NPI and location question and answer during provider Enrollment

What is NPPES? NPPES stands for the National Plan and Provider Enumeration System. The Center for Medicare and Medicaid Services (CMS) has contracted with Cognosante, L.L.C., to serve as the NPI Enumerator.

Organizations that are health care providers must obtain at least one NPI. Corporations are also eligible for subpart NPIs if they are needed to identify components of their business independently from the “parent” organization. If a corporation provides more than one provider type at the same physical location, an additional NPI will be required to identify the additional provider types separately.

How do I get my NPI? For the most efficient processing and receipt of NPIs, use the NPPES web-based application process. Simply log onto the National Plan and Provider Enumeration System (NPPES) at https://nppes.cms.hhs.gov/NPPES/Welcome.do and apply online.

Am I required to have an NPI for my provider type? Yes, unless you are an atypical provider according to NPPES criteria . Then your atypical provider identifier will be your WV Medicaid Provider ID number.

What about NPIs for different locations and different services. How do we register, can we use one NPI? If the different service locations all pay to the same Pay-To, separate NPIs are not required. If you want separate service locations to be their own Pay-To, they must enroll separately, and need to obtain separate NPIs. If you are a provider who has different provider types at the same location, each provider type will be enrolled separately, and need to obtain a separate NPI. You can access more information on subpart enumeration and separate NPIs at the National Plan & Provider Enumeration System (NPPES) at: https://nppes.cms.hhs.gov/NPPES/Welcome.do

Do we need a separate NPI for 2 provider types in the same location?

If you are a provider who has different provider types at the same location, each provider type will be enrolled with a separate Medicaid provider record, and needs to obtain a separate NPI.

I am an individual who is incorporated. Do I need a group NPI and what do I use as a Pay-To NPI? An incorporated individual should obtain a Type 2 Organizational NPI for the corporation in addition to the Type 1 Individual NPI. The Type 2 Organizational NPI will be used as the Pay-To NPI and the Type 1 Individual NPI will be used to enroll the provider in WV Medicaid as a rendering provider to the organization.

Reporting the NPI on anti-markup and reference laboratory claims

Summary

The Provider Enrollment, Chain, and Ownership System (PECOS) allow the contractor to verify all national provider identifiers (NPIs), regardless of the jurisdiction in which they are enrolled.

Beginning April 1, 2015, physicians and suppliers billing anti-markup and reference laboratory claims must report the national provider identifier (NPI) of the physician or supplier who actually performed the service. This new requirement applies to all claims, including claims for services where the performing provider is out of the processing contractor's jurisdiction.

This article is based on Change Request (CR) 8806, which provides guidance for physicians and suppliers billing anti-markup and reference laboratory claims. Effective for anti-markup and reference laboratory claims submitted with a receipt date on and after April 1, 2015, billing physicians and suppliers are required to report the name, address, ZIP code, and the National Provider Identifier (NPI) of the performing physician or supplier when the performing physician or supplier is enrolled in a different contractor's jurisdiction. Make sure your billing staffs are aware of this update.

The Health Insurance Portability and Accountability Act of 1996 (HIPPA) requires that all covered health care entities follow the same standard for submitting and processing electronic claims transactions. According to the instructions for use of the American National Standards Institute (ANSI) X12 837 professional electronic claim transaction, suppliers must submit the NPI that matches the name and address of the servicing provider/supplier identified on the claim.

On anti-markup and reference laboratory claims, physicians and other suppliers are required to identify the supplier's name, address, and ZIP code in Item 32 of the CMS-1500 claim, or the corresponding loop and segment of the ANSI X12 837 professional electronic claim format. The NPI of the physician or supplier who actually performed the service is required in Item 32a of the CMS-1500 claim form or the corresponding loop and segment of the ANSI X12 837 professional electronic claim transaction.

However, prior to the implementation of the Provider Enrollment, Chain, and Ownership System (PECOS), MACs used systems that were specific to each MAC and did not allow MACs from one State to view provider enrollment information from another State. This systems limitation prevented MACs from being able to share information about existing providers/suppliers, and increased the potential for fraud. As a result, physicians and suppliers that were enrolled in another MAC's jurisdiction could not validate the NPI in Item 32a of the CMS-1500 claim form or on the ANSI X12 837 professional electronic claim format, because the function was not available in PECOS.

Medicare and Medicaid cross over claim - with different NPI

 If a claim is submitted to Medicare and 3 lines pay and 2 deny--will the two denied lines crossover on that claim? 

