NPI Everyone?

NPI, 3 little letters of the alphabet. Who could have predicted their meaning and impact? Meaning: National Provider Identifier. Impact: bigger than a 3-word definition.

Most people in the medical community are well aware that NPI is the new standard for Provider IDs across insurance carriers. In May 2005, the Centers for Medicare & Medicaid Services (CMS) started encouraging health care providers to apply for their NPI number(s). The purpose of the NPI is to consolidate all the different payor-assigned IDs for a Group/Billing provider, Individual/Rendering providers, Referring, Ordering, and Supervising providers, and facilities into NPI numbers assigned by CMS for providers.

As part of the application process, CMS wants providers to include their legacy (current) identifiers for all payors. If reporting a Medicaid number, include the associated state name. This information is critical in the development of crosswalks to aid in the transition to the NPI. Taxonomy (specialty) codes are also an important piece of the application process. Be sure to provide all of your payors with as much information as possible when informing them of your NPI number(s).

Implementation of the crosswalks started in October 2006 as part of Stage 2 of the testing process for Medicare electronic submissions. As a result, incomplete crosswalks at many Medicare carriers caused informational edit/error messages to appear on response reports. Various codes are available for a state’s Medicare carrier to report error and edit information, and the range of M340 to M351 codes relates to invalid NPI vs PIN numbers. Claims with these codes and the word “informational” have been accepted. If you see the word “rejected” instead of “informational”, follow up is recommended. Most Medicare carriers have not yet gotten the crosswalks into place, and have no time estimate of when they will be. Therefore, these informational messages could continue for some time into early 2007.

Taxonomy codes also will be validated with the NPI eventually, so be sure to safeguard your enrollment information to confirm your taxonomy code(s) for future reference.

As for forms, CMS has stated in a recent transmittal that the 1500 implementation will become effective Jan 1, 2007. This is a delay from the Oct 1, 2006 date recommended by the Nat’l Uniform Claim Committee (NUCC). CMS requires the delay so the system changes can be made.

The form CMS-1500 (08-05) will be effective Jan 2007, but will not be mandatory until Apr 2, 2007. Timeline is as follows:

• 01/02/2007: Payors & vendors ready to handle revised form CMS-1500 (08/05).
• 01/02/2007 - 03/30/2007: Providers can use either the current form CMS-1500 (12/90) or the revised form CMS-1500 (08/05). NPIs can be included when a revised CMS-1500 (08/05) is submitted, but are not yet required. If an NPI is reported, it is strongly encouraged to also submit the corresponding legacy ID number. Failure to provide the legacy number with an NPI could result in a delay of processing the claim.
• 04/02/2007 - 05/22/2007: Current form CMS-1500 (12/90) is discontinued. All rebilling of claims as of this date should use the revised form CMS-1500 (08/ 05) even if earlier submissions were on the current form. Medicare will reject any claim received on a CMS-1500 (12/90). Use of the NPI is still not required on the new form, but is recommended, along with legacy numbers.
• 05/23/2007 - forward: CMS systems will only accept NPI numbers. Coordination of Benefits (COB) transactions sent to small health plans will continue to carry legacy identifiers, if requested by such a plan, through May 22, 2008. Medicare legacy numbers may no longer be reported on paper claims to Medicare.