 1 has been delayed until September 4. In order to ensure edits are reflected in the NPI Registry when it first becomes operational and in the first downloadable file, health care providers need to submit their edits no later than Monday, August 20. Health care providers who submit edits on paper need to ensure that they are mailed in time for receipt by the NPI Enumerator by that date.
The NPI Registry will operate in a real-time environment. This means that FOIA-disclosable data for newly enumerated providers, as well as updates and changes to enumerated providers' FOIA-disclosable data, will be available in the NPI Registry as that information is applied to NPPES. The NPI Registry will enable a user to query by, for example, NPI or provider name, and will return a list of all NPPES records that meet the query specifications. The user selects from that list the NPPES records he/she wants to see. The NPI Registry will then display the FOIA-disclosable data for those records. About a week later, CMS will make available a file for downloading that will contain the FOIA-disclosable NPPES data of enumerated health care providers. Technical expertise will be required to download that file and to import that data into a relational database or to otherwise manipulate the data.
Click Here for Additional Information
07.24.07 Potential Issues Related to Clearinghouse Practices
CMS is warning that some Clearinghouses are stripping the National Provider Identifier (NPI) off the claim prior to its submission to Medicare. This could adversely affect Medicare providers in two ways. First, providers may be under the false impression that their claims are being successfully submitted to Medicare, through their clearinghouse, using an NPI. Second, without the NPI, these claims will not count toward PQRI participation for Eligible Professionals. Stripping of NPIs may also be occurring even though the NPI appears on remittance advice because some clearinghouses are adding the NPI to the remittance prior to sending to the provider. CMS urges Medicare providers that use clearinghouses to check with their clearinghouse to assure NPIs are not being stripped from claims. If the provider determines that their clearinghouse is stripping NPIs from the claim, the provider may wish to consider other billing options.
CMS has also become aware that some clearinghouses are not forwarding to providers NPI informational claim error messages being sent by Medicare carriers. Providers who use clearinghouses should make sure they are in fact receiving NPI informational claim error messages so that issues can be addressed timely.
07.17.07 NPI/Legacy Provider Mismatch Warning Edits
Cahaba GBA, LLC, is now issuing warning edits on audit trail reports when a legacy provider number is submitted on an electronic claim along with an NPI and the NPI used does not match the NPI Cahaba has in its system for that legacy provider number. While these claims are not being rejected it is important that you resolve these edits as quickly as possible. Due to the limitations of the warning editing system, you may not get this warning message on all of your claims.
View PDF
06.06.07 NPI/Legacy Provider Mismatch Warning Edits
Cahaba GBA, LLC, is now issuing warning edits on audit trail reports when a legacy provider number is submitted on an electronic claim along with an NPI and the NPI used does not match the NPI we have in our system for that legacy provider number. While these claims are not being rejected it is important that you resolve these edits as quickly as possible.
View PDF
06.04.07 Stage 3 NPI Changes for Transaction 835 and Standard Paper Remittance Advice
Be aware that Stage 3 of the NPI implementation is nearing. Make sure you have your NPI, know how to use it, and are prepared to receive it back in your remittance advice processes. This article gives advice on how to make sure your staff is aware of how the NPI implementation impacts the remittance advice transactions you receive.
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06.04.07 Unique Physician Identification Number Discontinuance
This article is based on Change Request (CR) 5584 which announces that the Centers for Medicare & Medicaid Services (CMS) will discontinue assigning Unique Physician Identification Numbers (UPINs) on June 29, 2007. The National Provider Identifier (NPI) is a requirement of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), and the NPI will replace the use of UPINs and other existing legacy identifiers.
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06.04.07 CMS-1500 Claim Form (8/05) New Submission Deadline
The Form CMS-1500 is the paper claim form that physicians and suppliers, who qualify for an exemption from the mandatory electronic claims submission requirements (as set forth in the Administrative Simplification Compliance Act, Public Law 107-105 (ASCA) and the implementing regulation at 42 CFR 424.32), use to submit claims. Therefore, CR 5616, from which this article is taken, announces, based on the information at hand, that beginning July 2, 2007, you will need to submit claims using the Form CMS-1500 (08-05).
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05.23.07 The NPI Compliance Deadline is Here!
At this point, any covered entity that is noncompliant, and has not implemented a contingency plan, is at risk for enforcement action. As this guidance pertains to claims transactions, it means that:
- Providers must have and use their NPI;
- Clearinghouses must accept and use NPIs; and
- Health plans must accept and send NPIs in claims transactions.
Providers should be:
- Aware of contingency plans for any health plans they bill. Contingency plans may differ by health plan.
- Aware that health plans may lift their contingency plans (and require an NPI on claims or other HIPAA transactions) any time before May 23, 2008.
- Working with vendors and clearinghouses with whom they contract, to make sure the NPI is being passed to health plans.
- Paying close attention to how and when health plans will be testing implementation of the NPI.
- Aware that, for those health plans that did not establish a contingency plan, providers are required to use their NPIs now. This means that if you are not using your NPI, your claim may be rejected or denied.
