February 2008

Provider NPI Testing for Medicare Claims

Providers that already had claims processed correctly using both National Provider Identifier (NPI) and legacy provider numbers are encouraged to submit a small batch of Medicare claims using only the NPI. These submissions will function as a test to make sure future claims will process correctly using only the NPI. If claims continue to be processed correctly, begin increasing the number of Medicare claims submitted using only the NPI.

If the Medicare claims are being rejected, logon to the National Plan and Provider Enumeration System (NPPES) to validate your provider data. If the NPPES data is correct and claims are still being rejected, providers should contact their carrier, contractor or third-party vendor to validate what data they have on record.

National NPI Roundtable Scheduled
The Centers for Medicare & Medicaid Services (CMS) will host a national NPI roundtable February 6, 2008 from 11:30 a.m. to 1 p.m., PST. The CMS roundtable will focus on the status of the Medicare implementation and feature a question and answer session after the presentation. Please check the CMS Communications page of the CMS Web site for details. 

Need More Information?
More information can be found in the NPI area of the CMS Web site. Providers can apply for an NPI online on the NPPES Web site or call the NPI enumerator to request a paper application at 1-800-465-3203. Providers can review all past NPI announcements from CMS on the CMS Communications page.

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February 2008

Provider Updates and Requirements from CMS

Social Security Numbers (SSNs) Should Not Be Reported in Some NPPES Information Fields
As Centers for Medicare & Medicaid Services (CMS) has mentioned in previous outreach messages and on the CMS NPI Web site, some health care providers have reported Social Security Numbers (SSNs) in fields on their National Plan and Provider Enumeration System (NPPES) records that the Freedom of Information Act (FOIA) requires CMS make publicly available. For example, there are instances where SSNs are reported in the Other Provider Identification Numbers, License Number, and Employer Identification Number (EIN) fields in providers’ NPPES records. The information that providers report in these particular fields as well as others is fully disclosable by CMS to the public and, therefore, SSNs should never be reported in any of these fields. 

Because SSNs are 9-digit numbers, CMS has been suppressing all 9-digit numbers found in any FOIA-disclosable field except for ZIP code and telephone/fax number fields. This means that these 9-digit numbers, whether or not they are SSNs, are not displayed in the NPI Registry and cannot be found in the monthly NPPES downloadable file. If these 9-digit numbers are legitimate EINs, other provider identification numbers or license numbers, health plans and others who are using the NPI Registry and the downloadable file are not able to see them. They are not able to see all of the NPPES data they may need in order to accurately match providers in NPPES to the providers in their own files, thus making it more difficult to link NPIs to legacy identifiers.  In some cases, this may adversely affect payments to providers by health plans.

It is imperative that providers immediately review their NPPES records to ensure that they did not inadvertently report an SSN in an FOIA-disclosable field. If they did, they need to delete that SSN immediately and, if appropriate, replace it with the correct information (e.g., an EIN). Providers should review their NPPES records on the NPPES Web site in order to view all of the information they reported. If they need assistance in deleting inappropriately reported SSNs, they may contact the NPI Enumerator at 1-800-465-3203. If they need assistance in knowing which NPPES fields are disclosable under FOIA, they should review the National Plan and Provider Enumeration System (NPPES) Data Elements Data Dissemination – Information for Providers document, dated June 20, 2007, which can be found on the in the NPI area of the CMS Web site.

Providers cannot rely on the information disclosed in the NPI Registry or in the downloadable file in trying to determine if they inappropriately reported SSNs in FOIA-disclosable fields because CMS suppresses these numbers, as explained above. These numbers will not be seen in the NPI Registry or the downloadable file.

In order to protect your personal information from public disclosure, please correct this information immediately if this situation pertains to you.

Important Crosswalk Information and Dates for Medicare Providers
Beginning October 2006, Medicare began using a crosswalk “bypass” so Medicare claims with an NPI and legacy number were processed using only the legacy number to avoid claim rejections due to NPI/legacy pair mismatches on the crosswalk. As of October 29, 2007 all Medicare contractors have lifted the bypass logic and are editing against the Medicare crosswalk.  As a result, claims that include non-matching NPIs and legacy identifiers are now rejecting.  The following table is a review of the next set of dates that are crucial for compliance with the NPI regulations.

Medicare’s Key Dates

March 1, 2008

• Medicare FFS 837 professional (837P) and CMS-1500 claims must include an NPI in the primary fields on the claim (i.e., the billing, pay-to, and rendering fields).
• You may continue to submit NPI/legacy pairs in these fields or submit only your NPI on the claim.
• You may not submit claims containing only a legacy identifier in the primary fields.
• Failure to submit an NPI in the primary fields will result in your claim being rejected or returned because it could not be processed.
• Until further notice, you may continue to include legacy identifiers only for the provider secondary fields.

May 23, 2008

• In keeping with the Contingency Guidance issued on April 3, 2007, CMS will lift its NPI contingency plan, meaning that only the NPI will be accepted and sent on all HIPAA electronic transactions (837I, 837P, NCPDP, 276/277, 270/271 and 835), paper claims and SPR remittance advice.
• This also includes all secondary provider fields on the 837P and 837I. The reporting of legacy identifiers will result in the rejection of the transaction.
• CMS will also stop sending legacy identifiers on COB crossover claims at this time.

List Medicare Legacy Identifiers in Appropriate NPPES Fields
The Medicare crosswalk only uses numbers listed in the Medicare fields within the “Other Provider Identification Numbers” section of the NPPES application. This section has fields for Medicare UPIN, Medicare OSCAR/Certification, Medicare PIN and Medicare NSC as shown in the following example:

Issuer	Number	State	Issuer (for Other Number Type only)
Medicare UPIN
Medicare Oscar/Certification
Medicare PIN
Medicare NSC
Medicaid		State is required if Medicaid number is furnished
Other, Specify:

If claims are rejecting, providers should review their NPPES records (not their NPI Registry records), to confirm that Medicare legacy identifiers are reported in the appropriate fields of the “Other Provider Identification Numbers” section.

Definition of the Term “Billing Provider”
Although the segment/loop title is “Billing Provider” on the electronic and paper institutional claims (837I and UB-04 claims) and the electronic and paper professional claims (837P and CMS-1500 claims), the loop/segment actually identifies the billing entity. The billing entity does not have to be a health care provider to use this loop. The term “Billing Provider” is defined as the billing entity that is identified in the following loops, field locators, or items in the 837I/UB-04 and the 837P/CMS-1500 claim formats, respectively.

Institutional Claims

• 837I (electronic claim) – Loop 2010AA (Billing Provider Name)
• UB-04 (paper claim) – Field Locator (FL) 01

Professional Claims

• 837P (electronic claim) – Loop 2010AA (Billing Provider Name)
• CMS-1500 (paper claim) – Field 33

Medicare Informational Warnings on 837P Transactions With No NPI
Since October 15, 2007, Medicare physicians, non-physician practitioners and other providers and suppliers who bill carriers and Medicare Administrative Contractors (MACs) using the 837 v.4010A1 professional transaction have been receiving informational warnings that indicate there was no NPI entered in the primary provider fields on the claim. Medicare is including these “Provider Identification Code Qualifier Invalid Value” warning messages on pre-pass reject reports sent either to providers directly or to their bulletin board. 

For more information on these warnings, please see the November 2007 CMS Announcements.