The National Provider Identifier (NPI) Frequently Asked Questions

Transcription

1 The National Provider Identifier (NPI) Frequently Asked Questions Overview The Centers for Medicare & Medicaid Services (CMS), under the administrative simplification provisions of the Health Insurance Portability and Accountability Act (HIPAA), health care providers who submit standard electronic transactions was required to use a National Provider Identifier (NPI) by May 23, 2007 (small health plans by May 23, 2008). Large health plans such as Harvard Pilgrim was able to accept and send the NPI as the primary provider identifier on standard electronic transactions on this date. On April 2, 2007, CMS announced it would implement a contingency plan for covered entities (other than small health plans) unable to meet the May 23, 2007 deadline for compliance. The guidance clarifies that covered entities that have been making a good faith effort to comply with NPI provisions may, for up to twelve months, implement contingency plans that could include accepting legacy provider numbers on HIPAA transactions in order to maintain operations and cash flow. For more information about Harvard Pilgrim s response to this announcement, please refer to the questions and answers in NPI Contingency End Date section of s. Harvard Pilgrim s NPI Contingency Plan End Date was May 23, Beginning May 23, 2008, Harvard Pilgrim required that all provider electronic transactions and paper claims be submitted with a valid NPI as the provider identifier. Covered entities, as defined by HIPAA, are required to use the NPI as the primary provider identifier on standard electronic transactions. HIPAA standard transactions must have the appropriate valid NPI in the NM109 element in all provider loops submitted. Transactions submitted with only legacy identifiers, or with legacy identifiers in the NM109 element, will be rejected. Harvard Pilgrim Health Care p. 1 Updated on 01/07/2009

2 Contents Page General Questions...3 Implementation...6 NPI Contingency Plan End Date...7 Claim Submissions...8 Subparting...9 Systems, Testing and Reporting...10 Atypical Providers.11 Harvard Pilgrim Health Care p. 2 Updated on 01/07/2009

3 General Questions Q: What is the NPI, and what does it look like? A: The NPI is a unique, government-issued standard identifier mandated by Health Insurance Portability and Accountability Act (HIPAA). The purpose is to simplify the administrative processing of certain health care information, and to improve the efficiency and effectiveness of standard transactions. It will also replace all other billing provider numbers, including Harvard Pilgrim s provider ID number. This means that providers can use their NPI for transacting business with any health plan with which they are affiliated. The NPI is a unique, 10-digit permanent identifier (9 digits, plus a check digit) assigned to eligible health care providers. It does not expire or change, and is administered by CMS, and, once assigned, the Provider s NPI will not change, except under certain circumstances specified by CMS. It will remain with the provider regardless of job and location. Q: Who is eligible for the NPI? A: Individuals doctors, nurses, dentists, medical students, etc. who provide health care can obtain a unique NPI from the CMS Enumerator. Organizations hospitals, group practices, clinics, pharmacies including on-line pharmacies, etc. that provide health care can obtain unique NPIs for their organization and subparts from the CMS Enumerator. Q: What is a covered provider? A: A covered provider is a health care provider who transmits any health information in electronic form in connection with a transaction for which the Secretary of Health and Human Services has adopted a standard. This is true even if the health care provider uses a business associate to do so. Q: What does enumeration mean? A: Enumeration is the process of applying for and obtaining your NPI. Pre-enumeration involves conducting the analysis required to identify the best NPI structure for your organization. Q: How can a provider apply for an NPI? A: Health care providers may obtain their NPI by applying online through the Centers for Medicare and Medicaid Services. Go to and click on the link that says National Provider Identifier, on the right side of the screen. The CMS NPI Registry (online NPI lookup tool) is available to anyone who wants to search for provider NPIs. Q: Where can I go to find out more information about NPI and Electronic File Interchange (EFI)? A: For more details about NPI and EFI, visit Harvard Pilgrim Health Care p. 3 Updated on 01/07/2009