Read Tip Sheet
04.27.07 NPI Update
The Centers for Medicare & Medicaid Services (CMS) has posted its new compliance contingency guidance FAQs. Medicare providers should pay special attention to the Medicare information section in the document for important news on the Medicare FFS Contingency Plan.
View PDF
04.16.07 Reminder from the National Association of Chain Drug Stores
Georgia's community pharmacies have significant concerns about the potential disruption to patient care posed by state implementation of the National Provider Identifier (NPI) on May 23, 2007. CMS has authorized states to accept a legacy number for prescribers for up to 12 months. In states like Georgia that have not committed to allowing prescribers to use traditional identifiers in transition, many patients may be unable to obtain their prescriptions because pharmacies might not have on file valid, tested, prescriber NPIs.
Pharmacies without valid prescriber NPIs at point-of-sale could be forced to weigh the ongoing provision of uncompensated services against the continuing health care needs of the patient(s) before them. The NACDS urges physicians to obtain valid NPIs in time for use on May 23.
04.04.07 NPI Update
The Centers for Medicare & Medicaid Services (CMS) announced that it is implementing a contingency plan for covered entities (other than small health plans) who will not meet the May 23, 2007, deadline for compliance with the National Provider Identifier (NPI) regulations under the Health Insurance Portability and Accountability Act (HIPAA) of 1996.
Letter from AMA President
Read Compliance Rule
03.29.07 NPI Update
Provider Outreach and Education has scheduled three NPI educational events during the month of April.
View PDF
02.28.07 NPI Update
There are less than 90 days left between today and the NPI compliance date of May 23, 2007. It is estimated that it may take at least this much time to implement the NPI into your business practices. Failure to prepare could result in a disruption in cash flow. Will you be ready to use your NPI? Time is running out!
View PDF
02.01.07 Only 20 Percent Have Applied for NPI
Only 20 percent of Georgia's Medicaid providers have applied for their NPIs! Georgia Medicaid will comply with federal regulations and begin using the National Provider Identifier (NPI) as the provider identifier on all standard transactions on or before the May 23, 2007 compliance date.
View PDF
Submittal Form
01.11.07 Entering NPIs into PC-ACE
After upgrading to version 1.76 you may enter your NPI information into PC-ACE. To do so:
- Start PC-ACE
- Click on Reference File Maintenance (The button with the picture of the folder with the sheet of paper)
- Click on the “Provider” tab
- Double click on each provider number listed to bring up the provider information screen
- For each provider that has an NPI assigned enter the NPI in the field labeled “NPI”, on the right side of the screen between “Group Label” and “Tax ID/Type.” Enter the NPI for each provider who has been assigned one, including group numbers.
Call EDI Services at 866.582.3253 if you have any questions.
01.04.07 Medicare Fee for Service Implementation of the National Provider Identifier
On May 23, 2007, the NPI will replace health care provider identifiers that are in use today in HIPAA standard transactions. It is estimated that, once a provider obtains an NPI, it may take up to 120 days to implement the NPI in current business practices. Following the key points in this article will assist Medicare providers as they transition from the application stage to the implementation stage to ensure NPI readiness.
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01.01.07 NPI: Get It. Share It. Use It.
Only five months remain until the NPI compliance date - are you ready to use your NPI? A recent survey of the health care industry, conducted by the Workgroup for Electronic Data Interchange (WEDI), indicates that providers should be moving from the enumeration stage into the implementation stage to ensure NPI readiness by the compliance date. Remember, it is estimated that it may take up to 120 days to complete the work needed in order to implement the NPI into your current business practices. The following steps will assist you in your preparation:
- Enumerate: Have you applied for your NPI(s)? Not only should individual providers (Type 1) have enumerated, but organizations and subparts (Type 2) should have enumerated also.
- Update: Have you received your software application updates, upgrades and/or changes relevant to NPI? Be sure that the updates not only addresses the HIPAA Transactions, but includes the CMS1500, UB04 and/or Dental claim form changes.
- Communicate: Have you communicated your NPI(s) to your health plans and other organizations you work with? Keep in mind, as outlined in current regulation, all covered providers must share their NPI with other providers, health plans, clearinghouses, and any entity that may need it for billing purposes -- including designation of ordering or referring physician.
- Collaborate: Do you know the readiness of your trading partners (such as health plans, TPAs, clearinghouses, etc...)? It's important to work with your trading partners to know their readiness with NPI and how it impacts you.
- Test: Have you started testing the NPI, both internally and externally? Not only do you need to test the HIPAA Transactions such as 837 Claims, but if you process 835 Remittance Advice, be sure to test that your system can process the NPI appropriately. Also, if you submit paper claims, be sure that you've tested the data being printed in the correct fields.
- Educate: Have you educated your staff on what the NPI is and the use of it? It's important that staff who may be using the NPI in day-to-day work, such as verification of eligibility, or other tasks that may need the NPI, be aware of the NPI and the provider identifiers that it replaces. The staff may have to change policies and procedures.
- Implement: Have you implemented the NPI into your business practices? Once testing is complete, changes will go into production. Prior to doing this, you'll need to make sure your trading partners are ready to process with the NPI only.