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MIR-2006-10AB, October 2006
MLN Matters. . .Information for Medicare Providers
(Issued by the Centers for Medicare & Medicaid Services)
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Modification of National Provider Identifier (NPI) Editing Requirements in CR4023 and an Attachment to CR4320
Provider Types Affected
Providers, physicians, and suppliers who bill Medicare fiscal intermediaries (FI), including regional home health intermediaries (RHHI), and Medicare carriers including durable medical equipment regional carriers (DMERC) (or durable medical equipment Medicare administrative contractors (DME MAC) if appropriate)
Provider Action Needed
Impact to You
This article is based on CR5229, which corrects certain business requirements from CR4023 that relate to edits for National Provider Identifiers (NPIs) and provider legacy identifiers when reported on claims, particularly for referring/ordering or other secondary providers, effective October 1, 2006 and later. Additionally, CR5229 revises Attachment 1 to CR4320.
What You Need to Know
Some of those business requirements erroneously assumed that any provider for whom information is reported in a claim, including a referring/ordering or other secondary provider, would need to be enrolled in Medicare and therefore listed in the Medicare Provider Identifier Crosswalk. This is not always the case. CR5229 modifies those business requirements.
What You Need to Do
These modifications will enable correct processing of affected claims in MLN Matters Number: MM5229 Related Change Request Number: 5229 October 2006 and later, and will avoid the unnecessary rejection of many claims that involve a referring/ordering or other secondary provider. Please refer to the Background section of this article and to CR5229 for additional important information regarding these modifications.
Background
The Medicare Learning Network (MLN) articles, MM4023 and MM4320 which are based on CR4023 and CR4320 respectively, contain important information about the stages of the NPI implementation process. Some of this information is updated in the current article. The links to these articles are located in the Additional Information section of this article.
The Health Insurance Portability and Accountability Act (HIPAA) of 1996 requires issuance of a unique national provider identifier (NPI) to each physician, supplier, and other provider of health care (45 CFR Part 162, Subpart D (162.402-162.414). To comply with this requirement, The Centers for Medicare & Medicaid Services (CMS) began to accept applications for, and to issue NPIs on May 23, 2005. Applications can be made by mail and online at https://nppes.cms.hhs.gov  .
During Stage 2 of the NPI implementation process (October 2, 2006 - May 22, 2007), Medicare will utilize a Medicare Provider Identifier Crosswalk between NPIs and legacy identifiers to validate NPIs received in transactions, assist with population of NPIs in Medicare data center provider files, and to report NPIs on remittance advice (RA) and coordination of benefit (COB) transactions.
Primary and Secondary Providers
Providers, for NPI provider identifier editing purposes, are categorized as either “primary” or “secondary” providers. Primary providers include billing, pay-to, and rendering providers. Primary providers are required to be enrolled in Medicare for the claim to qualify for payment.
Secondary providers are all other providers for which data could be reported on an institutional (837-I) or professional (837-P), free billing software or direct data entry (DDE) claim, or on a revised CMS-1500 or a UB-04 (once those paper claims are accepted by Medicare). Since the UB-92, the currently used CMS-1500, and the HIPAA NCPDP format do not allow reporting of both NPIs and legacy identifiers, information on secondary providers in those claims is not included in the following requirements. Secondary providers may be enrolled, but are not required to be enrolled in Medicare (unless they plan to bill or be paid by Medicare for care rendered to Medicare beneficiaries).
Secondary Provider Claims
Claims Submitted with NPI and Medicare Legacy Identifier:
During Stage 2, claim submitters should submit a provider’s Medicare legacy identifier whenever reporting an NPI for a provider. Failure to report a Medicare legacy number for a provider enrolled in Medicare could result in a delay in processing of the claim. When an NPI and a legacy identifier are reported for a provider, Medicare contractors will apply the same edits to those numbers that would have been applied if that provider was a primary provider. (See MM4023.)
There are two exceptions:
- A Medicare contractor cannot edit a surrogate Unique Provider Identification Number (sometimes called a dummy UPIN, such as OTN000). Despite its name, a surrogate is not actually unique for a specific provider.
- Only a National Supplier Clearinghouse (NSC) identification number or a UPIN should ever be reported as the legacy numbers on a claim sent to a DMERC/DME MAC. If a carrier Provider Identification Number (PIN) is reported as a legacy identifier with an NPI, DMERCs/DME MACs will edit as if the NPI was the only provider identifier reported for that provider.
Claims Submitted with NPI Only:
The NPI is edited to determine if it meets with the physical requirements of the NPI (ten digits, begins with a 1, 2, 3, or 4, and the check digit in the tenth position is correct), and whether there is a Medicare Provider Identifier Crosswalk entry for that NPI.
