Credentialing, 855 Forms and NPI for Community Health Centers National Association of Community Health Centers (NACHC) 7200 Wisconsin Avenue, Suite 210 Bethesda, MD 20814 301-347-0400 301-347-0459 FAX www.nachc.com
Agenda Introduction Credentialing Why? NPI PECOS 855 Forms CMS 588 Locum Tenens State Medicaid & Other Payers Summary
Disclaimer: 1. The guidelines, interpretations, and recommendations set forth as part of this training session are presented as a guide only. Attendees understand and recognize that actual coding/billing decisions are the sole liability and responsibility of the provider(s) and respective billing staff. Priority Management Group, Inc. does not accept any liability or responsibility in this regard. 2. The presentation today includes discussion about a particular commercial product/service and the presenter may have a significant financial interest/relationship with the organization that provides this product/service.
Credentialing Why? Provider participation = Opportunity for optimal payer payment Vetting Process for Payers o Avoidance of fraud o Tracking of problem providers Ability to better direct beneficiaries to specialists & certain provider types Payer compliance with National Committee for Quality Assurance (NCQA) o E.g., 98% Board Certified Doctors Ability to Maximize Cost Containment o Special Contracts with IPAs or large groups
National Provider Identifier (NPI) 1 of 3 HIPAA (1996) mandated creation of National Plan & Provider Enumeration System (NPPES) NPI: Standard unique health identifier for providers o Assigned by the NPPES FQHC MUST obtain NPIs prior to enrolling in Medicare OR before submitting change to existing Medicare enrollment information NPI Application SEPARATE from Medicare enrollment Apply on-line: https://nppes.cms.hhs.gov Contact Info: NPI Enumerator is Fox Systems o Use link above or call 800-465-3203 o customerservice@npienumerator.comnpi
National Provider Identifier (NPI) 2 of 3 Subparts at FQHC, all Core Providers & individual sites require independent NPIs FQHCs are Type 2 entities for purpose of NPI due to corporation status vs. sole proprietor status For more information about subparts: www.cms.hhs.gov/nationalprovidentstand Search for NPI o https://nppes.cms.hhs.gov/nppes/npiregistryhome.do Medicare Identification Number o a.k.a., CMS Certification Number (CCN) or Medicare legacy number (e.g., UPIN) o Generic term for any number other than the NPI used to identify a Medicare provider
National Provider Identifier (NPI) 3 of 3 How to use the NPI Part A/NGS Must have NPI for each clinic location o Provider Transaction Access Number (PTAN) for each location MUST bill under NPI (which is linked in the Medicare system to PTAN) Individual Providers do NOT need PTAN for NGS billing just core provider with NPI o Part B Two Options: One NPI & One PTAN for ALL locations (NC) One NPI & One PTAN for EACH location MAC dependent variables exist NPPES will assign NPI to ANYONE regardless of credentials
Provider Enrollment, Chain & Ownership System (PECOS) Welcome to PECOS (recorded since 1993) o https://pecos.cms.hhs.gov/pecos/login.do Individual & Group NPI Data Managed o MUST enroll & maintain own data o Option exists to afford someone else control How To (INCREDIBLE PDF Detail) o http://www.cms.hhs.gov/medicareprovidersupenroll/d ownloads/pecoswebscreenexample.pdf Why is PECOS used? Submit an enrollment application to Medicare View & update existing enrollment information View status of applications submitted via PECOS
PECOS Required Data (1 of 2) Must have the following in place to use PECOS: Active National Provider Identifier (NPI) National Plan and Provider Enumeration System (NPPES) User ID and password Personal identifying information. (Legal name on file with the Social Security Administration, DOB, SSN Schooling information (School Name & Graduation year) Professional license information. (Medical license number, Original effective date, Renewal date,& State where issued) Certification information. (Number, Original effective date, Renewal Date, State where issued) Specialty/secondary specialty information
PECOS Required Data (2 of 2) Must have the following in place to use PECOS: Drug Enforcement Agency (DEA) number (&, If applicable, information regarding any final adverse actions. Practice location information. (Physical location) Special Payment Information Medical Record Storage Information Billing Agency Information (if applicable) Any Federal, State, and/or local (city/county) professional licenses, certifications and/or registrations specifically required to operate as a health care physician or non-physician practitioner EFT Transfer documentation all 855 forms NOTE: Detail presented to demonstrate why providers MUST manage this personally or afford incredible access to intimate personal detail.
