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Provider Authentication by Medicare Provider Contact Centers (GEN)
Posted May 7, 2008
MLN Matters Number: SE0814
Related Change Request (CR) #: 5089, 5277
Related CR Release Date: N/A
Related CR Transmittal #: N/A
Effective Date: N/A
Implementation Date: N/A
The NPI Will Be Required for All HIPAA Standard Transactions on May 23rd
As of May 23, 2008, the National Provider Identifier (NPI) will be required for all Health Insurance Portability and Accountability Act (HIPAA) standard transactions. This means:
- For all primary and secondary provider fields, only the NPI will be accepted and sent on all HIPAA electronic transactions (837I, 837P, NCPDP, DDE, 276/277, 270/271 and 835), paper claims (UB-04 and CMS-1500) and standard paper remittance (SPR) remittance advice; and
- Reporting of Medicare legacy identifiers in any primary or secondary provider fields will result in the rejection of the transaction.
Provider Types Affected
Physicians, other providers, and suppliers who bill Medicare contractors (carriers, fiscal intermediaries (FI), regional home health intermediaries (RHHI), Part A/B Medicare Administrative Contractors (A/B MACs), or Durable Medical Equipment Medicare Administrative Contractors, (DME MACs)) for services provided to Medicare beneficiaries.
What You Need to Know
SE0814 covers the implementation of the National Provider Identifier (NPI) and the Provider Transaction Access Number (PTAN), effective May 23, 2008, as the provider authentication elements used when providers make telephone or written inquiries to the Medicare fee-for-service contractor provider contact centers.
Note: For providers enrolled in Medicare before May 23, 2008, their PTAN initially will be their legacy provider number. New providers enrolling in Medicare on or after May 23, 2008, will be assigned a PTAN as part of the Medicare enrollment process.
Background
In order to protect the privacy of Medicare beneficiaries and to comply with the requirements of the Privacy Act of 1974 and the Health Insurance Portability and Accountability Act (HIPAA), customer service staff at Medicare provider contact centers (PCCs) must properly authenticate the identity of providers/staff that call or write to request beneficiary protected health information before disclosing it to the requestor.
Please refer to the Medicare Contractor Beneficiary and Provider Communications Manual (Pub. 100-9), Chapter 3, §30, and Chapter 6, §80, for a complete discussion of this PCC authentication update. You can find these manual sections at www.cms.hhs.gov/manuals/downloads/com109c03.pdf and www.cms.hhs.gov/manuals/downloads/com109c06.pdf on the Centers for Medicare & Medicaid Services (CMS) Web site.
Provider Authentication
The elements for provider authentication of telephone (either customer service representative (CSR) or Interactive Voice Response (IVR)) and written inquiries are presented in the table below.
Provider Authentication Elements for Telephone & Written Inquiries
| On or after May 23, 2008 |
IVR |
Provider NPI and PTAN |
| On or after May 23, 2008 |
CSR |
Provider NPI and PTAN |
| On or after May 23, 2008 |
Written, including fax and email |
Provider name, and either provider NPI or PTAN |
Written Inquiries - Exception to Above Authentication Requirements
CMS allows an exception for written or faxed inquiries submitted on a provider's official letterhead, and email inquiries (with an attachment on letterhead). If the provider's name and address are included in the letterhead and clearly establish the provider's identity, no NPI or PTAN is required for authentication.
Additional Information
If you have any questions, please contact your carrier, FI, A/B MAC, or DME MAC at their toll-free number, which may be found at www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site. For the Upstate Medicare Division (UMD), you can call the toll-free provider line at 877-567-7173.
Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2007 American Medical Association. |
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