November 2007

Provider Requirements for Updating NPPES Data

Health care providers are required by the National Provider Identifier (NPI) Final Rule to update their National Plan and Provider Enumeration System (NPPES) data. The Final Rule states that covered health care providers must notify the NPPES of changes in their required NPPES data elements within 30 days of the changes.  Failure to update provider information may be considered an act of non-compliance with the NPI regulation, and a complaint may be filed against covered health care providers who do not comply with this provision or any other provisions of the rule.

Providers can make most updates online with the user ID and password that were selected when they first applied for an NPI. Providers that mailed NPI application forms can also enter their changes online by selecting a user ID and password at the time they enter an update.

Some updates to provider data must be submitted on the CMS-10114 form because they require an original signature of the provider or from an authorized official signing for an organization.

These types of updates may include:

1. NPI applications and updates from providers who do not have a Social Security Number (SSN) or who do not want to report their SSN to NPPES;
2. Requests to deactivate an NPI;
3. Requests to reactivate an NPI;
4. Changes to an incorrect SSN;
5. Changes to an incorrect birth date;
6. Changes to an incorrect Employer Identifier Number (EIN);
7. All changes to an EIN;
8. Re-setting the password due to a change in the contact provider or the authorized official.

When to Contact the NPI Enumerator for Assistance
The NPI enumerator can only assist providers with questions about the following topics:

• Status of an NPI application, update or deactivation
• Forgotten or lost NPIs
• Lost NPI notification
• Difficulties accessing NPPES
• Forgotten or lost user IDs and passwords
• Requests for a paper application

Providers may call the NPI enumerator at 1-800-465-3203, TTY 1-800-692-2326, or e-mail questions to CustomerService@NPIenumerator.com.

Note:

The NPI Enumerator is closed on federal holidays.

Medicare Announces a New Important NPI Date  
Effective March 1, 2008 , all Medicare fee-for-service claims must include an NPI in the primary fields on electronic transaction (837P) or CMS-1500 claim form. Primary fields on these forms include the “billing ,” “pay-to ” and “rendering” fields. Providers may continue to submit NPI/legacy pairs in these fields or to submit only the NPI on the claim. Claims should not be submitted with only a legacy identifier in the primary fields. Claims with no NPI indicated in the primary fields will be rejected.  Until further notice, providers may continue to include legacy identifiers only for the secondary fields.

Medicare Informational Warnings on Claims With No NPI
Since October 15, 2007, providers and medical suppliers who bill carriers and Medicare Administrative Contractors (MACs) using electronic transactions (837P) or CMS-1500 claim forms have been receiving “Provider Identification Code Qualifier Invalid Value” warning messages from Medicare. These messages inform providers that no NPI was entered on the primary fields of the claim. Medicare is including these messages on reports sent to providers.

The informational warnings consist of one or more of the following messages:

Message	Loop	Ref	Element	Value
M389	2010AA	NM108	Billing Provider Identification Code Qualifier	Invalid value
The edit sets when the 2010AA Loop and NM1 are submitted, but NM108 does not contain “XX.” If the claim contains a 2300 REF01 = P4 and REF02 = 31 (VA claim), the edit does not set.
Message	Loop	Ref	Element	Value
M390	2010AB	NM108	Pay To Provider Identification Code Qualifier	Invalid value
The edit sets when the 2010AB loop and NM1 are submitted, but NM108 does not contain “XX.” If the claim contains a 2300 REF01 = P4 and REF02 = 31 (VA claim), the edit does not set.
Message	Loop	Ref	Element	Value
M391	2310B	NM108	Claim Level Rendering Provider Identification Code Qualifier	Invalid value
The edit sets when the 2310B loop and NM1 are submitted, but NM108 does not contain “XX.” If the claim contains a 2300 REF01 = P4 and REF02 = 31 (VA claim), the edit does not set.
Message	Loop	Ref	Element	Value
M392	2420A	NM108	Detail Level Rendering Provider Identification Code Qualifier	Invalid value.
The edit sets when the 2420A loop and NM1 are submitted, but NM108 does not contain “XX.” If the claim contains a 2300 REF01 = P4 and REF02 = 31 (VA claim), the edit does not set.

Providers should contact their third-party vendor to find out more about these warning messages upon receipt.  It is possible that the third-party vendor removed the NPI prior to submitting the claim to Medicare. Providers may also want to call the carrier or MAC to inquire about the message in order to submit claims with the correct information.

Testing Medicare Claims Using Only the NPI
Providers that find their claims being processed correctly using their NPI and a legacy provider number may want to submit some Medicare claims using only the NPI. These submissions will serve 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 rejected, logon to the NPPES Web site to validate your provider data such as legacy identifier(s) in the “Other Provider Identification Numbers” section. If the NPPES data is correct and claims still are being rejected, providers should contact their carrier, contractor or third-party vendor to validate what data they have on record.

Need More Information?
The NPI application is a good resource. It includes detailed instructions on how NPI data should be submitted and how to update provider records.  Providers can also refer to the NPI Application Help page located on the NPPES Web site.

More information can be found on the Centers for Medicare & Medicaid Services (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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November 2007

Potential Issues With NPIs Submitted by Third-Party Vendors

To prepare for the final National Provider Identifier (NPI) implementation, Medicare Fiscal Intermediaries (Medicare FIs), Part A and Part B Medicare Administrative Contractors (A/B MACs) and carriers are contacting providers whose third-party vendors are not submitting the provider’s NPI correctly on claims. Submitting Medicare claims with incorrect NPI-related information has an adverse affect on claims processing and may result in claim rejection.

The Centers for Medicare & Medicaid Services (CMS) discovered the following problems with some of the claim submissions by third-party vendors:

• The NPI is not included on the claim.
• The NPI information submitted is incorrect.
• The NPI was deleted from the claim prior to its submission to Medicare for processing and then re-entered on the Medicare Remittance Advice (RA) notice so that the provider does not know the NPI was removed prior to submission.
• Some third-party vendors are not relaying NPI-related error messages back to providers from the claims they submit to Medicare. These messages are designed to inform providers about the challenges Medicare encounters attempting to “crosswalk” the NPI to a legacy identifier.

Medicare FIs, A/B MACs and carriers are now validating claims by comparing the NPI/legacy identifier pair submitted on the claim to the NPI/legacy identifier pair listed on the Medicare NPI Crosswalk file. If the NPI information is incomplete or incorrect, the claim will reject.

Providers or third-party vendors that would like to learn more about NPI-related claims processing problems or that have any information regarding these issues should e-mail Aryeh Langer (Aryeh.Langer@cms.hhs.gov) or Nicole Cooney (Nicole.Cooney@cms.hhs.gov) at CMS with their questions prior to the final NPI implementation.