4 Q: Will the NPI be included as part of the renewal/initial license application process by the Massachusetts Board of Registration in Medicine (BORIM)? A: Yes, on August 15, 2005, BORIM began sending out the new Full License Renewal forms with the NPI authorization page, which will be for those physicians who are renewing beginning December Massachusetts physicians will not be able to renew their licenses unless they do one of the following: Provide authorization for BORIM to obtain an NPI number on their behalf Provide NPI assigned to them by the Enumerator Provide contact information of other individuals that will obtain an NPI on their behalf Go to the BORIM Web or contact BORIM for more information. Q: What does Harvard Pilgrim intend to do for new legacy numbers? If a provider joins an LCU and already has a Harvard Pilgrim legacy number, how will Harvard Pilgrim handle that situation? A: Harvard Pilgrim will continue assigning legacy provider numbers on our core system (AMISYS) to support our NPI crosswalk approach. Q: Does Harvard Pilgrim have a Companion Guide? If so, where can it be accessed? A: A complete listing of Harvard Pilgrim's Companion Guides for HIPAA transactions is available at Click on E-Transactions, then Companion Guides. Q: Will Harvard Pilgrim require providers to re-enroll after they get NPIs? A: No, Harvard Pilgrim will not require providers to re-enroll as a result of the NPI. Harvard Pilgrim has mapped its legacy provider identifiers to NPIs. We will continue to work collaboratively with our network providers to ensure no disruption in transaction processing. Q: How can providers submit their NPIs to Harvard Pilgrim? A: The easiest way to submit an NPI to Harvard Pilgrim is online, at our NPI Submission Center. Visit and click on News & Information, and then click on Hook into HIPAA/NPI. A link entitled Submit your NPI online will appear on the left menu. Q: How can providers confirm that Harvard Pilgrim has received their NPI(s) and mapped them to corresponding Harvard Pilgrim legacy identifiers? A: Providers who are registered users of HPHConnect for Providers may confirm NPI mapping there. Instructions for obtaining this information are included on HPHConnect for Providers. To register (it's free), go to and click on the registration link at the top of the screen. Harvard Pilgrim Health Care p. 4 Updated on 01/07/2009

5 Q: If a provider makes an error when submitting an NPI, what can be done to correct it? A: Harvard Pilgrim s Provider Change Form has been updated to include a section for submitting NPI corrections. All corrections to NPI must be communicated to Harvard Pilgrim via the new form located at Completed forms can be submitted to the Provider Processing Center at Harvard Pilgrim via , post mail, or fax: ppc@hphc.org Mail: Harvard Pilgrim Health Care Attn: Provider Processing Center, 2nd floor 1600 Crown Colony Drive Quincy, MA Fax: (617) , Attn: Provider Processing Center. Requests for corrections will not be accepted via phone. This process should not be used to submit NPIs for the first time or to request changes to demographic information associated with legacy (AMISYS) IDs. Q: How will Harvard Pilgrim communicate information about NPI to providers? A: We will continue to communicate information about NPI to providers through our normal communication channels. Look to future issues of our monthly newsletter, Network Leader, our monthly EOP messages, messages on the home page of HPHConnect and on our provider Web site at (Hook into HIPAA). Q: Will Harvard Pilgrim display NPIs in online and paper directories? A: Harvard Pilgrim made a decision not to display NPIs in online and paper directories, including display of NPIs on Harvard Pilgrim s public web site. Any changes to this approach will be communicated through standard communication channels. Q: What is Harvard Pilgrim's approach for using the CMS NPPES data? A: Harvard Pilgrim continues to capture and store the CMS provided NPPES monthly extract (full file updates) and uses it as verification and gap analysis of our existing NPI Crosswalk table. As part of HPHC s ongoing analysis work, we identify and load missing NPIs from the NPPES file into our NPI Crosswalk for providers that are licensed in Massachusetts, Maine, New Hampshire, Rhode Island, and Vermont.. Q: Do I need to update Harvard Pilgrim of changes to my NPI and provider demographic data, such as billing addresses, etc. since I am already required to submit these changes to CMS NPPES? A: Harvard Pilgrim requires that providers continue to submit changes to their provider demographic information, including billing address, practice address, etc. to Harvard Pilgrim. If providers have changes to their demographic information, they must complete the Provider Change Form, which is located at Harvard Pilgrim Health Care p. 5 Updated on 01/07/2009

