What's New

Updated: December 17, 2007

In October 2007, the Department of Health Care Services (DHCS) announced the extension of Medi-Cal’s “dual-use” period to continue beyond November 26, 2007. During the dual-use period, providers have been required to use both the Medi-Cal provider number and the National Provider Identifier (NPI). The only exception to the dual-use rule was for those transactions where both sets of provider identifiers are not supported. In these cases, providers were instructed to continue to use the Medi-Cal provider number. Effective December 17, 2007, providers will no longer need to use both sets of identifiers on claims, as DHCS will be able to accept either an NPI only, or a Medi-Cal provider number only. Providers who are not ready to transition to using the NPI may continue to submit their Medi-Cal provider number until instructed otherwise.

Claims Submission Update
Effective December 17, 2007, claims submitted using both identifiers will be processed based solely on the NPI. If the Medi-Cal provider number is included along with the NPI (dual-use), it will not be used for processing beyond December 17, 2007. As a result of using the NPI on claims, paper Remittance Advice Details (RADs), ASC X12N 835 Health Care Claim Advice/Payment and/or Supplemental Claims Processing Information (SCPI), (formerly known as Automated Remittance Data System, or ARDS), will be consolidated under the single NPI received.

Note:

When a claim is submitted with an NPI (including dual-use claims) the associated Medi-Cal provider number(s) will be end-dated effective for dates of service beyond the date of NPI claim submission.

Using only the associated Medi-Cal provider number(s) following an NPI claim submission will result in claim denials for subsequent dates of service.

Transition Results
Medi-Cal providers who had obtained an NPI and began submitting it along with their Medi-Cal provider number on the ASC X12N 837 v.4010A1 claim transaction and universal claim forms allowed for Medi-Cal to compare provider claim submission data with NPI registration data. As a result, it was found that claims payment success under the NPI is likely. However, discrepancies were found between the NPI/Medi-Cal provider number combinations received and the NPI/Medi-Cal provider number combinations registered with Medi-Cal. Some NPIs submitted on claims were not registered with Medi-Cal at all, and some were not valid NPIs, and appear to have been erroneously entered on the claim. For a complete list of discrepancies found, please refer to the NPI Registration Errors and Discrepancies document.

Providers are reminded that claims processing is based on how registration was completed. Provider NPI(s) were linked or associated with Medi-Cal provider numbers – specifically, the programs, types or categories of service that the current provider number allows. Examples include: Family PACT, California Children’s Services, physician services, inpatient hospital services, outpatient clinic services, prosthetic appliances, Durable Medical Equipment, hearing aids and ground or air transportation. If the appropriate NPI, as determined by provider’s NPI registration, does not match the NPI submitted on the claim, claim processing delays or denials will result.

Providers are urged to immediately verify the accuracy of their NPI registration with Medi-Cal, as well as critically evaluate their practice management systems, billing, clearinghouse or software solutions, in terms of NPI readiness. NPI registration with Medi-Cal can be easily verified through the Register, Update or Inquire About NPIs page or by contacting the Telephone Service Center (TSC) at 1-800-541-5555 and selecting the options described at the end of this article.

Claims Inquiry, Appeal Forms and Treatment Authorization Requests
Separate instructions have been published for Claims Inquiry Form (CIF, 60-1) and Appeal Form (90-1) completion, as the provider number used may be dependent on the claim form on which the original service was billed. Treatment Authorization Request (TAR) form submissions on or after December 17, 2007 may be completed using either the provider’s NPI or the Medi-Cal provider number. Providers who are submitting claims using an NPI are encouraged to also submit TARs using the applicable NPI. For TARs already approved using the Medi-Cal provider number, claims may be submitted with either the NPI or Medi-Cal provider number.

Accessing Medi-Cal Applications
In addition, the NPI becomes the provider’s “key” for accessing Medi-Cal applications, including Transactions Services on the Medi-Cal Web site and the Provider Telecommunications Network (PTN). Using the NPI for these systems will enable providers to retrieve all claim data (as determined by provider NPI registration), versus the multiple inquiry method using unique Medi-Cal provider numbers.

Registration
All covered health care providers must obtain an NPI, as well as register or share their NPI(s) with payers and providers alike. Even providers who do not bill for services need to disclose their NPIs to those providers who do bill (for example, physicians who order lab tests or refer patients for diagnostic testing must be identified on the lab’s or testing facility’s claims). Providers who plan to retire before the May 23, 2008 compliance date, but have claims that will not be submitted until after the compliance date, still need an NPI. Without an NPI, payment on those claims may be delayed or denied.

Only providers defined by the HIPAA final rule and Medi-Cal policy as “atypical” will continue to use their Medi-Cal provider numbers.

At this time, a significant number of providers have not registered their NPI(s) with Medi-Cal. Provider claim processing and payment is at risk if registration is not completed immediately. The deadline to register NPIs with Medi-Cal has been extended to December 14, 2007 to facilitate this effort. Providers who are already registered but need to update any information may do so using the NPI Collection (NPIC) tool only through December 14, 2007. Effective December 15, 2007, providers must submit all information updates to their registered NPI by submitting a supplemental application form to the Medi-Cal Provider Enrollment Division (PED).

Subpart Reminders
Providers who are replacing multiple Medi-Cal and Child Health and Disability Prevention (CHDP) provider numbers with one NPI are reminded that the “pay-to” address, EFT account and PIN of the first Medi-Cal or CHDP number entered during the registration process will, by default, transfer to the new single NPI record. This registration choice also consolidates RADs, 835 transactions (for example, Claims Payment and Remittance Advice) and 1099 tax forms under the one NPI record. Providers should carefully consider if their business requirements, such as cost reporting, are met using a consolidated model.

Medicare/Medi-Cal Crossover Claims
To the extent an NPI is used to bill on a claim to Medicare, and the claim crosses over electronically with an NPI to Medi-Cal after December 12, 2007, Medi-Cal will use that NPI to process the crossover claim. Additionally, RADs, ASC X12N 835 Health Care Claim Advice/Payments and/or SCPIs will be consolidated under one NPI record.

Medicare announced that beginning January 1, 2008, NPIs will be required for identification of the primary providers (the “Billing” and “Pay-To” providers) on Medicare electronic and paper institutional claims (837I and UB-04 claims). Providers may continue to use the legacy identifier as long as the NPI is also used in the appropriate fields. NPI/legacy identifier pairs will be transmitted to secondary payers like Medi-Cal until May 24, 2008.

Medicare also announced that beginning March 1, 2008, NPIs will be required for identification of the primary providers (the “Billing,” “Pay-To,” and “Rendering” providers) on Medicare electronic and paper professional claims (837P and CMS-1500 claims). NPI/legacy identifier pairs will be transmitted to secondary payers like Medi-Cal until May 24, 2008.

Provider compliance with this Medicare mandate will ensure smooth processing of Medicare/Medi-Cal crossover claims. Medi-Cal is prepared to accept both identifiers in crossover files transmitted by the Medicare Coordination Of Benefits Contractor (COBC). The claims will be processed by Medi-Cal using the NPI and reported accordingly on the paper RAD, ASC X12N 835 Health Care Claim Advice/Payment and/or SCPI, as elected by the provider.

Questions About NPI Registration and Updates
For questions regarding NPI registration or updating registered NPI information, providers may contact the Medi-Cal Telephone Service Center (TSC) by calling 1-800-541-5555, and selecting language preference (option 11 for English; option 12 for Spanish), option 16 from the main menu, then option 18 from the submenu. For all other questions, providers may call TSC and select the appropriate options.