NPI crosswalk

NPI and Legacy Identifiers

The NPI 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.

Beginning May 23, 2007 (May 23, 2008, for small health plans), the NPI must be used in lieu of legacy provider identifiers.

Legacy provider identifiers include:

• Online Survey Certification and Reporting (OSCAR) system numbers;

•  National Supplier Clearinghouse (NSC) numbers;

• Provider Identification Numbers (PINs); and

• Unique Physician Identification Numbers (UPINs) used by Medicare.

They do not include taxpayer identifier numbers (TINs) such as:

• Employer Identification Numbers (EINs); or

• Social Security Numbers (SSNs).

Primary and Secondary Providers

Providers are categorized as either “primary” or “secondary” providers:

• Primary providers include billing, pay-to, rendering, or performing providers. In the DME MACs, primary providers include ordering providers.

• Secondary providers include supervising physicians, operating physicians, referring providers, and so on.

Crosswalk

During Stage 2, Medicare will utilize a Crosswalk between NPIs and legacy identifiers to validate NPIs received in transactions, assist with population of NPIs in Medicare data center provider files, and report NPIs on remittance advice (RA) and coordination of benefit (COB) transactions.

Key elements of this Crosswalk include the following:

• Each primary provider’s NPI reported on an inbound claim or claim status query will be cross-walked to the Medicare legacy identifier that applies to the owner of that NPI.

• The Crosswalk will be able to do a two-directional search, from a Medicare legacy identifier to NPI, and from NPI to a legacy identifier.

• The Medicare Crosswalk will be updated daily to reflect new provider registrations.

Worker compensation - Some standard definition 

k) “Duplicate bill” means a bill that is exactly the same as a bill that has been previously submitted with no new services added, except that the duplicate bill may have a different “billing date.”

(l) "Electronic Standard Formats" means the ASC X12N standard formats developed by the Accredited Standards Committee X12N Insurance Subcommittee of the American National Standards Institute and the retail pharmacy specifications developed by the National Council for Prescription Drug Programs (“NCPDP”) identified in Section Two - Transmission Standards, which have been and adopted by the Secretary of Health and Human Services under HIPAA.. See the Companion Guide for specific format information.

(m) “Explanation of Review” (EOR) means the explanation of payment or the denial of the payment using the standard code set found in Appendix B – 1.0. EORs use the following standard codes:

(1) DWC Bill Adjustment Reason Codes provide California specific workers? compensation explanations of a payment, reduction or denial for paper bills. They are found in Appendix B – 1.0 DWC Bill Adjustment Reason Code / CARC / RARC Matrix Crosswalk.

(2) Claims Adjustment Group Codes represent the general category of payment, reduction, or denial for electronic bills. The most current, valid codes should be used as appropriate for workers? compensation. These codes are obtained from the Washington Publishing Company http://www.wpc-edi.com.

(3) Claims Adjustment Reason Codes (CARC) represent the national standard explanation of payment, reduction or denial information. These codes are obtained from the Washington Publishing Company http://www.wpc-edi.com. A subset of the CARCs is adopted for use in responding to electronic bills in workers? compensation in Appendix B – 1.0 DWC Bill Adjustment Reason Code / CARC / RARC Matrix Crosswalk.

(4) Remittance Advice Remark Codes (RARC) represent supplemental explanation for a payment, reduction or denial. These are always used in conjunction with a Claims Adjustment Reason Code. These codes are obtained from the Washington Publishing Company http://www.wpc-edi.com. A subset of the RARCs is adopted for use in responding to electronic bills in workers? compensation in Appendix B – 1.0 DWC Bill Adjustment Reason Code / CARC / RARC Matrix Crosswalk.

(n) "Health Care Provider" means a provider of medical treatment, goods and services, including but not limited to a physician, a non-physician or any other person or entity who furnishes medical treatment, goods or services in the normal course of business.

(o) “Health Care Facility” means any facility as defined in Section 1250 of the Health and Safety Code, any surgical facility which is licensed under subdivision (b) of Section 1204 of the Health and Safety Code, any outpatient setting as defined in Section 1248 of the Health and Safety Code, any surgical facility accredited by an accrediting agency approved by the Licensing Division of the Medical Board of California pursuant to Health and Safety Code Sections 1248.15 and 1248.4, or any ambulatory surgical center or hospital outpatient department that is certified to participate in the 

Medicare program under Title XVIII (42 U.S.C. Sec. 1395 et seq.) of the federal Social Security Act.

(p) “Itemization” means the list of medical treatment, goods or services provided using the codes required by Section One – 3.0 to be included on the uniform billing form.

(q) “Medical Treatment” means the treatment, goods and services as defined by Labor Code Section 4600.

(r) “National Provider Identification Number” or “NPI” means the unique identifier assigned to a health care provider or health care facility by the Secretary of the United States Department of Health and Human Services.

Account Receivable - New provider

When a new provider has joined the group, we need to ensure the following:

Does the provider have all the credentials?

Does the provider have a State License? Without State License the doctor cannot perform in that State.

Does the provider have a contract with major carriers in the State? 

If so we can just write a letter to the carrier saying that this provider has joined the group and request them to merge the provider with the group.

Where the provider does not have a contract with a carrier, a fresh application for enrollment is required.

A Fresh application in Form 855 is filled and signed by the doctor and sent to the carrier. This form should be filled up with details such as the doctor’s name, his Social Security Number (SSN), his State License Number, the name and address of the facility in which he is or will be providing services, the name and address of the group of which he has become a member, the name of the owner of the group, the pay-to address of the group etc.

The carrier processes it and sends in intimation mentioning the provider #. This provider # becomes the individual provider # for that doctor and needs to be stated in Box 24j and Box 33-PIN # in the CMS.

Box 33 of the CMS also contains the Pay-to address where the checks and EOBs need to be sent by the carriers. But Medicare and Medicaid do not go by what is mentioned in this box with regard to pay-to address. Based on the pay-to address mentioned in Form 855 at the time of enrollment the carrier records it in its system. All checks and EOBs will be sent to this address. If there is a change of address, the carriers need to be notified in Form 855-C. Based on this, the carriers update this information in their system.

In this regard the following terms need to be understood:

Employer Identification Number (EIN): This is a tax identification (tax id) number of the group into which the doctor has joined. This number is allotted by the IRS for the purpose of submitting the tax returns. The group needs to show this number in all claim forms and correspondence with the carrier.

W-9 Form: This is a “Request for tax payer identification number and certification” form. This shows the provider’s individual tax id # (SSN) or the group tax id # (EIN) along with the pay-to address. This can be used for updating the tax id # and the pay-to address with the carriers. This should be signed by the provider.

Also do the NPI crosswalk.

Account Receivable specialist

Account receivable billing

Account receivable new provider

Account receivable reports

Account receivable common terms

Account receivable aging follow up