855 Forms A Delineation Part A (Intermediary) vs. Part B (Carrier) Part A = National Government Services (NGS) or MAC Intermediary (latter as of April 2009) o Carrier is Part B HOWEVER All Encounter Rate inquiries through Part A & FFS questions through Part B E.g., NC Cigna is Part B and Palmetto is Part A 855-A (Part A Group Application) o Institutional Claim Form (Loop 2010AA, ANSI 837I) 855-B (Part B GROUP Application) o Individual FFS Claim Forms (Loop 2010AA, ANSI 837P) 855-I (Each individual core provider for Part B Only) o Individual FFS Claim Forms (Loop 2310B, ANSI 837P) 855-R (Each individual core provider for Part B Only) o Re-Assignment (ANSI 837P)
855 Forms Paper or Electronic Paper Applications, Initial: 80% within 60 calendar days of receipt 90% within 120 calendar days of receipt 99% within 180 calendar days of receipt Web Based Applications (PECOS), Initial 90% within 45 calendar days of receipt 95% of CMS-855 Web-based initial applications within 60 calendar days of receipt 99% of CMS-855 Web-based initial applications within 90 calendar days of receipt NOTE: If required documents are missing and not timely submitted upon request, this will result in a longer processing time
855 Forms Change/Edit of Info Change of Information o 80% within 45 calendar days o 90% within 60 calendar days o 99% within 90 calendar days Provider Enrollment s Goal: o Process the majority of Change of Info within 45 calendar days or sooner o If required documents are missing, and/or not timely submitted upon request longer processing time o Afforded up to 90 calendar days to process Change of Information Applications
Reasons for Returned Forms No signature Incorrect Version Copied application Stamped signature Signature not dated Failed to submit required forms Completed in pencil Applicant submitted wrong application Application received more than 30 days prior to the effective date listed on the application Source: NHIC Provider Outreach & Education presented by Lori Langevin 5/10/10
CMS 855-A Institutional (1 of 2) Completed for Encounter Rate billing Who completes this? Community Mental Health Center Comprehensive Outpatient Rehabilitation Facility Critical Access Hospital End-Stage Renal Disease Facility Federally Qualified Health Center Histocompatibility Laboratory Home Health Agency Hospice Hospital Indian Health Services Facility Organ Procurement Organization Outpatient Physical Therapy &/or Occupational Therapy &/or Speech Pathology Services Religious Non-Medical Health Care Institution Rural Health Clinic Skilled Nursing Facility
PECOS Log-In use NPPES log-in & password o https://pecos.cms.hhs.gov/pecos/login.do Completed for ALL freestanding locations o One for each site Link to Paper Application (Not recommended): http://www.cms.gov/cmsforms/downloads/cms 855a.pdf CMS 855-A Institutional (2 of 2) Link to Paper Application (Not recommended): o http://www.cms.gov/cmsforms/downloads/cms855a.pdf PECOS Process Education & Info o PECOS Webex training below o http://www.cms.gov/medicareprovidersupenroll/04_inter netbasedpecos.asp
CMS 855-B Group Practice/Clinic Complete 855-B if you are a medical practice or clinic that will bill for Medicare Part B services (e.g., group practices, clinics, independent laboratories, portable x-ray suppliers) o https://www.cms.gov/cmsforms/downloads/cms855b.pdf Needed for FFS, Part B Billing o Loop 2010AA, ANSI 837P 855-B will result in PTAN obtainment PTAN not needed to bill but needed to be linked with NPI to be paid (this is done by Medicare in the background) NPI, PTAN, and last five units of tax ID needed for claim research
CMS 855-I Individual (1 of 2) Anesthesiology Assistant Audiologist Certified nurse midwife Certified registered nurse anesthetist Clinical nurse specialist Clinical social worker Mass immunization roster biller Nurse practitioner Occupational therapist in private practice Physical therapist in private practice Physician assistant Psychologist Clinical Psychologist Registered Dietitian Nutrition Professional Speech Language Pathologist FFS billing Who completes this?
CMS 855-I Individual (2 of 2) Link tlink to Paper Application (Not recommended): o https://www.cms.gov/cmsforms/downloads/cms855i.pdf PECOS Process Education & Info o o PECOS Webex training below http://www.cms.gov/medicareprovidersupenroll/04_internetbasedpecos.asp PECOS Log-In https://pecos.cms.hhs.gov/pecos/login.do Completed for ALL individual clinicians o One for each provider Paper Application (Not recommended): o https://www.cms.gov/cmsforms/downloads/cms855i.pdf PECOS Process Education & Info o o PECOS Webex training below http://www.cms.gov/medicareprovidersupenroll/04_internetbasedpecos.asp PECOS Log-In https://pecos.cms.hhs.gov/pecos/login.do Completed for ALL individual clinicians o One for each provider
CMS 855-R Professional 855-R = Reassignment Used with 85855-R = Reassignment Used with 855-I to reassign payment to corporation Averts tax liability for individual providers to the corporate entity for which they work Linked to corporate data from 855-B Allows clinicians to work for more than one practice simultaneously EFT Requisite 5-I to reassign payment to corporationerts tax liability for individual providers to the corporate entity for which they work
Locum Tenens Medicare Part B Services Only Part A only requires Face-to-Face with Core Provider AND billing under group name/npi NOT standard across commercial or Medicaid Strict guidelines* Must replace departed provider (not new site, no provider or newly arrived doctor with no par #) Must be paid not volunteer Up to 60 Days, wait a day, and restart *MCPM, Chapter 1, Section30.2.11, C Q6 modifier in 24D on CMS 1500
CMS 588 Form & ECS Agreement Electronic Fund Transfer (EFT) https://www.cms.gov/cmsforms/downloads/cms588.pdf Requisite for ANY Medicare participating provider NO EXCEPTIONS Electronic Claim Submission (ECS) Agreement Unique as they are dependent on regional MAC Clearinghouse will completed their ECS data, CHC updates NPI, PTAN, address, etc. When you get 855 Approval, MAC is defined in notice Contact clearinghouse for correct ECS forms Direct Option exists but NOT recommended
Utilize Credentialing Verification Organization, if able Medicaid & Commercial Payers Similar to aforementioned Medicare Varies dramatically state to state Use on-line vs. paper when able For all payers (including Medicare) PAY ATTENTION TO DEADLINES/TIMELINES Keep time-dated diary of events Maintain contact names & phone/email Copy EVERYTHING before sending Original signatures only Send any paper CERTIFIED MAIL only
Summary Use PECOS and Other Electronic Filing Options Maintain Current Listing of Providers and Locations Know Re-Credentialing Timelines Educate Clinicians and Billing Team Commit to Educate (Top down)
Contact Information Priority Management Group, Inc. (PMG) 700 School Street Pawtucket, RI 02860 P: 401-616-2000 F: 401-616-2001 www.chcbilling.com Raymond Jorgensen, President & CEO Raymond.JORGENSEN@gopmg.com Robert Skeffington, CHBME, Partner and Co-founder Robert.SKEFFINGTON@gopmg.com Carolyn Peucker, Vice President, Consulting and Compliance