Provider Types Affected
Physicians, providers, and suppliers who submit claims for services to Medicare carriers, including durable medical equipment regional carriers (DMERCs) and fiscal intermediaries (FIs), to include regional home health intermediaries (RHHIs)

Provider Action Needed
The requirements for Stage 2 apply to all transactions that are first processed by Medicare systems on or after October 2, 2006, and are not based on the date of receipt of a transaction, unless otherwise stated in a business requirement. Please note that the effective and implementation dates shown at the end of the article reflect the dates that Medicare systems will be ready, but the key date for providers regarding the use of the NPI in Stage 2 is October 1, 2006.

Background
The Health Insurance Portability and Accountability Act (HIPAA) of 1996 requires issuance of a unique national provider identifier (NPI) to each physician, supplier, and other provider of health care (45 CFR Part 162, Subpart D (162.402-162.414)). To comply with this requirement, the Centers for Medicare & Medicaid Services (CMS) began to accept applications for, and to issue NPIs, on May 23, 2005. Applications can be made by mail and also online at https://nppes.cms.hhs.gov.

NPI and Legacy Identifiers
The NPI is a ten-position, intelligence-free numeric identifier (ten-digit number). This means that the numbers do not carry other information about healthcare providers, such as the state in which they live or their medical specialty. Beginning May 23, 2007 (May 23, 2008, for small health plans), the NPI must be used in lieu of legacy provider identifiers.

Legacy provider identifiers include:

• Online Survey Certification and Reporting (OSCAR) system numbers;
• National Supplier Clearinghouse (NSC) numbers;
• Provider Identification Numbers (PIN); and
• Unique Physician Identification Numbers (UPIN) used by Medicare.

They do not include taxpayer identifier numbers (TIN) such as:

• Employer Identification Numbers (EIN); or
• Social Security Numbers (SSN).

Primary and Secondary Providers
Providers are categorized as either “primary” or “secondary” providers:

• Primary providers include billing, pay-to, rendering, or performing providers. In the DMERCs, primary providers include ordering providers.
• Secondary providers include supervising physicians, operating physicians, referring providers, and so on.

Crosswalk
During Stage 2, Medicare will utilize a Crosswalk between NPIs and legacy identifiers to validate NPIs received in transactions, assist with population of NPIs in Medicare data center provider files, and report NPIs on remittance advice (RA) and coordination of benefit (COB) transactions. Key elements of this Crosswalk include the following:

• Each primary provider’s NPI reported on an inbound claim or claim status query will be crosswalked to the Medicare legacy identifier that applies to the owner of that NPI.
• The Crosswalk will be able to do a two-directional search, from a Medicare legacy identifier to NPI, and from NPI to a legacy identifier.
• The Medicare Crosswalk will be updated daily to reflect new provider registrations.

 NPI Transition Plans for Medicare FFS Providers
Medicare’s implementation involving acceptance and processing of transactions with the NPI will occur in separate stages, as shown in the table below:

Claim Rejection
Claims will be rejected if:

• The NPI included in a claim or claim status request does not meet the content criteria requirements for a valid NPI; this affects:
  • X12 837 and Direct Data Entry (DDE) screen claims (DDE claims are submitted to Medicare intermediaries only);
  • National Council of Prescription Drug Plan (NCPDP) claims (submitted to Medicare DMERCs only);
  • Claims submitted using Medicare’s free billing software;
  • Electronic claim status request received via X12 276 or DDE screen; and
  • Non-X12 electronic claim status queries;
• An NPI reported cannot be located in Medicare files;
• The NPI is located, but a legacy identifier reported for the same provider in the transaction does not match the legacy identifier in the Medicare file for that NPI;
• Note: If only provider legacy identifiers are reported on an inbound transaction prior to May 23, 2007, pre-NPI provider legacy number edit rules will be applied to those legacy identifiers.
  

Claims include the NPI but do not have a taxpayer identification number (TIN) reported for the billing or pay-to provider in electronic claims received via X12 837, DDE screen (FISS only), or Medicare’s free billing software.

Additional Information
X12 837 Incoming Claims and COB
During Stage 2, an X12 837 claim may technically be submitted with only an NPI for a provider, but you are strongly encouraged to also submit the corresponding Medicare legacy identifier for each NPI in X12 837 Medicare claims.

Use of both numbers could facilitate investigation of errors if one identifier or the other cannot be located in the Medicare validation file. When an NPI is reported in a claim for a billing or pay-to provider, a TIN must also be submitted in addition to the provider’s legacy identifier as required by the claim implementation guide.

National Council of Prescription Drug Plans (NCPDP) Claims
The NCPDP format was designed to permit a prescription drug claim to be submitted with either an NPI or a legacy identifier, but not more than one identifier for the same retail pharmacy or prescribing physician. The NCPDP did provide qualifiers, including one for NPIs, to be used to identify the type of provider identifier being reported.

