Part A News: Attention Electronic Submitters: New Edits

Attention Electronic Submitters: New Edits

Attention Electronic Submitters: New Edits

NPI Informational Edits Will Soon Change to Claim Deletions

Currently, claim level rejections occur if the primary provider’s National Provider Identifier (NPI) is missing on a claim. Primary providers include billing/pay-to, rendering, and other payer rendering providers (i.e., MSP). When primary provider information is submitted, the NPI must be submitted. Submission of the legacy identifier is optional.

The following informational edits will continue to be encountered on the MCS Edit Report for electronic claims that include the legacy identifier for primary providers. Effective May 23, 2008, when CMS ends the NPI contingency, these edits will change from informational edits to claim deletions (rejections). If you encounter an informational edit, take action to correct it now to avoid claim deletions (rejections) in the future.

Edit Number	Edit Message	Loop	Segment and Data Element	Edit Logic
M402	Invalid Value	2010AA	REF01	The edit sets when the 2010AA contains a 1C or 1G in the REF01 element.
M403	Invalid Value	2010AB	REF01	The edit sets when the 2010AB contains a 1C or 1G in the REF01 element.
M404	Invalid Value	2310B	REF01	The edit sets when the 2310B contains a 1C or 1G in the REF01 element.
M405	Invalid Value	2420A	REF01	The edit sets when the 2420A contains a 1C or 1G in the REF01 element.
M406	Invalid Value	2330E	REF01	The edit sets when the 2330E contains a 1C or 1G in the REF01 element.

New Edits for Prior Authorization or Referral Claims

Effective for electronic claims received after 4:00 p.m. on April 4, 2008, claims containing a prior authorization number or a referral number must also contain the referring provider information at either the claim level or service line level.

The following claim level rejections will occur on the MCS Edit Report for electronic claims that report a prior authorization number or referral number without the referring provider information.

Edit Number	Edit Message	Loop	Segment and Data Element	Edit Logic
M430	Invalid Value	2300AA	REF01	The edit sets when the 2300 contains a 9F in the REF01 element and there is not a referring provider found in 2310A or 2420F loop.
M431	Invalid Value	2330B	REF01	The edit sets when the 2300 contains a 9F in the REF01 element and there is not a referring provider found in 2310A or 2420F loop.

Rejection of Electronic Claim Status Requests that Lack National Provider Identifiers (NPIs)

Beginning May 23, 2008, all electronic claim status requests (X12N 276) must use only the HIPAA-mandated NPI for provider identification, not the Medicare legacy number. Claim status requests without an NPI will be returned to the sender. All claim status responses (X12N 277) returned to the sender as a result of the claim status request will contain only NPIs as of May 23, 2008, even if the claim status request is received prior to May 23, 2008, using a legacy number. In returning the NPI, Medicare will use a crosswalk file that relates the legacy number to the provider’s NPI. If the legacy number maps to more than one NPI, Medicare will return the first active NPI in the 277 response.

Providers are strongly encouraged to begin reporting the NPIs in X12N 276 inquiries prior to May 23, 2008. It is particularly important if the provider has more than one NPI, but was assigned only one legacy number by Medicare for claims submission purposes.
For more information, please read the MLN article at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5726.pdf.

NPI Changes for the ERA and SPR

Effective April 7, 2008, NPIs received on claims will be cross-walked to the Medicare legacy number(s) for processing. Medicare’s internal provider files will continue to be based upon records established in relation to the legacy identifiers.

CMS will adjudicate Medicare Fee-for-Service claims based upon a unique NPI/Legacy combination, but the remittance advice, both electronic and paper, and any output using Medicare Remit Easy Print (MREP) will have only the NPI as the primary provider identification. The Taxpayer Identification Number (TIN) will be used as the secondary identifier for the Payee. The NPI regulation permits continued use of TIN for tax purposes if the implementation guide allows it.
Submitted NPIs will be cross-walked to the Medicare legacy number(s) for processing. Medicare’s internal provider files will continue to be based upon records established in relation to the legacy identifiers. The cross-walk may result in:

Scenario I	Single NPI	Cross-walked to	Single Medicare legacy number
Scenario II	Multiple NPIs	Cross-walked to	Single Medicare legacy number
Scenario III	Single NPI	Cross-walked to	Multiple Medicare legacy numbers

CMS will adjudicate Medicare Fee-for-Service claims based upon a unique NPI/Legacy combination for Scenarios II and III, but the remittance advice, both electronic and paper, and any output using Medicare Remit Easy Print (MREP) will have only NPI as the primary provider identification. The Taxpayer Identification Number (TIN) will be used as the secondary identifier for the Payee. The NPI regulation permits continued use of TIN for tax purposes if the implementation guide allows it.

