April 2008

NPI Updates for Medicare Providers

The Centers for Medicare & Medicaid Services (CMS) encourages all health care providers to be prepared for the May 23, 2008 deadline when Medicare will only accept the National Provider Identifier (NPI) for all medical billing transactions. Health care providers and associated health plans should be ready for this transition, especially if the health plan is primary or secondary to Medicare.

Medicare Fee-for-Service (FFS) Update
Medicare has received more than 98 percent of claims from providers that used an NPI, or an NPI with a legacy provider number when billing. CMS encourages providers to bill Medicare claims using only the NPI as a test transaction to see if any claims will be impacted prior to the May 23, 2008 deadline.

Steps to Make Billing NPI-only Claims Easier

1. Bill claims using the Medicare legacy provider number and NPI – Once all claims are being processed correctly using both provider identifiers, then begin step 2.
2. Bill claims using only the NPI – Start submitting a few claims using only the NPI. If those claims continue to be processed correctly, gradually submit more NPI-only claims. Once NPI-only claims continue to be processed correctly, then begin step 3.
3. Bill claims using only the NPI on other types billing transactions – CMS will require use of the just the NPI on 270/271, 276/277, 835 remittance advice and National Council for Prescription Drug Programs (NCPDP) transactions. Providers should start submitting a few claims using only the NPI for these types of transactions. If those claims continue to be processed correctly, gradually submit more NPI-only claims as noted in step 2.

Reminder: Work with Clearinghouses to Allow NPI-only Testing
CMS discovered that some clearinghouses may not allow claims billing using only the NPI prior to the May 23, 2008 deadline. CMS encourages Medicare providers to work with clearinghouses to allow the use of NPI-only billing to facilitate testing to verify that claims will be processed correctly.

Institutional Providers Required to Identify Subparts When Submitting Taxonomy Codes
Medicare will be using alternative data to obtain the NPI/ Online Survey Certification and Reporting System (OSCAR) certification number match for institutional providers. Medicare will now use the fiscal intermediary shared system (FISS) to obtain a one-to-one match between an institutional Medicare provider’s primary facility NPI (such as that of a psychiatric unit or a rehabilitation unit) and the OSCAR certification numbers of its subparts instead of taxonomy codes. Currently, there are three FISS levels used to validate the NPI/OSCAR match:

• Level 1 match: Type of bill (TOB) to OSCAR certification number – If the FISS is unable to identify a valid match, the search will continue with the second level match.
• Level 2 match: Revenue code to OSCAR certification number – If the FISS is unable to identify a valid match, the search will continue with the third level match.
• Level 3 match: Facility ZIP code on the claim – This final level prompts the FISS to limit the list of OSCAR certification numbers by matching the facility ZIP code on the claim to the ZIP code recorded on the FISS master provider address file. It is the final match level.

Note:

If the FISS is unable to make a valid match, the claim will suspend with reason code 32105 and the provider will receive an additional development letter (ADR) requesting the OSCAR certification number.

On January 1, 2007, Medicare implemented the use of taxonomy codes for all claims submitted by institutional providers for the primary facility and its subparts. Medicare discovered that using taxonomy codes was not accurate for obtaining an identical match between the NPI of the primary facility and the multiple OSCAR certification numbers of its subparts. As a result, the FISS replaced the use of taxonomy codes until further notice.

Action Required by Institutional Providers with Subparts
Medicare providers are encouraged to clearly identify all subparts related to their organization.  Providers can review the following documents for more information about this topic:

• The “Medicare Expectations on the Determination of Subparts” paper
• For Health Care Providers Who Are Organizations fact sheet
• August 2007 Medicare Bulletin (Volume 9; Number 8)
• Medicare Learning Network Matters (MLN; #SE0608) newsletter
• National Plan and Provider Enumeration System (NPPES) Web site

NPI Roundtable Replay: Medicare Implementation Q&A Session
A replay of the recent NPI roundtable Medicare Implementation discussion is available to providers until 9:00 p.m. PDT, April 22, 2008. CMS subject matter experts answer questions from the provider community on various topics related to NPI and Medicare. Providers can call 1-800-642-1687 to hear the recorded replay of the discussion. The pass code is 39334628.

Note:

Providers can also review the CMS Communications page of the CMS Web site for other NPI-related announcements.