 If a provider bills multiple lines to Medicare and Medicare pays one or more lines but denies the others, the paid line(s) (as long as there are PRs) will be crossed over to Medicaid and the provider must resubmit the crossover payment as an adjustment to Medicaid to add the additional lines.

What if the deductible causes the claim to be zero paid by Medicare? 

The claim will still be crossed over and the deductible will be paid by Medicaid.

 Are Medicare Part C or Part D claims part of the crossover process? 

No, Part C and Part D claims will not be part of the crossover process.

 What will happen if I bill Medicare with a different NPI than I use to bill Medicaid? 

The NPI that is used on your Medicare claim must be enrolled with NY Medicaid.  Your crossover claims will not be processed if the NPI on your Medicare claim is not enrolled with NY Medicaid. In this case, Medicaid will reject the cross over claim back to Medicare and Medicare will send a notification letter of the rejection to the provider

How do I enroll my NPI with NY Medicaid to take advantage of payments of crossover deductibles and coinsurance? 

Enrollments application can be found on this website under Provider Enrollment. Questions about the enrollment process may be directed to the eMedNY Call Center at 1-800-343-9000.

How to Avoid Provider Identification Errors on Claims

Florida Blue recently made several changes to our claims processing system to comply with HIPAA 5010 requirements. In February 2012, process enhancements were made to ensure that a provider’s National Provider Identifier (NPI) and Tax ID number are matched appropriately.

We have seen an increase in the volume of provider correctable error codes that cause claim processing delays. Below are reminders to help you reduce the number of WEBV040 and WEBV042 claims processing errors displayed when claim data (or information) does not match information registered with Florida Blue

Billing Provider Section

This section is used to provide information regarding the billing provider for services rendered. It should match the name written on the check or electronic funds transfer from Florida Blue.

• OPTION 1: If you are registered as a group provider (PA, LLC, etc.) with Florida Blue and you want to bill as a group provider, enter the appropriate group name, Tax ID number and the group NPI (type 2).

− THE MATCH: Group Name matches Group NPI matches Group Tax ID

Billing NPI and Group NPI - provider number update from Medicaid

Starting in April 2011, electronic Florida Medicaid claims must be submitted with only an NPIin the billing/pay-to provider and the rendering/treating provider loops for providers who are required to obtain an NPI.  Electronic claims that include a Medicaid provider number in these loops will deny as of April 1, 2011.

Some providers are submitting electronic claims with both the Medicaid ID and the NPI on the claim, in the billing/pay-to provider loop and/or the treating/rendering provider loop.  In some cases, the Medicaid ID and NPI being submitted by providers do not match the identifiers that are on the provider’s Medicaid provider file, which will cause problems with claim adjudication when the April 1 changes requiring only an NPI go into effect.  Claims may deny or process for an incorrect provider if the NPI is not associated with the correct Medicaid ID.

To assist providers, claims that are being submitted with mismatched provider numbers in the billing/pay-to provider loop and/or the treating/rendering provider loop are posting the Explanation of Benefits (EOB) 1087, Adjustment Reason Code 208, and Remark Code N521 on paid claims with this problem.  If your paid claims do not post these explanations, stop sending the Medicaid ID on electronic transactions now.  The absence of these explanation codes is an indication that the data you are submitting on claims matches the data on the Medicaid provider file and that your claims will process correctly with only the NPI in these loops.

Rendering NPI vs Billing NPI

What is Rendering NPI and where it will get printed?

If the practitioner rendering the service is part of a billing group, the individual practitioner’s National Provider Identifier (NPI) should be reported in the Rendering Physician # area (2310B loop, segments NM108 [XX] and NM109 [NPI], of the 837P electronic claim or Item 24J of the CMS-1500 paper claim form).

• Note: If you submit claims on the CMS-1500 paper claim form, report the NPI of the individual practitioner in the lower, non-shaded portion of Item 24J. No information should appear in the upper, shaded portion of Item 24J, as your claim will be returned to you as unprocessable.

• The NPI is required for all rendering providers. If the NPI is missing, invalid, or submitted in the wrong area (e.g., valid NPI submitted in the upper, shaded portion of Item 24J), your claims will be returned as unprocessable.

What is Billing NPI and where it will get printed?

The billing entity’s National Provider Identifier (NPI) should be reported in the 2010AA Billing Provider Loop of the 837P electronic claim or Item 33a of the CMS-1500 paper claim form. Do not place any information in the 837P 2010AA loop, REF02 (item 33b of the paper form), as it is no longer used.