The Companion Documents and Flat Files for Part B will be updated to reflect these changes and the updated documents will be posted on the CMS Web site at http://www.cms.hhs.gov/ElectronicBillingEDITrans/11_Remittance.asp#TopOfPage.

The following three scenarios refer to Medicare reporting of NPIs in remittance advice processes.

Note: Current requirements concerning the reporting of provider names and addresses still apply.

Scenario I - Single NPI cross-walked to single legacy number:

Electronic Remittance Advice (ERA) -
Under this scenario, Medicare will report the NPI at the Payee level as the Payee Primary ID, and the TIN, Employer Identification Number (EIN), or Social Security Number (SSN) in the REF Segment as the Payee Additional ID. Medicare will report any relevant Rendering Provider NPI at the Claim Level if it is different from the Payee NPI. Contractors, as appropriate, will also report relevant Rendering NPI(s) at the Service Line Level if different from the Claim Level Rendering Provider NPI. Under this scenario, there will be one remittance advice and one check/Electronic Funds Transfer (EFT) issued per NPI.

Standard Paper Remittance (SPR) -
Medicare will insert the appropriate Payee NPI at the header level. The ERA reporting requirements apply to the corresponding SPR fields. Note: Current requirements concerning the reporting of provider names and addresses still apply.

Scenario II - Multiple NPIs cross-walked to Single Medicare legacy number:

ERA -
Under this scenario, Medicare will report the NPI at the Payee Level as the Payee Primary ID, and the TIN, EIN/SSN in the REF Segment as Payee Additional ID. Then Medicare will add any relevant Rendering Provider NPI at the Claim Level if it is different from the Payee NPI. Contractors, as appropriate, will add any relevant Rendering NPI(s) at the Service Line Level if it is different from the Claim Level Rendering Provider NPI. Under this scenario, adjudication will be based on the unique combination of NPI/legacy number, and there will be multiple remittance advices and checks/EFTs based on that unique combination.
SPR -
Medicare will insert the appropriate NPI number at the header level. The ERA reporting requirements apply to the corresponding SPR fields. Note: Current requirements concerning the reporting of provider names and addresses still apply.

Scenario III - Single NPI cross-walked to Multiple Medicare legacy numbers:
ERA -
Under this scenario, Medicare will report the NPI at the Payee Level as the Payee Primary ID, and the TIN, EIN/SSN in the REF Segment as Payee Additional ID. Then, Medicare will add any relevant Rendering Provider NPI at the Claim Level if it is different from the Payee NPI. Contractors, as appropriate, will add relevant Rendering NPI(s) at the Service Line Level if it is different from the Claim Level Rendering Provider NPI. Under this scenario, adjudication will be based on the unique combination of NPI/legacy number, and there will be multiple remittance advices and checks/EFTs based on that unique combination.
SPR -
Insert the appropriate NPI number at the header level. The ERA reporting requirements apply to the corresponding SPR fields. Note: Current requirements concerning the reporting of provider names and addresses still apply.

For All Three Scenarios - the Medicare Remit Easy Print (MREP) software program will be handled as follows:
MREP Software -
Medicare will show the Payee NPI at the header level and add any relevant Rendering Provider NPI at the claim level if different from the Payee NPI, and any relevant Rendering NPI(s) at the service line level if different from the claim level Rendering Provider NPI.

For additional information regarding how Medicare will return the NPI in the ERA and SPR, please read the MLN Matters article on the CMS Web site at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5452.pdf

New NPI Reporting Edits

Mandatory Reporting of NPI for Primary Providers

Effective for EDI claims received after 4:00 p.m. on February 29, 2008, all Medicare Part B electronic claims must contain the NPI for any primary (i.e., billing/pay-to and rendering) provider. Failure to submit the NPI for the billing/pay-to and/or rendering provider will generate batch and claim level rejections.

When the NPI is not submitted on your electronic claims for the primary provider, you will see the following edit number and message displayed on the MCS Edit Report:

Edit Number	Edit Message	Loop/Segment/Data Element	Edit Condition
M389	Invalid Value	2010AA NM108	The edit sets when 2010AA loop and NM1 are submitted but the NM108 does not contain XX.
M390	Invalid Value	2010AB NM108	The edit sets when 2010AB loop and NM1 are submitted but the NM108 does not contain XX.
M391	Invalid Value	2310B NM108	The edit sets when 2310B loop and NM1 are submitted but the NM108 does not contain XX.
M392	Invalid Value	2420A NM108	The edit sets when 2420A loop and NM1 are submitted but the NM108 does not contain XX.