6 Completed Provider Change Forms can be sent via to or fax to These updates are critical for accurate claims processing. Implementation Q: How has Harvard Pilgrim approached its implementation of NPI? A: Harvard Pilgrim built a crosswalk to map legacy provider numbers to NPIs. Q: Did the NPI requirement provide a big change to Harvard Pilgrim with respect to systems or operations? A: Harvard Pilgrim has not converted its legacy provider numbers to NPIs within our core system. Our most complex challenge was developing a crosswalk to map existing Harvard Pilgrim numbers to NPIs. Q: What does NPI mean to Harvard Pilgrim? A: Harvard Pilgrim must accept and send the NPI as the primary identifier for providers on HIPAA transactions (inbound/outbound) on or after May 23, Legacy provider numbers can no longer be submitted as the primary identifier for providers on HIPAA transactions on or after the compliance date of May 23, As the health care industry moves toward a standard identifier, many of our business processes and those of our vendors/business partnerships has been impacted by this change. Q: How are Harvard Pilgrim providers and other trading partners affected by Harvard Pilgrim s approach? A: Efforts to collect, map, and verify NPIs to Legacy ID numbers will be ongoing, as will communication to providers encouraging NPI compliance. Q: How will Harvard Pilgrim support transaction testing before and after May 23, 2007? A: At the end of June 2007, Harvard Pilgrim implemented a test environment to support provider s testing of their NPI programming for claims submission. The output of the testing will be a 277 Claims Acknowledgment submitted to the provider. The testing will not confirm correct claim adjudication or produce an 835. Q: Will Harvard Pilgrim s project timeline change as a result to the CMS announcement regarding NPI contingency? A: Harvard Pilgrim has focused on collecting NPIs to mitigate risks of payment or transaction inaccuracies on and after May 23, In parallel, our technology approach was designed to accommodate the submission of NPI only, Legacy ID only or dual submission of NPI on or after May 23, This approach has accommodated providers and other trading partners in various stages of readiness for NPI implementation. Harvard Pilgrim Health Care p. 6 Updated on 01/07/2009

7 NPI Contingency Plan End Date Q: Has Harvard Pilgrim defined its NPI Contingency Plan End Date when NPI will be required on HIPAA electronic transactions and paper claims? A: Beginning May 23, 2008, Harvard Pilgrim required that all provider electronic and paper transactions be submitted with a valid NPI as the provider identifier. HIPAA standard transactions must have the appropriate valid NPI in the NM109 element in all provider loops submitted. Transactions submitted with only legacy identifiers, or with legacy identifiers in the NM109 element, will be rejected. Paper claims, including UB-04, CMS-1500 and ADA J400 forms, must be submitted with a valid NPI in the correct provider fields on the form. Paper claims submitted without an NPI, or without an NPI in the correct field location, will be returned to providers for correction and resubmission. The HIPAA standard electronic transactions include: 837 Professional / Institutional / Dental Claims, 270 / 271 Benefit Eligibility / Inquiry and Response, 276 / 277 Claims Status Inquiry and Response, 278 Referral / Authorization. Please refer to HPHC Companion Guides for additional Q: Why is Harvard Pilgrim continuing to accept transactions submitted with a legacy identifier in secondary fields? A: Beginning May 23, 2008, Harvard Pilgrim will reject HIPAA standard electronic transactions submitted without a valid NPI as the primary provider identifier. While we understand that the intent of the Rule is to use NPIs only in standard transactions. HPHC has elected not to implement a hard edit on the secondary identifier fields, preferring instead to rely on the provider's status as a covered entity to implement the NPI standards. This decision was made to reduce potential delays in claims processing and minimize disruption to day-to-day operations. Q: Where can providers obtain detailed NPI submission requirements for electronic and paper claims? A: For electronic claims submission information, refer to the 837 Institutional and Professional Companion Guides at or call the EDI Team at (800) For additional details on paper claims, please refer to the Billing and Reimbursement section of the Harvard Pilgrim Provider Manual at or call the Provider Service Center at (800) Harvard Pilgrim Health Care p. 7 Updated on 01/07/2009

