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MIR-2007 06AB, June 2007
MLN Matters. . .Information for Medicare Providers
(Issued by the Centers for Medicare & Medicaid Services)
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Medicare Fee-For-Service (FFS) National Provider Identifier (NPI) Implementation Contingency Plan (CR# 5595)
Note: This article was revised on April 24, 2007, to reflect changes made to CR5595, which CMS re-issued on April 24. The article was changed to reflect in bold print that “As long as covered entities, including health plans and covered health providers, continue to act in good faith to come into compliance, meaning they are working towards being able to accept and send NPIs, they may establish contingency plans to facilitate the compliance of their trading partners.” The article also has a revised transmittal number, release date, and Web address for accessing CR5595. All other information remains the same.*
Provider Types Affected
Physicians, providers, and suppliers who conduct HIPAA standard transactions, such as claims and eligibility inquiries, with Medicare contractors (carriers, Fiscal Intermediaries, (FI), including Regional Home Health Intermediaries (RHHI), Medicare Administrative Contractors (MAC), Durable Medical Equipment Regional Carriers (DMERC), and DME Medicare Administrative Contractors (DME MAC))
Provider Action Needed
Impact to You
As early as July 1, 2007, Medicare fee-for-service (FFS) contractors may begin rejecting claims that do not contain an NPI for the primary providers.
What You Need to Know
CR 5595, from which this article is taken, announces that (effective May 23, 2007) Medicare fee-for-service (FFS) is establishing a contingency plan for implementing the National Provider Identifier (NPI). In this plan, as soon as Medicare considers the number of claims submitted with an NPI for primary providers (Billing, pay-to and rendering providers) is sufficient, Medicare (after advance notification to providers) will begin rejecting claims without an NPI for primary providers, perhaps as early as July 1, 2007.
What You Need to Do
If you have not yet done so, you should obtain your NPI now. You can apply on line at https://nppes.cms.hhs.gov/  on the CMS Web site. You should also make sure that your billing staffs begin to include your NPI on your claims as soon as possible.
Background
The 1996 Health Insurance Portability and Accountability Act (HIPAA) required that each physician, supplier, and other health care provider conducting HIPAA standard electronic transactions, be issued a unique national provider identifier (NPI). CMS began to issue NPIs on May 23, 2005; and to date, has been allowing transactions adopted under HIPAA to be submitted with a variety of identifiers, including:
- NPI only,
- Medicare legacy only, or
- An NPI and legacy combination.
On April 2, 2007, the Department of Health and Human Services (DHHS) provided guidance to covered entities regarding contingency planning for NPI implementation. As long as covered entities, including health plans and covered health providers, continue to act in good faith to come into compliance, meaning they are working towards being able to accept and send NPIs, they may establish contingency plans to facilitate the compliance of their trading partners. (You can find this guidance on the CMS Web site at: http://www.cms.hhs.gov/NationalProvIdentStand/Downloads/NPI_Contingency.pdf  .)
In CR 5595, from which this article is taken, Medicare fee-for-service (FFS) announces that it is establishing a contingency plan that follows this DHHS guidance. For some period after May 23, 2007, Medicare FFS will:
- Allow continued use of legacy numbers on transactions;
- Accept transactions with only NPIs; and
- Accept transactions with both legacy numbers and NPIs.
After May 23, 2008, legacy numbers will NOT be permitted on ANY inbound or outbound transactions.
As part of this plan, Medicare FFS has been assessing health care provider submission of NPIs on claims. As soon as the number of claims submitted with an NPI for primary providers (Billing, pay-to and rendering providers) is determined sufficient (and following appropriate notice to providers), Medicare will begin rejecting claims that do not contain an NPI for primary providers following appropriate notification. (See Important Information below.)
In May 2007, Medicare FFS will evaluate the number of submitted claims containing a NPI. If this analysis demonstrates a sufficient number of submitted claims contain a NPI, Medicare will begin to reject claims without NPIs on July 1, 2007. If, however, there are not sufficient claims containing NPIs in the May analysis, Medicare FFS will assess compliance in June 2007 and determine whether to begin rejecting claims in August 2007.
CMS also recognizes that the National Council of Prescription Drug Programs (NCPDP) format only allows for reporting of one identifier. Thus, NCPDP claims can contain either the NPI or the legacy number, but not both, until May 23, 2008.
In addition, in regards to the 835 remittance advice transactions and 837 Coordination of Benefits (COB) transactions, Medicare FFS will do the following until May 23, 2008:
- If a claim is submitted with an NPI, the NPI will be sent on the associated 835 remittance advice; otherwise, the legacy number will be sent on the associated 835.
- If a claim is submitted with an NPI, the associated 837 COB transaction will be sent with both the NPI and the legacy number; otherwise, only the legacy number will be sent.
By May 23, 2008, the X12 270/271 eligibility inquiry/response supported by CMS via the Extranet and Internet must contain the NPI.
Important Information
CR 5595 also provides specific important information that you should be aware of:
- Once a decision is made to require NPIs on claims, Medicare FFS will notify (in advance) providers and Medicare contractors about the date that claims without NPIs for primary providers will begin to be rejected. That date will supersede all dates announced in previous CRs and MLN Matters articles.
- In editing NPIs, Medicare considers billing, pay-to, and rendering providers to be primary providers who must be identified by NPIs, or the claims will be rejected once the decision is made to reject.
- All other providers (including referring, ordering, supervising, facility, care plan oversight, purchase service, attending, operating, and “other” providers) are considered to be secondary providers. Legacy numbers are acceptable for secondary providers until May 23, 2008. If a secondary provider’s NPI is present, it will only be edited to assure it is a valid NPI.
Additional Information
You can read CR 5595 by visiting http://www.cms.hhs.gov/Transmittals/downloads/R1227CP.pdf on the CMS Web site. You can also learn more about the NPI at http://cms.hhs.gov/NationalProvIdentStand/ on the CMS Web site.
If you have any questions, please contact your Medicare contractor 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: MM5595 Revised
Pub. 100-4, Transmittal #:R1227CP, CR# 5595
Related CR Release Date: April 24, 2007
Effective Date: May 23, 2007
Implementation Date: May 23, 2007
PQRI Information Available
A new CMS Web page dedicated to providing information on the Physician Quality Reporting Initiative (PQRI) is now available.
On December 20, 2006, the President signed the Tax Relief and Health Care Act of 2006 (TRHCA). Section 101 under Title I authorizes the establishment of a physician quality reporting system for eligible professionals by CMS. CMS has titled the statutory program the Physician Quality Reporting Initiative. For more information, visit http://www.cms.hhs.gov/pqri on the CMS Web site.
Additional Information Provided by National Government Services, Inc.
* No previous MLN article was published for CR 5595.
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