This category includes FAQs about hard copy or electronic claim submission.

For additional questions regarding NPI, contact the Telephone Service Center (TSC) at 1-800-541-5555, select language preference (option 11 for English; option 12 for Spanish), select option 16 from the main menu, then select option 18 from the submenu.

A. Individual Providers (Entity Type 1)
Examples of individual providers include physicians, nurses, psychologists, pharmacists, chiropractors, physical therapists, acupuncturists, speech therapists and others.

1. When a provider is billing Medi-Cal for a surgery, do they need to include the facility’s National Provider Identifier (NPI) on the claim?
   A. Yes. Effective December 17, 2007, the facility’s NPI is required on the claim.
2. Should the referring provider’s NPI or license number be entered on the claim?
   A: The referring physician’s NPI is required in the referring NPI field on the claim effective December 17, 2007. However, the Department of Health Care Services (DHCS) is allowing one exception. The exception allows the billing provider to use the referring provider’s license number should they be unable obtain the NPI.
3. Will the NPI replace the primary physician’s Medi-Cal provider number on the new CHDP Confidential Screening/Billing Report (PM 160) form?
   A: Yes. Effective December 17, 2007, the NPI is accepted on the PM 160 form, as well as all other claim forms. Providers who are not ready to transition to using the NPI may continue to submit their Medi-Cal provider number until instructed otherwise.

B. Organizations (Entity Type 2)
Examples of organizations include hospitals, home health agencies, clinics, nursing homes, residential treatment centers, laboratories, ambulance companies, group practices, HMOs, supplier of Durable Medical Equipment (DME) and pharmacies.

4. If an institution has obtained one NPI for multiple Medi-Cal provider numbers and is paid differently for each provider number, how does Medi-Cal determine payment after the institution’s Medi-Cal provider numbers are no longer valid?
   A: The claims payment system will use data contained on the claim to accurately adjudicate the claim. Also of importance is accuracy of provider location information contained on the Medi-Cal provider master file, as well as the service location submitted on the claim. Inaccurate service location information may lead to payment irregularities. Providers are encouraged to verify their service location information by calling the Telephone Service Center (TSC) at 1-800-541-5555.
5. When a facility has two provider numbers, how is Medi-Cal going to determine between them when both have the same taxonomy code?
   A: The claims payment system will use data contained on the claim to accurately adjudicate the claim.
6. For Federally Qualified Health Centers (FQHCs), how will the claims processing system know how to pay Evaluation and Management (E & M) using code 01 when the NPI is used on the claim instead of the Medi-Cal provider number with a FQHC prefix?
   A: FQHC E&M code 01 is specific to FQHC providers; therefore, the appropriate payment for FQHC providers will result. FQHC payment outcomes, however, are subject to variance by location due to differing negotiated rates by location. In the event an FQHC location meets the test of a covered entity in context to the NPI final rule (i.e., conducts HIPAA standard transactions such as eligibility, claims, etc.), that separate location must identify itself using a unique NPI subpart.
7. If an organization did not apply for subpart NPIs for their multiple Medi-Cal provider numbers, how will Medi-Cal process claims under one NPI without the provider information specific to each of the Medi-Cal provider numbers?
   A: Medi-Cal plans to utilize information within the claims processing system, in addition to information submitted on claims (i.e., the “Service Address” required on all Medi-Cal claims), to replace the multiple identifiers previously used. As noted above, a provider should consider whether or not each location meets the test as a separate covered entity within a parent organization, as described in the NPI final rule.
8. If a provider obtained one NPI for the organization, can they use this NPI for their Family PACT (Planning, Access, Care and Treatment) and Cancer Detection Program (CDP) program or do they need to obtain separate NPIs for each program?
   A. With the adoption of the NPI, a separate provider number is no longer required. If a provider chose to consolidate their various Medi-Cal provider numbers under one NPI, that provider must ensure that registration of this one NPI occurs independently for each and every provider number with Medi-Cal so that these numbers link to their new NPI. As noted above, a provider should consider whether or not each location meets the test as a separate covered entity within a parent organization as described in the NPI final rule.
9. When a hospital runs clinics for physical therapy, occupational therapy, speech therapy, audiology services or other services, should the hospital or the specific therapist be listed as the billing provider on the claim?
   A: If each provider bills the Medi-Cal program directly, their individual NPI must be reported on the claim as the billing provider's NPI. The hospital’s NPI must be reported in the Service Facility Location Information field on the claim.
   
