NPI Mapping for Billing Providers
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1 NPI Mapping for Billing Providers All Providers enrolled with the New Jersey Medicaid Program need to have their National Provider Identifier (NPI) registered with New Jersey Medicaid. The NPI is a numeric 10-digit identifier, consisting of nine numbers plus a standard checkdigit in the 10th position. It is accommodated in all standard transactions and contains no embedded information about the health care professional it identifies. Effective with the implementation of Version 5010 of the HIPAA 837 Claim Transactions all providers need to be identified on the 837 claim using the provider s NPI. It is no longer appropriate to use the New Jersey Medicaid provider number to identify the provider. Every New Jersey Medicaid provider is required to have obtained an NPI and the NPI needs to be associated to every appropriate New Jersey Medicaid provider number. A single NPI can be associated to multiple New Jersey Medicaid Provider Numbers and multiple NPIs can be associated to a single New Jersey Medicaid Provider Number. It is essential that you have your NPI registered with New Jersey Medicaid so that we can continue to accept your claims electronically. While you are required to use the NPI on incoming claims, New Jersey Medicaid will continue to process your claims and make payment under your New Jersey Medicaid provider number. This means that the New Jersey MMIS must be able to cross-walk the NPIs on the incoming claims to New Jersey Medicaid provider numbers. If the NJMMIS is unable to cross-walk the NPI to a New Jersey Medicaid provider number, your claim will not be paid. If you are enrolled as a New Jersey Medicaid Provider but have not applied for and been issued an NPI, then you need to submit a request for an NPI. The Centers for Medicare and Medicaid Services (CMS) is contracted with Cognosante, LLC, to assign NPIs. There are two ways for you to apply for an NPI: 1. Web-based application: Visit 2. Telephone: Call the NPI Enumerator at or TTY and request an application. Molina Medicaid Solutions 3705 Quakerbridge Road, Suite 101, Trenton, NJ Fax:
2 If you have been issued an NPI but have failed to register the NPI with New Jersey Medicaid, you need to register your NPI with New Jersey Medicaid as soon as possible. Pease either mail or fax a written request to Molina Medicaid Solutions. Your request needs to be on your letterhead and must include the following information: Your New Jersey Medicaid Provider Number Your National Provider Identifier (NPI) The taxonomy code(s) under which your NPI is registered with NPPES You can mail this information to Molina Medicaid Solutions at the following address: Molina Medicaid Solutions Provider Enrollment Department 3705 Quakerbridge Road, Suite 101 Trenton, NJ You can fax this information to Molina Medicaid Solutions at The more providers linked to a single NPI number, the more complicated the NPI mappings become to obtain the intended NJ Provider ID. This also makes submission of the data needed to map to a specific Billing Provider more restrictive. More than one NPI can be linked per provider as needed. Providers can forward information in writing to Provider Enrollment to add or remove providers from the NPI listed for their facility as needed. Each NPI registered with New Jersey Medicaid is mapped to a New Jersey Medicaid provider number using any of three different mapping types. Each of these mapping types are described below. 1 to 1 Mapping One Medicaid provider identification number linked to one NPI. Ex: (NJMMIS Provider ID NPI ) When a file is sent electronically, our system automatically looks for defects that will reject the file, such as: Incorrect transaction sets, Medicaid electronic payer identification number, and the Billing Provider s NPI number. Page 2 of 5
3 Once the file is submitted, the NPI will be verified to make sure the NPI loop and segment (2010AA / NM108 & NM109) is populated with a valid 10 digit NPI number. Once the file is received it is then entered into the pre-adjudication process where the files are processed in more detail. At this point, the system will locate the NPI number in our system to verify it is a valid number. Once the number is validated, the Billing Provider s NPI is linked to the Billing provider s Medicaid Provider ID number under the NPI mapping rules. If a NJ Medicaid Provider ID Number cannot be determined for the Billing Provider, the claim is rejected. Taxonomy Mapping Taxonomy codes are national specialty codes used by providers to indicate their specialty at the claim level. Taxonomy codes are 10 characters, consisting of numbers and alpha characters. The taxonomy code must be a valid taxonomy code. Only those taxonomy codes that are registered with NPPES should be included on your 837 claim transactions submitted to Molina Medicaid Solutions. Some Providers have several providers linked with one NPI number. In this event, the providers under the NPI can be linked with different Taxonomy s. Example 1: NPI Taxonomy 261Q00000X = NJMMIS Provider Number Example 2: NPI Taxonomy 281Q00000X = NJMMIS Provider Number The examples above illustrate where the provider has a single NPI but has been enrolled with New Jersey Medicaid under two different provider numbers. Claims for New Jersey Medicaid Provider Number must be submitted using taxonomy code 261Q00000X and claims for New Jersey Medicaid Provider Number need to be submitted using taxonomy code 281Q00000x in order for these claims to be processed corrected. Zip Mapping A provider can be linked by zip code as well. Example: NPI Zip = New Jersey Medicaid Provider Number In this example a claim submitted with an NPI of and a zip code of will be processed under New Jersey Medicaid Provider Number When the initial cross-walk is built by Molina Medicaid Solutions, it will be built using Page 3 of 5
4 the servicing address zip code. If the zip code that is submitted on the 837 claim transaction does not match the service location zip code for the provider, the claim may be denied or processed under the incorrect New Jersey Medicaid provider number. Some Providers have several providers linked with one NPI number. In this event, the providers under the NPI can be linked by different Zip s. A provider can contact the Provider Enrollment Unit to add, update, or remove a zip code mapping to an NPI, but it must also be the Servicing Address zip code. The system will attempt to link the Billing Provider s zip code (in 2010AA/N403) with the provider number that is mapped with the zip code placed on the NPI Mapping file, dependent upon the NPI hierarchy. Crosswalk Hierarchy We search using the NPI and no other info, if we can crosswalk from the NPI to one provider (map type 1), no more searching is required; if not We search using NPI and taxonomy code, if we can crosswalk from the NPI and taxonomy to one provider, no more searching is required; if not We search using NPI and zip code, if we can crosswalk from the NPI and zip code to one provider, no more searching is required; if not We post an edit that we are unable to crosswalk the NPI. The system will attempt to link the Billing Provider s zip code (in 2010AA/N403) with the provider number that is mapped with the zip code placed on the NPI Mapping file, dependent upon the NPI hierarchy. If the zip code that is submitted on the 837 files does not match a zip code under the NPI, the claim will reject. If the claim is submitted with the wrong zip code for the intended Billing Provider ID and the zip code is valid and linked with another provider under the NPI, the claim will be accepted under the provider that is linked with the zip code that was billed. Mapping Examples 1 to 1 = One NPI to One New Jersey Medicaid Provider Number In this example, the provider has been assigned a single NPI and has been enrolled in New Jersey Medicaid under a single New Jersey Medicaid provider number. We define this as a 1 to 1 crosswalk. Any claim submitted with NPI will be mapped to New Jersey Medicaid provider number regardless of the taxonomy code or zip code. Page 4 of 5
5 Provider NPI # Mapping Type Taxonomy Zip to Many = One NPI to many New Jersey Medicaid Provider Numbers, mapped by Zip or Taxonomy Provider NPI # Mapping Type Taxonomy Zip Zip Zip Taxonomy 261Q00000X Please note in the example above: The first two providers ( and ) should never bill with the taxonomy code of 261Q00000X and provider must always use the taxonomy code 261Q00000X. This will prevent incorrect mappings and payments for unintended providers. *Please contact the EDI unit at if you have any questions or concerns in regards to electronic file submissions (837) or E-R-A (835) reports. Page 5 of 5
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