National Government Services, Inc. Medicare Monthly Review Part A and B
A Combined Part A and Part B Newsletter

MMR-2007 08B, August 2007

Clarification of the National Provider Identifier (NPI) Reporting Requirements for Ambulance Service Claims (5564)

Provider Types Affected
Providers and suppliers who bill Medicare carriers and Medicare Administrative Contractors (MACs) for ambulance services

What You Need to Know
CR 5564, from which this article is taken, notifies carriers and Medicare Administrative Contractors (MACs) to not require you to include the ordering/referring physician’s National Provider Identifier (NPI) on your claims for ambulance services.

You should make sure that your billing staffs are aware of this exception.

Background
Section 1833(q) of the Social Security Act (the Act), requires that the ordering/referring physician’s name be provided on all claims for Medicare-covered services and items resulting from a physician’s order or referral. In addition, when the NPI reporting requirements go into effect according to the Medicare fee-for-service NPI contingency plan, the ordering/referring physician’s NPI will also be required on these claims; except, however, on claims for ambulance services (as explained in the paragraphs below). (See MLN Matters article, MM5595, available at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5595.pdf on the CMS Web site for details about the NPI contingency plan.)

The Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandate the adoption of a standard unique health identifier for each health care provider. In response to this mandate, the Centers for Medicare & Medicaid Services (CMS) in the National Provider Identifier (NPI) final rule (published on January 23, 2004) established the NPI as this standard.

Although providers/suppliers may begin reporting the NPI as early as January 1, 2007, all health care providers covered under HIPAA must comply with the requirements of the NPI final rule in accordance with Medicare’s NPI contingency plan. At the appropriate date, Medicare will reject claims in which the appropriate name and NPI are not entered in the required fields of the Form CMS-1500 paper claim format, version 08-05 (fields 17 and 17B, respectively), and the ANSI X12 837-P electronic claim format, version 4010A (NM1 segment of the 2310A and/or 2420E loop, respectively).

However, ambulance services (particularly transports provided in response to a 911 or 911-equivalent emergency call) are often ordered by someone other than a physician. In these situations, the name and the NPI of the ordering/referring physician are not available. Thus, CMS does not feel that it is appropriate to require that this information be submitted on the claim form. Therefore, CR 5564, from which this article is taken, instructs carriers and the Medicare Administrative Contractors (MACs) that the ordering/referring physician’s NPI is not required on claims for ambulance services.

Additional Information
You can find the official instruction, CR 5564, issued to your carrier or MAC by visiting http://www.cms.hhs.gov/Transmittals/downloads/R1251CP.pdf on the CMS Web site.

If you have any questions, please contact your carrier or MAC 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: MM5564
Related Change Request (CR) #: 5564
Related CR Release Date: May 25, 2007
Effective Date: July 1, 2007
Related CR Transmittal #: R1251CP
Implementation Date: July 2, 2007