8 Claim Submissions Q: How will paper claims submission be affected by Harvard Pilgrim s approach and CMS s contingency plan announcement? A: Harvard Pilgrim s timeline and requirements for the submission of new paper claim forms will not change from what has been publicized to date. Harvard Pilgrim required the use of the new CMS-1500, UB-04 and ADA J400 paper claim forms. Older versions of the paper claim forms will no longer be accepted. As of June 1, 2007, use of the red and white version of the new CMS 1500 (rev ) form is required in order for claims to be considered for payment. Click here for information about obtaining and filling out the new CMS-1500 Form. As of May 23, 2007, use of the new red and white version of the UB-04 form is required in order for claims to be considered for payment. Click here for more information about the UB-04 Form. As of November 1, 2007, use of the new version of the ADA J400 form is required in order for claims to be considered for payment. Q: When did Harvard Pilgrim begin including the NPI on the 835 Electronic Remittance transaction? A: On May 23, 2007, Harvard Pilgrim began including the NPI on the 835 transaction. Q: Will Harvard Pilgrim require taxonomy codes to support claims processing? A: Harvard Pilgrim does not require the use of taxonomy codes for claims adjudication, and does not anticipate using these codes in the future. Q: What is Harvard Pilgrim s policy regarding placement of the NPI on a referring physician s claim form when neither Harvard Pilgrim or the submitting entity has the referring physicians NPI? A: PCPs making referrals for specialty care will be required to provide their NPI in place of their legacy Harvard Pilgrim provider ID at the time of the referral request whether requesting by phone, fax or through HPHConnect or NEHEN. Specialists billing for these services will be required to include the referring physician s NPI, along with their own, when submitting claims. Providers or facilities submitting notifications or requests for authorizations will also be required to provide the requesting and servicing provider NPIs in place of the legacy Harvard Pilgrim provider IDs. Status inquiry will also require the provider NPI in place of the legacy ID. To support NPI use, demographic information such as address for requesting & servicing providers and TIN for requesting providers will be needed when submitting referral authorization transactions or inquiring on the status of these transactions through the NEHEN application. Harvard Pilgrim Health Care p. 8 Updated on 01/07/2009

9 Subparting Q: What is an NPI subpart? A: HIPAA-covered entities are legal entities. Often, a health care provider that is an organization may be comprised of components that function as health care providers somewhat independently of the parent (the covered organization health care provider of which they are a part). These components, which we call subparts, might conduct their own HIPAA standard transactions, be certified by the state separately from their parent, or be located at the same location as, or a different location from, their parent. Comment [B1]: Suggest combining these, or striking number 11. The covered organization health care provider needs to determine if it consists of any such subparts, and, if it does, it must determine if any of those subparts needs to have its own unique NPI in order to be identified in HIPAA standard transactions. Many providers that are enrolled in Medicare are actually subparts. Examples of subparts may include different components of an organization health care provider, such as different departments of a hospital, and separate physical locations of an organization health care provider, such as the different locations of the members of a chain. Q: How do I determine if my organization needs to subpart? A: It is the provider/facility decision to subpart or not. The decision should be based on an organization s business need. Providers should complete an analysis of the provider numbers currently used and how they relate to their proposed NPI schema. Key questions providers should ask themselves are: 1. Are some numbers set up for special reimbursement? 2. Do some indicate service location? 3. Are system changes required? Providers should get in touch with their vendors, clearinghouses and payers to find out their rollout dates for accepting NPI. Q: Why is Subpart Determination Necessary? A: Subpart determination ensures that entities within a covered organization health care provider that need to be uniquely identified in HIPAA standard transactions obtain unique NPIs for that purpose. The NPI Final Rule provides guidance to covered organization health care providers in determining subparts and whether or not they should have NPIs. A subpart that conducts any of the HIPAA standard transactions separately from the parent must have its own unique NPI. If Federal regulations exist that require an entity to have its own unique identification number for purposes of billing Federal health plans, such as Medicare, the covered organization health care provider would need to ensure that, if it were composed of subparts that were affected by such regulations, each subpart obtained its own NPI in order to be compliant with those regulations. This is because NPIs will eventually Harvard Pilgrim Health Care p. 9 Updated on 01/07/2009