If the NPI is located in the Crosswalk:
- The Taxpayer Identification Number (TIN) (Employer Identification Number (EIN) or Social Security Number (SSN) and legacy identifier will be sent to the trading partner in addition to the NPI if coordination of benefits (COB) applies.
- However, only the TIN will be forwarded to the COB payer if there is more than one legacy identifier associated with the same NPI in the Medicare Provider Identifier Crosswalk because it may be difficult to know which Medicare legacy identifier applies to that claim.
If the NPI is not located in the Crosswalk:
- No supplemental identifier can be reported to a COB payer.
- However, the claim will not be rejected if the NPI for a referring/ordering provider or another secondary provider cannot be located in the Medicare Provider Identifier Crosswalk, with one exception. Reporting of a Medicare legacy identifier other than a surrogate UPIN signifies a provider is enrolled in Medicare. If a Medicare legacy identifier is reported and cannot be located in the Crosswalk, the claim will be rejected, regardless of whether an NPI was reported for that provider.
Claims (including UB-92 or the current CMS-1500 paper claims) submitted with Medicare Legacy Identifier Only
- A Medicare contractor may, but is not required to check a legacy number against the Medicare Provider Identifier Crosswalk.
- As at present, claims will be rejected if any Medicare legacy identifier reported on a claim does not meet the physical requirements (length, if numeric or alphanumeric as applicable) for that type of Medicare provider identifier.
COB and Medigap Trading Partners
Legacy identifiers will not be reported to these trading partners for secondary providers if they are not submitted on the claim sent to Medicare, are surrogate UPINs or if the provider is not enrolled in Medicare. If not enrolled, a legacy identifier or a TIN cannot be sent for a “secondary” provider because Medicare would not have issued a legacy identifier to or collected a TIN from that provider.
837-I or 837-P version 4010A1 Claims
Attachment 1 to CR4320 which is being revised as part of CR5229 addresses (among other issues), the identification of secondary providers for which the 837-I or 837-P version 4010A1 implementation guides only require reporting of an NPI or other identifier “if known.” Unless there is a pre-existing Medicare instruction that mandates the reporting of a specific identifier for those “if known” types of providers, there is no requirement for entry of any identifier for those entities/individuals. If there is no such requirement, claims received that lack an identifier for those types of providers will not be denied...
Note that “secondary” providers such as a referring/ordering physician are not required to be enrolled in Medicare as a condition for payment of the services or supplies they order, furnish, supervise delivery of, etc. for beneficiaries when those services are billed, paid-to or rendered by “primary” providers. For example, Medicare could pay:
- A hospital for services ordered for a patient for inpatient hospital care when the admitting or attending physician is not enrolled in Medicare;
- Hospital surgery costs when the surgeon is not enrolled in Medicare; or
- A hospital when services are purchased from another provider “under arrangements” even if that other provider is not enrolled in Medicare.
Implementation Date
The implementation date for this instruction is October 2, 2006.
Additional Information
CR4320, issued February 1, 2006, “Stage 1 Use and Editing of National Provider Identifier Numbers Received in Electronic Data Interchange Transactions, via Direct Data Entry Screens, or on Paper Claim Forms” is located at http://www.cms.hhs.gov/transmittals/downloads/R204OTN.pdf  on the CMSWeb site.
The associated MLN article (with the same title) MM4320, can be found at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM4320.pdf on the CMS Web site.
CR4023, dated November 3, 2005, “Stage 2 Requirements for Use and Editing of National Provider Identifier (NPI) Numbers Received in Electronic Data Interchange (EDI) Transactions, via Direct Data Entry (DDE) Screens, or Paper Claim Forms” is located at http://www.cms.hhs.gov/transmittals/downloads/R190OTN.pdf on the CMS Web site. MM4023, the associated MLN article, is located at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM4023.pdf on the CMS Web site.
CR5229 is the official instruction issued to your Medicare carrier/DMERC (DME MAC if appropriate), FI/RHHI regarding changes mentioned in this article. CR5229 may be found at http://ww.cms.hhs.gov/Transmittals/downloads/R234OTN.pdf on the CMS Web site.
If you have questions, please contact your local Medicare carrier/DMERC (DME MAC if appropriate), or FI/RHHI at their toll-free number, which may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site.
Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.
MLN Matters Number: MM5229
Related Change Request (CR) #: 5229
Related CR Release Date: August 18, 2006
Effective Date: October 1, 2006
Related CR Transmittal #: R234OTN
Implementation Date: October 2, 2006
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