Important note: The NPI of the billing provider is required on all claims. Claims will be returned as unprocessable if:

• Any information appears in the 837P 2010AA loop, REF02 (item 33b of the paper form). This item should be left blank.

• The billing provider’s NPI is missing, invalid, or is located in the wrong area (e.g., valid NPI submitted in Item 33b.)

Reminder: When billing services rendered by an individual associated with an incorporated entity or a group, the individual practitioner’s NPI must be reported in the Rendering Physician’s area (the 2310B Rendering Provider Loop of the 837P electronic claim or Item 24J of the paper claim form) and the billing entity or group identifier would be reported as indicated above. 

If billing services for an Independent Lab, Ambulatory Surgical Center (ASC), Independent Diagnostic Testing Facility (IDTF), Ambulance Supplier, or solo practitioner not associated with a group, a rendering provider identifier in Item 24J or loop 2310B is not required.

When do I need to report a rendering provider on my claim?

If your Pay-to provider is a multispecialty or single-specialty group you must declare the NPI of the individual who provided the service in box 24J of the CMS 1500 or in Loop 2310B segment NM109 of the 837P. Please be aware the rendering provider must be an individual that is enrolled with Idaho Medicaid as a part of your group. There are no exceptions to this rule and this will always be required on the claim.

When do I need to report a rendering provider on my claim?

If your Pay-to provider is a multispecialty or single-specialty group you must declare the NPI of the individual who provided the service in box 24J of the CMS 1500 or in Loop 2310B segment NM109 of the 837P. Please be aware the rendering provider must be an individual that is enrolled with Idaho Medicaid as a part of your group. There are no exceptions to this rule and this will always be required on the claim.

On Electronic EMC form

837P Segment/ Data Element 837P Data Element 837P Location/Loop 

Rendering Provider NPI

 Rendering Provider NPI (Service Line Level) Loop 2420A, NM 109 (NM108 = XX)

 Rendering Provider NPI (Claim Level)   Loop 2310B, NM109 (NM108=XX)

Billing Provider NPI Billing Provider NPI Loop 2010AA, NM109 (NM108=XX)

Billing Provider TIN Billing Provider TIN Loop 2010AA, REF02 (REF01=EI)

Billing Health Care Provider Taxonomy Health Care Provider Taxonomy Code Loop 2000A, PRV03 (PRV01=BI)

On UB 04 FORM

The claim level Rendering Provider (Loop ID 2310D) is required when the Rendering Provider is different than the Attending Provider. For Medicare purposes this is required under federal regulatory requirements that call for a “combined claim”, that is, a claim that includes both facility and professional components (Critical Access Hospital Claim billing under Method II, Federally Qualified Health Centers, and Rural Health Clinics). 

The line level Rendering Provider is required when the Rendering Provider for this line is different than the Rendering Provider reported in Loop ID 2310D (claim level). Again, for Medicare purposes this is required under federal regulatory requirements that call for a “combined claim,” that is, a claim that includes both facility and professional components (Critical Access Hospital Claim billing under Method II, Federally Qualified Health Centers, and Rural Health Clinics*).

• Place the line item Rendering Physician National Provider Identifier (NPI) in Form Locator 43 (Revenue Code Description) for the line item that contains the services identified.

Do providers need Type 1 (Individual) and Type 2 (Organizational) NPIs?

A. All eligible individual providers (such as physicians, nurses, chiropractors, and physical therapists) are required to obtain a Type 1 (Individual) NPI. Providers who are in a solo practice and who bill currently with their Social Security Number or sole proprietorship Tax ID number may continue to bill as solo practitioners using only their Type 1 NPI. Per the regulation, individuals who have incorporated their practice must also obtain an organizational Type 2 NPI for their corporation. When billing, the individual Type 1 NPI will  be used to identify the provider who performed the service, while the organizational Type 2 NPI will identify the group or entity to be paid.

Individual health care providers who are part of an incorporated group practice will have an individual Type 1 NPI; the practice or clinic must obtain an organizational Type 2 NPI for the group for claims submission purposes.

Large corporations may have many groups working under a shared Tax ID number as DBAs. Since each DBA has its own BCBSIL billing number, each DBA may consider obtaining and using its own Type 2 NPI to maintain the one-to-one relationship.

Can a group of individual providers who are sharing an office space obtain one Type 1 NPI for all the individual practitioners to share?

A. No. An Individual Type 1 NPI cannot be shared. Each individual health care provider that may render health care services must obtain their own Individual Type 1 NPI. The Type 1 NPI of the rendering provider who performs the service is reported on claims, in addition to the appropriate billing NPI.

