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

National Provider Identifier (NPI) Required to Enroll in Electronic Data Interchange (EDI), and Update of Telecommunication and Transmission Protocols for EDI (MM5637)

Note: This article was revised on July 17, 2007, to reflect a new Web address in the Additional Information section for NPI information. All other information remains the same.

Provider Types Affected
Physicians and other providers who bill Medicare contractors (carriers, fiscal intermediaries (FI), including regional home health intermediaries (RHHI), Medicare Administrative Contractors (A/B MAC), or Durable Medical Equipment Medicare Administrative Contractors (DME MAC)) for services provided to Medicare Beneficiaries

Provider Action Needed

Impact to You
If not already enrolled for use of electronic billing and other electronic data interchange (EDI) transactions, you will not be able to enroll to begin use if you have not yet obtained a National Provider Identifier (NPI).

What You Need to Know
CR 5637, from which this article is taken, announces that providers must obtain an NPI, as a condition for initial enrollment, for the use of EDI. Your Medicare contractor will not issue you an EDI access number and password until you obtain an NPI.

What You Need to Do
If you have not already obtained your NPI, you should apply now. You can apply on line by going to https://nppes.cms.hhs.gov/ .

Background
Since May 2006, providers have been required to obtain a National Provider Identifier (NPI) prior to initial Medicare enrollment, or before updating their enrollment records, but were not required to have an NPI, as a condition for enrollment, in order to begin using electronic data interchange (EDI) transactions.

CR 5637, from which this article is taken, announces that (effective October 1, 2007) providers will need to obtain an NPI, as a condition for initial enrollment, for the use of EDI.

This is being implemented to further support efforts by the Centers for Medicare & Medicaid Services (CMS) to have all providers obtain NPIs as soon as possible. Moreover, as indicated in MLN Matters article MM5595 ( http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5595.pdf ), Medicare is monitoring claims to determine the level of NPI reporting. This is being done to determine when it will be reasonable for Medicare to begin rejecting claims that lack an NPI for billing, pay-to, or rendering providers.

CR 5637 also updates EDI connectivity information in the Medicare Claims Processing Manual, Section 24 (General EDI and EDI Support Requirements, Electronic Claims and Coordination of Benefits Requirements, Mandatory Electronic Filing of Medicare Claims), Sections 20 (EDI Enrollment) and 30.3 (Telecommunications and Transmission Protocols) because some of the information in the manual is obsolete due to technology changes.

In summary, these changes are:

• Medicare contractors will use V.90 56K modems for EDI transactions submitted via dial-in connections;
• Medicare contractors will offer data compression in a means that an EDI transaction sender/receiver requests, using the V.90 56 K modem, PK ZIP version 2.04x or higher, WinZIP or V.42 bis data compression;
• DME MACs will reject standard National Council for Prescription Drug Programs (NCPDP) transactions that do not use the standard NCPDP electronic envelope;
• Medicare contractors may, but are not required to, accommodate other types of data compression that an EDI submitter/receiver requests.

Additional Information
You can find more information about the requirement for an NPI in order to be able to use EDI transactions, by going to CR 5637, located at http://www.cms.hhs.gov/Transmittals/downloads/R1283CP.pdf on the CMS Web site. As an attachment to CR 5637, you will find updated Medicare Claims Processing Manual, Section 24 (General EDI and EDI Support Requirements, Electronic Claims and Coordination of Benefits Requirements, Mandatory Electronic Filing of Medicare Claims), Sections 20 (EDI Enrollment) and 30.3 (Telecommunications and Transmission Protocols). You can find more information about EDI on the CMS website at http://www.cms.hhs.gov/ElectronicBillingEDITrans/ , and more information about the NPI at http://www.cms.hhs.gov/NationalProvIdentstand/ on the CMS Web site.

If you have any questions, please contact your carrier, FI, RHHI, A/B MAC, or DME MAC at their toll-free number, which may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip .

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: MM5637
Pub. 100-4, Transmittal# R1283CP, CR# 5637
Related CR Release Date: July 6, 2007
Effective Date: October 1, 2007
Implementation Date: October 1, 2007  

News Flash – The Centers for Medicare & Medicaid Services has announced the proposed rule that would establish new policies and payment rates for physicians and other providers who are paid under the Medicare physician fee schedule. Included in the proposed rule is important information directly related to 2008 PQRI. To view or download the proposed rule, visit, http://www.cms.hhs.gov/center/physician.asp , click on CMS-1385-P, then go to page 402 of the document.