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End of NPI Contingency and Effects on Medicare Payments (GEN)
Posted May 5, 2008
Please read this important information regarding Medicare Part B payments as related to National Provider Identifier (NPI) issues.
We are very concerned about providers who continue to have file and/or claim deletions due to NPI editing. Some providers were not even aware of the problem when they were contacted. If you are not sending an NPI, or there is a problem with the match of the NPI to the legacy ID on the crosswalk, you are no doubt experiencing payment problems. The Centers for Medicare & Medicaid Services (CMS) contingency plan for NPI ends on May 23, 2008. If you do not send an NPI or send a legacy number in any provider identification number field, your entire file or claims within the file will be rejected, depending on where the ID number is located.
This is very serious. You will not receive payment for rejected claims/files due to NPI issues (if they would have otherwise been paid). The Upstate Medicare Division (UMD) has been publishing information and calling providers about the use of NPIs in order to prevent this. However, claims are still being rejected despite multiple contacts to offices. Please continue reading so that your payments are not delayed.
DUE TO THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA), NPIs are the only acceptable provider IDs on claims. NPIs have been MANDATORY on claims since March 1, 2008. AFTER May 22, 2008, LEGACY IDs CAN NO LONGER BE SENT in ANY provider ID fields or claims/files WILL BE REJECTED.
Previously, legacy IDs could be sent in provider identification fields. These legacy IDs were the Provider Identification Number (PIN) and Unique Physician Identification Number (UPIN). If you sent UPINs on a claim, you must now send an NPI. Therefore, if you submit services that have been referred, ordered, supervised, or purchased, by another physician and you previously would have sent his/her UPIN, you must now send his/her NPI. (The PIN is now called the Provider Transaction Access Number (PTAN) and is, or was assigned by Medicare when you enrolled, and is used behind the scenes only now for Medicare purposes (e.g., EDI-ERA, adjudication & finance, IVR, etc.), whereas the NPI is the provider ID for all payers. Per the NPI Final Rule, only the NPI can be sent on claims.)
PLEASE send a claim file with NPIs ONLY immediately to make sure that your claims can process in the Medicare system. Download your EDI error reports for those claims the very next day, and make sure there are no rejections or informational edits regarding the use of legacy IDs (see edit ERROR numbers below). Contact our office if you have ANY questions. The toll-free provider number is 877-567-7173 and the EDI Help Desk number is 866-528-8097.
THE END OF THE NPI CONTINGENCY IS ONLY A FEW WEEKS AWAY. IF YOU ARE USING A BILLING SERVICE OR CLEARINGHOUSE AND THEY ARE NOT COMPLIANT, YOUR CLAIMS WILL BE REJECTED. CONTACT THEM NOW IF YOU ARE NOT SURE THEY WILL SEND ONLY THE NPI IN YOUR CLAIMS.
If you enumerated with the National Plan and Provider Enumeration System (NPPES) incorrectly, and need to make a change, please access your information online at NPPES (https://nppes.cms.hhs.gov/NPPES/Welcome.do) and make the change immediately. Then send a file (again - with NPI only). If your claims are subsequently rejected for Mismatch on Crosswalk, it could require an update to your provider enrollment information at our office. These are being worked on a priority basis so if you are having problems, contact us immediately. There have been situations where sole proprietors were set up as groups, or organizations and/or their subparts were not.
If the crosswalk is at issue, confirm your provider structure (legally, if necessary) (i.e., whether individual or organization, or subpart of an organization - for example, a hospital department or clinic that bills separately from a parent company is a subpart). Then verify that you obtained the proper NPI when you enumerated - Entity Type 1 NPI for individuals or sole proprietors, even if the sole proprietorship has employees (who are also Type 1); and Entity Type 2 NPI for organizational providers and any subparts (Type 2 also). If these are right on NPPES, and you know you have enumerated properly, and continue to get rejections, your Medicare enrollment is likely the issue, and you will need to work with our Provider Enrollment Department to prioritize changes as quickly as possible. (There are separate crosswalks for Type 1 & Type 2 NPIs.)
AGAIN THIS IS EXTREMELY URGENT IF YOU ARE HAVING PROBLEMS, OTHERWISE YOU WILL NOT GET PAID FOR YOUR MEDICARE CLAIMS.
The following list of edits report on your daily electronic error report if there is a problem. The first group is for NO NPI NPI IS MANDATORY now. The second group is for Mismatch on the NPI to legacy ID Crosswalk. Both of these groups are currently rejecting files and/or claims. Finally, the last group is for secondary provider IDs. That is, for ordering, referring, supervising, facility, or purchased service providers. These edits are currently set to informational. However, beginning May 23, 2008, these edits will reject claims. Therefore, claims hitting these informational edits will not be paid after May 22, 2008.
CHECK FOR THESE EDITS ON YOUR EDI ERROR REPORT DAILY:
NPI IS MANDATORY
M389 2010AA Billing Provider NPI Mandatory Rejects the entire file.
M390 2010AB Pay-to Provider NPI Mandatory Rejects the entire file.
M391 2310B Claim Level Rendering Provider Rejects the claim.
M392 Detail Level Rendering Provider Rejects the claim.
PRIMARY PROVIDER NPI MUST MATCH LEGACY ID ON CROSSWALK
M340 2010AA Billing Provider Mismatch on Crosswalk Rejects the file.
M341 2010AB Pay-to Provider Mismatch on Crosswalk Rejects the file.
M343 Claim Level Rendering Provider Mismatch on Crosswalk Rejects the claim.
M347 Detail Level Rendering Provider Mismatch on Crosswalk Rejects the claim.
SECONDARY PROVIDER NPIs ARE MANDATORY
M393 2310A Claim Level Referring Provider ID Must Be NPI.
M394 2310C Claim Level Purchase Service Provider Must Be NPI.
M395 2310D Claim Level Service Facility Provider Must Be NPI.
M396 2310E Claim Level Supervising Provider Must Be NPI.
M397 2420B Detail Level Purchase Service Provider Must Be NPI.
M398 2420C Detail Level Service Facility Provider Must Be NPI.
M399 2420D Detail Level Supervising Provider Must Be NPI.
M400 2420E Detail Level Ordering Provider Must Be NPI.
M401 2420F Detail Level Referring Provider Must Be NPI. |
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