   However, if the hospital obtained a single NPI or subpart NPIs for all its departments/clinics, the claim will be billed using either the hospital’s single or subpart NPI. Since there will only be one RAD or 835 transaction issued for each NPI, it will be the hospital’s responsibility to determine the payment due to the provider based on the Remittance Advice Details (RAD) or the 835 transaction issued for the one NPI or subpart NPI.
10. Does a clinic need to bill using different NPI numbers, depending on which provider rendered the service, or should a clinic use their own NPI number?
    A: If each provider who renders the service bills the Medi-Cal program directly, as the billing provider their individual NPI must be reported on the claim. The clinic’s NPI must be reported in the Service Facility Location Information field on the claim.
    
    However, if the clinic obtained an NPI and uses it for billing all services rendered, then the claim will be billed using the clinic’s NPI. Since there will only be one RAD or 835 transaction issued for each NPI, it will be the clinic’s responsibility to determine the payment due to the provider who rendered the service. The individual practitioner who rendered the service will need to be identified in the “rendering” provider field by their individual (type 1) NPI.
11. Since there is only one remittance per NPI, what happens if a provider obtained one NPI for several Medi-Cal group provider numbers and only submits a portion of claims electronically?
    A: If a provider obtained one NPI to replace several Medi-Cal group provider numbers, there will only be one remittance advice generated, and it will include all claims submitted electronically or on paper. It will be the group’s responsibility to determine the payment that is due to each provider based on the Remittance Advice Details (RAD) or the 835 transaction issued for the one NPI. Providers may, at their discretion, register separate NPI subparts if the desire is to differentiate payment remittance.
12. Will pharmacies be required to use a prescribing physician’s NPI beginning December 17, 2007? If yes, what if the prescribing physician does not provide an NPI?
    A: Yes. Effective December 17, 2007, the prescribing physician’s NPI is required. A message will be returned to the provider when an identifier other than an NPI is submitted, but the claim will not be rejected. Although the DHCS does not intend to deny claims where the prescribing ID is not an NPI, the DHCS encourages providers to make every effort now to build in NPI use into their business processes. When NPI is available through NPPES, and use is more widespread, DHCS will make NPI submission for the prescribing provider mandatory.
13. Will there be a crosswalk for Pharmacy Point of Service (POS) claim reversals and rebills for dates of service prior to December 17, 2007?
    A: No. There are no crosswalks for POS claim reversals and rebills for dates of service prior to December 17, 2007. The Medi-Cal provider number used in the original transaction is required for reversal and rebill transactions beginning December 17, 2007. The provider number used on reversals or rebills must match the provider number on the original transaction. Please refer to the June 2007 Pharmacy Medi-Cal Update for more information.
14. How will the NPI affect pharmacy billing on the POS device since POS devices are set-up with Medi-Cal provider numbers?
    A: In preparation for Medi-Cal’s NPI implementation, a POS device software update to accommodate the 10-digit NPI began August 25, 2007. To accommodate reversals and transition of NPI after December 17, 2007, POS software accommodates either the NPI or Medi-Cal provider number.
15. Do Home Health Agencies (HHA) bill using an NPI?
    A: Yes, all Health Insurance Portability and Accountability Act (HIPAA)-covered health care providers must obtain an NPI to identify themselves in HIPAA-standard transactions. For Medi-Cal, the NPI is also required when using hard copy claim forms. A provider is required to obtain an NPI unless they are considered an “atypical” provider (Blood Banks, Christian Science Practitioner, Multipurpose Senior Services Program).
16. How does the NPI implementation affect home infusion companies with billing?
    A: Home infusion companies are required to obtain and register an NPI in order to bill Medi-Cal.
17. Which NPI does a provider use for billing when the individual owner also works at a different clinic?
    A: If the provider is a member of a provider group and is providing services as a rendering provider of the group, then the group’s NPI will need to be entered on the claim as the billing provider and the rendering/individual NPI will need to be entered in the appropriate rendering provider NPI field.
    
    If the provider is providing services at a different clinic as an individual, then the individual provider’s NPI will need to be entered on the claim as the billing provider.