• For Stage 1, retail pharmacies were directed to continue filing their NCPDP claims with their individual NSC number and to report the UPIN of the prescribing physician.
• During Stage 2, retail pharmacies will be allowed to report their NPI, and/or the NPI of the prescribing physician (if they have the prescribing physician’s NPI) in their claims.

When an NPI is submitted in an NCPDP claim, it will be edited in the same way as an NPI submitted in an X12 837 version 4010A1 claim. The retail pharmacy will be considered the primary provider and the prescribing physician as the secondary provider for NPI editing purposes.

Paper Claim Forms
The transition period for the revised CMS-1500 is currently scheduled to begin October 1, 2006 and end February 1, 2007. The transition period for the UB-04 is currently scheduled for March 1, 2007 through May 22, 2007.

Pending the start of submission of the revised CMS-1500 and the UB-04, providers must continue to report legacy identifiers, and not NPIs, when submitting claims on the non-revised CMS-1500 and the UB-92 paper claim forms.

Provider identifiers reported on those claim forms are presumed to be legacy identifiers and will be edited accordingly. “Old” form paper claims, received through the end of the transition period that applies to each form, may be rejected if submitted with an NPI.

Or, if they are not rejected—since some legacy identifiers were also ten digits in length—could be incorrectly processed, preventing payment to the provider that submitted that paper claim.

Standard Paper Remits (SPR)
The SPR FI and carrier/DMERC formats are being revised to allow reporting of both a provider’s NPI and legacy identifier when both are available in Medicare’s files. If a provider’s NPI is available in the data center provider file, it will be reported on the SPR, even if the NPI was not reported for the billing/pay-to, or rendering provider on each of the claims included in that SPR. The revised FI and carrier/DMERC SPR formats are attached to CR4023:

• CR 4023 Attachment 1: FI Standard Paper Remit (SPR) Amended Format for Stage 2; and
• CR 4023 Attachment 2: Carrier/DMERC SPR Amended Stage 2 Format.

Remit Print Software
The 835 PC-Print and Medicare Remit Easy Print software will be modified by October 2, 2006, to enable either the NPI or a Medicare legacy number, or both, if included in the 835, to be printed during Stage 2.

Free Billing Software
Medicare will ensure that this software is changed as needed by October 2, 2006, to enable reporting of both an NPI and a Medicare legacy identifier for each provider for which data is furnished in a claim, and to identify whether an entered identifier is an NPI or a legacy identifier.

In-Depth Information
Please refer to CR4023 for additional detailed NPI-related claim information about the following topics:

• Crosswalk
• X12 837 Incoming Claims and COB
• Non-HIPAA COB Claims
• NCPDP Claims
• DDE Screens
• Paper Claim Forms
• Free Billing Software
• X12 276/277 Claim Status Inquiry and Response Transactions
• 270/271 Eligibility Inquiry and Response Transactions
• 835 Payment and Remittance Advice Transactions
• Electronic Funds Transfer (EFT)
• Standard Paper Remits (SPR)
• Remit Print Software
• Claims History
• Proprietary Error Reports
• Carrier, DMERC, and FI Local Provider Files, including EDI System Access
• Security Files
• Med A and Med B Translators
• Other Translators
• Stages 3 and 4

CR 4023, the official instruction issued to your FI/ regional home health intermediary (RHHI) or carrier/durable medical equipment regional carrier (DMERC) regarding this change, may be found by going to http://www.cms.hhs.gov/Transmittals/ on the CMS Web site. From that Web page, look for CR 4023 in the CR NUM column on the right, and click on the file for that CR.

You may also wish to review Medlearn Matters article SE0555, Medicare’s Implementation of the National Provider Identifier (NPI): The Second in the Series of Special Edition Medlearn Matters Articles on NPI-Related Activities, which is available at http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/SE0555.pdf on the CMS Web site. This article contains further details on the NPI and how to obtain one.

Please refer to your local FI/RHHI or carrier/DMERC if you have questions about this issue. To find their toll-free phone number, go to http://www.cms.hhs.gov/MedlearnProducts/downloads/CallCenterTollNumDirectory.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.

For more information, visit the Medlearn Matters Web page at: http://www.cms.hhs.gov/MedlearnMattersArticles/.

Pub. 100-20, Transmittal# 190 , CR# 4023
Medlearn Matters Number: MM4023 Revised
Related CR Release Date: November 3, 2005
Effective Date: April 1, 2006
Implementation Date: April 3, 2006

Posted: 12/08/2005

CPT codes, descriptions, and other data only are copyright 2005 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Apply.