Medicare and National Provider Identifier (NPI)

The National Provider Identifier (NPI) is a Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification Standard. The NPI number is a unique identification number for covered health care providers. Covered health care providers and all health plans and health care clearinghouses will use the NPIs in the administrative and financial transactions adopted under HIPAA. The NPI number is a 10-position, intelligence-free numeric identifier (10-digit number). This means that the numbers do not carry other information about healthcare providers, such as the state in which they live or their medical specialty.

(Content for this section courtesy of Centers for Medicare & Medicaid Services)

AdvancedMD is NPI ready, even if you're not

AdvancedMD recently delivered a notice to all HBMA members nationwide regarding AdvancedMD's compliance and readiness concerning National Provider Identifier numbers for enterprise-class medical billing services.

Revised NPI Application Form June 28, 2007

The NPI Application/Update Form was revised and can now be downloaded from the CMS Web site. To access the revised form or for more information, visit the CMS NPI Web site.

Still unsure of what an National Provider Identifier / NPI is and why you need it? More information can be found below or at the CMS NPI page on the CMS website. Care Providers can apply for an NPI online or can call the NPI enumerator to request a paper application at 800-465-3203.

CMS Approves Plan April 24, 2007

As expected, the Centers for Medicare and Medicaid Services (CMS) has announced a contingency plan for the NPI implementation. This general announcement applies to all health plans. Each plan, including Medicare and Medicaid, is responsible for announcing their plan specific arrangements. Below is the Medicare specific plan.

The contingency plan announced by CMS largely follows the recommendations made by the HBMA and the National Committee on Vital and Health Statistics in a letter to HHS Secretary Michael Leavitt.

Details of the announcement are contained in a CMS document entitled, "Guidance on Compliance with the HIPAA National Provider Identifier (NPI) Rule After The May 23, 2007, Implementation Deadline".

According to the press release issued at the time of the announcement, "The enforcement guidance released today clarifies that covered entities that have been making a good faith effort to comply with the National Provider Identifier / NPI provisions may, for up to 12 months, implement contingency plans that could include accepting legacy provider numbers on HIPAA transactions in order to maintain operations and cash flows."

The final rule establishing the NPI as the standard unique health provider identifier for health care providers was originally published in 2004 and requires all covered entities to be in compliance with its provisions by May 23, 2007, except for small health plans, which must be in compliance by May 23, 2008.

(Content for this section courtesy of the Healthcare Billing & Management Association)

NPI Contingency Update April 23, 2007

For some period after May 23, 2007, Medicare FFS will allow continued use of legacy NPI numbers; it will also accept transactions with only NPIs, and transactions with both NPI and legacy identifiers.

After May 23, 2008, the legacy number will NOT be permitted on any inbound or outbound transaction. Medicare FFS has been assessing health care provider submission of NPI numbers on claims submitted. As soon as the number of claims submitted with an NPI for primary providers is sufficient to do so, Medicare will begin rejecting claims without an NPI for primary providers following appropriate notice.

In May 2007, Medicare FFS will evaluate the number of submitted claims containing a NPI number. If the analysis shows a sufficient number of submitted claims contain a NPI, Medicare will begin to reject claims on July 1, 2007, that do not contain NPIs.

If a sufficient number of claims do not contain NPIs in the May analysis, Medicare FFS will assess compliance in June 2007 and determine whether to begin rejecting claims in August 2007. Medicare FFS will provide advanced notification to providers, Medicare contractors and the shared systems of the date they are to begin rejecting claims when a decision has been made to do so. That date will supersede all dates announced in previous contractor communications.

CMS recognizes that the National Council for Prescription Drug Program (NCPDP) format permits reporting of only one identifier, and will accept either the NPI or legacy number on the NCPDP format until May 23, 2008.

In regard to the remittance advice and the 837 coordination of benefits (COB) transactions, the following will occur until May 23, 2008:

• If a claim is submitted with an NPI number, the NPI will be sent on the associated 835 remittance advice, otherwise the legacy number will be provided;
• If a claim is submitted with an NPI, the 837 coordination of benefits (COB) transaction will contain both the NPI and the legacy number, otherwise the legacy number will be provided.

By May 23, 2008, the X12 270/271 eligibility inquiry/response supported by CMS via Extranet and Internet must contain the NPI.

Once a decision is made to begin requiring National Provider Identifiers / NPIs on claims, primary providers i.e., billing, pay-to and rendering providers must be identified by their NPIs or the claims will be rejected once the decision is made as indicated above. Medicare contractors must then use the NPI crosswalk to locate the NPI and associated legacy identifier submitted on the claim for primary providers.

All other providers are considered secondary providers and include referring, ordering, supervising, facility, care plan oversight, purchase service, attending, operating and "other" providers. Legacy numbers are acceptable for secondary providers until May 23, 2008.

National Provider Identifier / NPI Contingency

The Centers for Medicare and Medicaid Services (CMS) recently announced a degree of leniency in the NPI final deadline of May 23rd, 2007. This contingency plan for the NPI implementation states that if covered entities (other than small health plans) show indications of good faith (progression towards NPI compliance) after the compliance date of May 23, 2007, CMS will not impose penalties.

Leniency was granted because medical transactions require the participation of two entities, each of whom is required to participate in the NPI process. Non-compliance by one party may result in difficulty of another party to declare full NPI compliance. Additionally, the NPI compliance deadline for small health plans is not until May 23, 2008, which creates additional compliance issues for medical professionals that work with these entities.

CMS states that if medical entities are making 'good faith' strides to implement NPI numbers they will grant leniency. 'Good faith' contingencies may include:

• Increased external testing with trading partners.
• Lack of availability of, or refusal by, the trading partner(s) prior to May 23,2007 for health plans (other than small health plans) to test the transaction(s) with the covered entity whose compliance is at issue.
• In the case of such a health plan, concerted efforts in advance of the May 23, 2007 and continued efforts afterwards to conduct outreach and make testing opportunities available to its provider community.
• For a health care provider, having obtained an NPI and having the ability to use it on HIPAA transactions.

Resources

Whether you’ve had your National Provider Identifier / NPI number for months or are applying for it, AdvancedMD software is NPI compliant and ready to accept the new system at any time. Use both your existing (legacy) number and the NPI number when submitting electronic claims and test transactions with those entities. If you're an AdvancedMD client there is no need to stress about compliancy with new regulations and initiatives, we’re always ready.

Apply for your NPI number as soon as possible. Visit the official registration site for details.

NPI Tips Facts

• AdvancedMD provides NPI capability automatically to AdvancedMD clients at no charge to subscribers.
• Not all payers are ready to accept the NPI number at this time. Use both your existing (legacy) number and the NPI number when submitting electronic claims.
• Notify your payers once you have obtained your NPI number. Test transactions with those entities well before the deadline. If you're an AdvancedMD® client and you don't use McKesson as your clearinghouse, you will need to notify your clearinghouse as well.
• Apply for your NPI number as soon as possible.

HCFA Changes

• Changes in the HCFA 1500 form to accommodate the NPI number take place January 1, 2007. It is optional to use an NPI number on the HCFA form until March 30, 2007. It becomes mandatory April 2, 2007. The new HCFA form will have new fields for identifier numbers on lines 17b, 32a and 33a.