10 replace the billing numbers that had been assigned by Medicare. Medicare Durable Medical Equipment (DME) suppliers must obtain NPIs for each physical location in order to comply with such Federal regulations. No similar Federal regulations exist for other types of Medicare providers. Q: Who is Affected by Subpart Delegation? A: Medicare providers that apply for NPIs as Organizations (Entity Type 2) are affected by the subpart concept. Organizations include hospitals, nursing homes, DME suppliers, supplier groups, home health agencies, ambulatory surgical centers, ambulance companies, and many others - some of which may be subparts of others. Individuals are considered legal entities, cannot designate subparts, and cannot be considered subparts. Q: If a provider subparts for a specific department/reason (e.g., DME, dialysis, psych) will this result in adjudication issues for Harvard Pilgrim? How will this affect the processing? A: Because Harvard Pilgrim has mapped the Harvard Pilgrim legacy numbers to NPIs, collaboration with providers in order to establish the appropriate crosswalk to facilitate accurate claim payment continues to be necessary. Q: What was Harvard Pilgrim s approach regarding the NPI and subparting? A: Harvard Pilgrim has contacted and worked collaboratively with select providers to obtain and understand their subparting approach. We believe working directly with providers to evaluate proposed subparting will proactively identify issues that could impact transaction processing once NPIs are required. Q: Does Harvard Pilgrim anticipate an NPI for every provider identifier currently use in their system? A: Harvard Pilgrim has evaluated our current enumeration strategy. We anticipate that every active number in our core processing system (AMISYS) will need to be mapped to an NPI. We expect to work collaboratively with providers in order to fully anticipate the impact of NPI implementation. Systems Testing and Reporting Q: Will NPI values be available in non-hipaa format reports/documents? A: Existing reports will remain as is, without the NPI at this time. Q: Where should providers put the NPI during the testing stage, primary or secondary? For the ordering Provider? For the rendering Provider? A: Harvard Pilgrim requires all providers to submit the NPI in the primary (NM-109) position, the TIN in REF-02 with an EI qualifier, and the AMISYS number in REF-02 with a G2 qualifier during the testing stage. Harvard Pilgrim Health Care p. 10 Updated on 01/07/2009

11 Atypical Providers Q: What is the definition of Atypical Service Provider? A: Providers / entities who do not meet the definition of a health care provider as defined under HIPAA are not eligible to obtain an NPI. Examples of providers / entities who are not health care providers and do not provide health care include some wig providers, state agencies submitting claims to health plans, non emergency transportation providers such as taxis, personal care attendants, building contractors, language interpreters, etc. These types of providers / entities are referred to as atypical service providers in the NPI Rule. Comment [B2]: Suggest combining these, or striking number 11. Q: What is happening? A: According to the NPI Rule, certain providers / entities who currently submit claims may not be eligible to obtain an NPI, and as such Harvard Pilgrim would not expect them to submit an NPI on claims for services provided to members for covered services. Examples of these entities include certain wig providers and the Commonwealth of Massachusetts submitting State Reclamation Claims. Q: How should these providers / entities submit claims to Harvard Pilgrim? A: In order for accurate adjudication, all claims submitted to Harvard Pilgrim must continue to include Harvard Pilgrim Health Care legacy provider ID number in the appropriate claim form field. Beginning May 23, 2008, claims submitted either by paper or electronically without a Harvard Pilgrim provider ID number would be returned for resubmission with the appropriate provider numbers included. Q: How can I validate whether I am considered an Atypical Service Provider at Harvard Pilgrim? A: This is a determination made by the provider. Providers should contact the CMS NPI Enumerator at if they have questions or need additional information. Harvard Pilgrim Health Care p. 11 Updated on 01/07/2009