Provider Types Affected
All Medicare physicians, providers, suppliers, and billing staff who submit claims for services to Medicare contractors (fiscal intermediaries (FIs), regional home health intermediaries (RHHIs), carriers, and durable medical equipment regional carriers (DMERCs) and durable medical equipment administrative contractors (DME MACs))

Background
This article instructs the Shared System Maintainers and FIs, RHHIs, carriers, and DMERCs/DME MACs how to report Medicare legacy numbers and NPIs on a Health Insurance Portability and Accountability Act (HIPAA)-compliant Electronic Remittance Advice (ERA) – transaction 835, and Standard Paper Remittance (SPR) advice, any output using PC Print or Medicare Remit Easy Print (MREP) between October 2, 2006 and May 22, 2007.

The Centers for Medicare & Medicaid Services (CMS) has defined legacy provider identifiers to include OSCAR, National Supplier Clearinghouse (NSC), Provider Identification Numbers (PIN), National Council of Prescription Drug Plans (NCPDP) pharmacy identifiers, and Unique Physician Identification Numbers (UPINs). CMS’s definition of legacy numbers does not include taxpayer identifier numbers (TIN) such as Employer Identification Numbers (EINs) or Social Security Numbers (SSNs).

Medicare has published CR4320 ( http://www.cms.hhs.gov/Transmittals/downloads/R204OTN.pdf   ) instructing its contractors how to properly use and edit NPIs received in electronic data interchange transactions, via Direct Data Entry screens, or on paper claim forms.

The following dates outline the regulations from January 2006 forward and are as follows:

• January 3, 2006 – October 1, 2006: Medicare rejects claims with only NPIs and no legacy number.
• October 2, 2006 – May 22, 2007: Medicare will accept claims with a legacy number and/or an NPI, and will be capable of sending NPIs in outbound transaction, e.g., ERA.
• May 23, 2007 Forward: Medicare will only accept claims with NPIs. Small health plans have an additional year to be NPI compliant.

Medicare providers may want to be aware of the following Stage 2 scenarios so that they are compliant with claims regulations and receive payments in a timely manner.

Key Points
During Stage 2, if an NPI is received on the claim, it will be crosswalked to the Medicare legacy number(s) for processing. The crosswalk may result in:

CMS will adjudicate claims based upon Medicare legacy number(s) even when NPIs are received and validated. The Remittance Advice (RA) may be generated for claims with the same legacy number but different NPIs. These claims with different NPIs will be rolled up and reported in a single RA accompanied by one check or electronic funds transfer (EFT).

During Stage 2, Medicare will report both the legacy number(s) and NPI(s) to providers enabling them to track payments and adjustments by both identifiers. The Companion Documents will be updated to reflect these changes, and the updated documents will be posted at http://www.cms.hhs.gov/ElectronicBillingEDITrans/11_Remittance.asp#TopOfPage   on the CMS Web site.

Scenario I – Single NPI crosswalked to single legacy number:

• ERA: Under this scenario, use the TIN (EIN/SSN) at the Payee level as the Payee ID, and the legacy number in the REF segment as Payee Additional ID. Then add the NPI at the claim and/or at the service level, if needed.
• SPR: Insert the legacy number at the header level and the NPI at the claim and/or at the service level, if needed.
• PC Print software: Show the legacy number at the header level and the NPI at the claim and/or at the service level, if needed.
• MREP software: Show the legacy number at the header level and the NPI at the claim and/or at the service level, if needed.

Scenario II: Multiple NPIs crosswalked to single Medicare legacy number:

• ERA: Under this scenario, use the TIN (EIN/SSN) at the Payee level as the Payee ID, and the legacy number in the REF segment as Payee Additional ID. Then add the specific NPIs at the claim and/or at the service level, if needed. The specific NPI associated with the claim(s)/service lines included in the ERA will need to be identified using additional information provided on the claim.
• SPR: Insert the legacy number at the header level. Add the specific NPIs at the claim and/or at the service level, if needed.
• PC Print software: Show the legacy number at the header level and the specific NPI at the claim and/or at the service level, if needed.
• MREP software: Show the legacy number at the header level and the specific NPI at the claim and/or at the service level, if needed.

Scenario III: Single NPI crosswalked to multiple Medicare legacy numbers:

• ERA: Under this scenario, use the TIN (EIN/SSN) at the Payee level as the Payee ID, and the appropriate legacy number in the REF segment as Payee Additional ID. Then add the NPI at the claim and/or at the service level, if needed. (Under this scenario, if there are 50 claims with the same NPI, and that NPI crosswalks to five legacy numbers, we will issue five separate RAs and five separate checks/EFTs per each legacy number.
• SPR: Insert the appropriate legacy number at the header level and the NPI at the claim and/or at the service level, if needed.
• PC Print software: Show the appropriate legacy number at the header level and the NPI at the claim and/or at the service level, if needed.
• MREP software: Show the appropriate legacy number at the header level and the NPI at the claim and/or at the service level, if needed.

Implementation
The implementation date for this instruction is October 2, 2006.

Additional Information
The official instructions issued to your Medicare FI, Carrier, RHHI, DMERC, or DME MAC regarding this change can be found at http://www.cms.hhs.gov/transmittals/downloads/R996CP.pdf on the CMS Web site. The revised sections of Chapter 22–Remittance Advice of the Medicare Claims Processing Manual is attached to CR5081. If you have questions, please contact your Medicare carrier, FI, RHHI, DMERC, or DME 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. The revised sections of Chapter 22–Remittance Advice of the Medicare Claims Processing Manual is attached to CR5081. If you have questions, please contact your Medicare carrier, FI, RHHI, DMERC, or DME MAC at their toll-free number, which may be found at   on the CMS Web site.

The MLN Matters article that provides additional information about Stage 1 use of NPI is available at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM4320.pdf 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: MM5081
Related Change Request (CR) #: 5081
Related CR Release Date: June 30, 2006
Effective Date: October 1, 2006
Related CR Transmittal #: R996CP
Implementation Date: October 2, 2006

Do you have your NPI? National Provider Identifiers (NPIs) will be required on claims sent on or after May 23, 2007. Every health care provider needs to get an NPI. Learn more about the NPI and how to apply for an NPI by visiting http://www.cms.hhs.gov/NationalProvIdentStand/   on the CMS Web site.

Posted: 07/27/2006

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