To prepare for the May 23, 2008, NPI contingency end, you are encouraged to send a small batch of claims with only the NPI in the primary provider fields. If the results are positive, begin increasing the number of claims in the batch. If you test now and your claims are processed successfully, you can approach the May 23, 2008, date with confidence. If you do not, you may face unanticipated cash flow problems.

New NPI Edits for Secondary Providers
Effective for electronic claims received after 4:00 p.m. on February 1, 2008, informational edits will occur if the secondary provider’s National Provider Identifier (NPI) is missing on a claim when secondary provider information is reported.
Secondary providers include referring, purchasing, supervising, facility, and ordering providers.

NEWS BYTES
IMPORTANT: Effective May 23, 2008, when CMS ends the NPI contingency, these edits will change from informational edits to claim deletions (rejections). When secondary provider information is submitted at that time, the NPI must be reported or the claim will be rejected.

The following new informational edits will be encountered on the MCS Edit Report for electronic claims received after 4PM on February 1, 2008, when a valid NPI is not received for secondary providers.

Edit Number		Loop	Data Element	Name	Description	Edit Logic
M393		2310A	NM108	Referring Provider Identification Code Qualifier	Invalid Value	Edit will set if NM108 is not XX or blank, or if NM108 is blank and the loop has a REF segment.
M394		2310C	NM108	Purchased Service Provider Identification Code Qualifier	Invalid Value	Edit will set if NM108 is not XX or blank, or if NM108 is blank and the loop has a REF segment.
M395		2310D	NM108	Service Facility Provider Identification Code Qualifier	Invalid Value	Edit will set if NM108 is not XX or blank, or if NM108 is blank and the loop has a REF segment.
M396		2310E	NM108	Supervising Provider Identification Code Qualifier	Invalid Value	Edit will set if NM108 is not XX or blank, or if NM108 is blank and the loop has a REF segment.
M397		2420B	NM108	Purchased Service Provider Identification Code Qualifier	Invalid Value	Edit will set if NM108 is not XX or blank, or if NM108 is blank and the loop has a REF segment.
M398		2420C	NM108	Service Facility Provider Identification Code Qualifier	Invalid Value	Edit will set if NM108 is not XX or blank, or if NM108 is blank and the loop has a REF segment.
M399		2420D	NM108	Supervising Provider Identification Code Qualifier	Invalid Value	Edit will set if NM108 is not XX or blank, or if NM108 is blank and the loop has a REF segment.
M400		2420E	NM108	Ordering Provider Identification Code Qualifier	Invalid Value	Edit will set if NM108 is not XX or blank, or if NM108 is blank and the loop has a REF segment.
M401	2420F		NM108	Referring Provider Identification Code Qualifier	Invalid Value	Edit will set if NM108 is not XX or blank, or if NM108 is blank and the loop has a REF segment.
M417	2310A		REF01	Referring Provider Reference Identification Code Qualifier	Invalid Value	The edit sets when REF01=1C or 1G.
M418	2310C		REF01	Purchased Service Provider Reference Identification Qualifier	Invalid Value	The edit sets when REF01=1C or 1G.
M419	2310D		REF01	Service Facility Location Provider Reference Identification Qualifier	Invalid Value	The edit sets when REF01=1C or 1G.
M420	2310E		REF01	Supervising Provider Reference Identification Qualifier	Invalid Value	The edit sets when REF01=1C or 1G.
M421	2420B		REF01	Purchased Service Provider Reference Identification Qualifier	Invalid Value	The edit sets when REF01=1C or 1G.
M422	2420C		REF01	Service Facility Location Provider Reference Identification Qualifier	Invalid Value	The edit sets when REF01=1C or 1G.
M423	2420D		REF01	Supervising Provider Reference Identification Qualifier	Invalid Value	The edit sets when REF01=1C or 1G.
M424	2420E		REF01	Ordering Provider Reference Identification Qualifier	Invalid Value	The edit sets when REF01=1C or 1G.
M425	2420F		REF01	Referring Provider Reference Identification Qualifier	Invalid Value	The edit sets when REF01=1C or 1G.
M426	2330D		REF01	Other Payer Referring Provider Reference Identification Qualifier	Invalid Value	The edit sets when REF01=1C.
M427	2330F		REF01	Other Payer Purchased Service Provider Reference Identification Qualifier	Invalid Value	The edit sets when REF01=1C.
M428	2330G		REF01	Other Payer Service Facility Location Provider Reference Identification Qualifier	Invalid Value	The edit sets when REF01=1C.
M429	2330H		REF01	Other Payer Supervising Provider Reference Identification Qualifier	Invalid Value	The edit sets when REF01=1C.

Posted: 04/01/2008