C. General Billing

18. Can a provider continue to submit their current provider number along with their NPI?
    A: Effective December 17, 2007, providers no longer need to use both sets of identifiers on claims. DHCS accepts either an NPI or a Medi-Cal provider number. Providers who are not ready to transition to using the NPI may continue to submit their Medi-Cal provider number until instructed otherwise.
19. If a provider has a claim with a date of service prior to December 17, 2007, should the provider use the Medi-Cal provider number or an NPI on the claim?
    A: Providers may use the NPI or a Medi-Cal provider number on the claim. Providers who are not ready to transition to using the NPI may continue to submit their Medi-Cal provider number until instructed otherwise.
20. If the NPI number is the same for both Medicare and Medi-Cal, does this automatically link crossover claims?
    A: Yes, but only if the NPI was registered with Medi-Cal. If not, Medi-Cal will not be able to recognize the NPI received by Medicare.
21. Will providers that are enrolled in different specialty programs (i.e., Family PACT, CDP, etc.) and obtained separate NPIs receive a separate RAD for each of the programs?
    A: Yes. If providers obtained separate NPIs for each of the specialty programs in which they are enrolled, separate RADs will be issued for each NPI. However, with the adoption of the NPI, a separate provider number is no longer required for each program. Medi-Cal will be able to link these provider types to the single NPI by utilizing information within the claims processing system in addition to information submitted on claims.
22. Will the referring physician’s NPI be required on the claim when billing electronically or on paper?
    A: Yes. Effective December 17, 2007, the referring physician’s NPI is required on all electronic and paper claims. However, DHCS is allowing exceptions. The exception to the requirement will allow the billing provider to use the license number should they be unable to get access to the referring provider’s NPI.
23. What happens to claims submitted with an NPI that is not registered with Medi-Cal?
    A: Claims submitted with an NPI that is not registered with Medi-Cal will not be processed. The DHCS will not be automatically registering NPI when NPPES data becomes available.
24. What is the NPI requirement for claim adjustments such as Claim Inquiry Forms (CIFs)?
    A: Effective December 17, 2007, claim adjustments may be submitted with the NPI or the Medi-Cal provider number until instructed otherwise. If the original claim was submitted with the Medi-Cal provider number and an NPI was obtained afterward , the NPI can be used on the claim adjustment.
25. If a claim is submitted with an NPI that has not been registered with Medi-Cal and the claim is denied, can the claim be resubmitted? Can the NPI still be registered?
    A: Yes. The claim may be submitted but the NPI will need to be registered prior to the resubmission of the claim. If a claim is submitted with an NPI that has not been registered, the claim will be rejected and Medi-Cal will not be able to notify the provider of the rejection.
    
    After December 17, 2007, an NPI can still be registered; however, the late registration will delay the processing of claims. Additionally, the hard copy NPI registration process may not be as quick as registration through National Provider Identifier Collection (NPIC), the online registration tool. Providers are strongly encouraged to register their NPI using the NPIC tool available through the Register, Update or Inquire About NPIs page.
26. Can Child Health and Disability Prevention (CHDP) providers bill electronically?
    A: Yes. CHDP providers can bill electronically using the proprietary Computer Media Claims (CMC) format. This format will be updated to accommodate the 10-digit NPI. The CHDP proprietary electronic billing format has been revised to accommodate NPI use. For more information, providers can review the CHDP provider manual.
27. How does Medi-Cal validate NPIs supplied by providers?
    A: Medi-Cal checks the validity of an NPI using algorithm logic and plans to also utilize file comparisons against other sources of data as needed.
28. Will the 10-digit NPI require new billing software?
    A: If a provider's software does not currently accommodate a 10-digit provider identifier and it cannot be updated to do so, then new billing software will be needed.
29. What is a health care clearinghouse?
    A: A health care clearinghouse supplies software that allows providers to electronically transmit claims through them and then transmits the claims to Medi-Cal. Health care clearinghouses are typically used by large-volume providers.
30. Does the NPI number replace the Medi-Cal provider number on claims only?
    A: No. Effective December 17, 2007, either the NPI or the Medi-Cal provider number is required for all transactions and communication with Medi-Cal. Only “atypical” providers (Blood Banks, Christian Science Practitioner and Multipurpose Senior Services Program) are exempt from submitting an NPI and will continue to use their Medi-Cal provider number.
31. If a provider registers an NPI on the Medi-Cal Web site, but the provider’s internal electronic billing system hasn’t been tested for Medi-Cal billing, will the claims be denied?
    A: A claim may be denied if the provider’s internal billing software is not updated to accommodate the NPI or if the NPI is not displayed on the claim correctly. Medi-Cal does not plan to require testing using the NPI specifically. If you use a POS device, then you will be requested to test the new software download, which was made available August 25, 2007.
32. After December 17, 2007, will Medi-Cal reject claims billed with other provider identification numbers such as a Taxpayer Identification Number (TIN)?
    A: Yes. The TIN is a data element on the claim and not a provider identification number. Effective December 17, 2007, DHCS only accepts either an NPI or a Medi-Cal provider number until instructed otherwise. Only “atypical” providers (e.g., Blood Banks, Christian Science Practitioner, Multipurpose Senior Services Program) are exempt from submitting an NPI and will continue to use their Medi-Cal provider number.
33. Will Medi-Cal require taxonomy codes on claims once the NPI is mandatory?
    A: Although Medi-Cal is requesting taxonomy codes with NPI registration, the taxonomy codes will not be used to adjudicate claims.