If my professional group practice has an Organizational (Type 2) NPI, in addition to my Individual (Type 1) NPI, which NPI number do I submit on claims?

A: To correctly submit 837 Professional Health Care Claims to BCBSIL, the sender’s billing and pay-to provider information must be included in the correct loops. The billing provider’s information must be contained in loop 2010AA, the pay-to provider information must be contained in loop 2010AB, the referring provider information must be contained in loop 2310A, and the rendering provider information must be contained in loop 2310B. To correctly submit 837 Institutional Health Care Claims to BCBSIL, the billing, pay-to provider, attending physician name, operating physician name, service facility name, and other provider name must be included in the correct loops. 

The billing provider’s information must be contained in loop 2010AA, the pay-to provider information must be contained in loop 2010AB, the attending physician name must be contained in loop 2310A, the operating physician name must be contained in loop 2310B, the other provider name must be contained in loop 2310C, and the service facility name must be contained in loop 2310E

IMPORTANT NPI BILLING INFORMATION:

Do not put the rendering provider NPI in the billing loop of the claim. Rendering information must go in the rendering loop and billing information must go in the billing loop. Claims will be rejected if billed incorrectly. 

Q. Where do I include my NPI on the CMS-1500?

A. The following fields are used for entry of the NPI:

Field 17b: Enter the NPI of the referring, ordering, or supervising provider.

Field 24j (unshaded): Enter the NPI of the rendering provider.

Field 32a: Enter the NPI number of the service facility location.

Field 33a: Enter the NPI number of the billing provider.

NOTE: As of May 23, 2008, the use of only the NPI is required on all claims—claims that include the BCBSIL provider number will be rejected

Filing Claims with NPIs

Your NPI is used for claims processing and internal reporting. Claim payments are reported to the Internal Revenue Service (IRS) using your tax identification number (TIN). To appropriately indicate your NPI and TIN on UB-04 and CMS 1500 claim forms, follow the corresponding instructions for each form included in this manual. Remember, claims processing cannot be guaranteed if you have not notified Blue Cross of your NPI, by using one of the methods above, prior to filing claims. See the first part of this section for more details on how to submit claims to Blue Cross.

For more information, including whom should apply for an NPI and how to obtain your NPI, visit our website or CMS’ site at  www.cms.hhs.gov/NationalProvIdentStand. If you have any questions about the NPI relating to your Blue Cross participation, please contact us at 1-800-716-2299, option 3.

Referring Physician NPIs

Referring physician NPIs are required on all applicable claims filed with Blue Cross and HMO Louisiana. Place the NPI in the indicated blocks of the referenced claim forms:

• CMS -1500: Block 17a

• UB-04: Block 78

• 837P: 2310A loop, using the NM1 segment ad the qualifier of DN in the NM101 element

• 837I: 2310D loop, segment NM1 with the qualifier of DN in the NM101 element

For more information on NPIs, visit www.bcbsla.com/providers >NPI.

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

Fastest way of getting NPI

What is the fastest way that I can obtain a National Provider Identifier (NPI) for me or my organization?

The web-based NPI application process is the fastest and most efficient way for a health care provider to obtain an NPI. To apply, go to https://nppes.cms.hhs.gov/nppes.

How should a provider request the National Provider Identifier (NPI) of another provider?

it is very important that health care providers share their NPIs with health plans and with other health care providers who need their NPIs for transaction purposes. For example, providers who refer patients to one another may need to report the referring providers’ NPIs on health care claims. 

NPI

When is an NPI entered in block 32 and how do I share my NPI with Medicare?

Medicare does not require an NPI in block 32a nor a legacy number in 32b. If you are using the new CMS-1500 version 08-05, and if you previously populated boxes 17a (referring provider), 24j (rendering provider), and 33 (billing provider) with your legacy number, you should begin using your NPI also. If the information in block 33 (billing) is different than block 32 (service facility), you should populate block 32 with the address information. There is no need to notify Medicare of your NPI number, you only need to send the number on your claim

Format of NPI

Format of NPI, HOW long it will take, need to enroll Medicare program

How long will it take to get an NPI?

We cannot predict the amount of time it will take to obtain a National Provider Identifier (NPI) because several factors come into play. Such factors include the volume of applications being processed at a given time, whether the application was submitted electronically or on paper, and whether the application was complete and passed all edits. We expect that a health care provider who submits a properly completed electronic application could have its NPI in 10 days.