Verifying NPPES Data
CMS has found a significant number of instances where either the Legal Business Name (LBN) and/or Employer Identification Number (EIN) of an organization health care provider who has been assigned an NPI do not match Internal Revenue Service (IRS) records. In some cases, this is caused by health care providers who are individuals who erroneously applied for NPIs as organizations and who reported their Social Security Numbers in the EIN field. As a first step to improving the quality of information in the National Plan and Provider Enumeration System (NPPES), we are requesting that organization health care providers verify their LBN and EIN within NPPES. This is especially important if the organization health care provider is experiencing any Medicare claims processing issues.
Important Information for Medicare FFS Providers
Effective March 1, 2008, all 837P and CMS-1500 claims received must have an NPI or NPI/legacy pair in the required primary provider fields. Failure to include an NPI will cause the claim to reject!
What to do if your 837P or CMS-1500 Claim Rejects
Check your record in the National Plan and Provider Enumeration System (NPPES)
o Validate that the legacy identifier sent on the claim is reported in your NPPES record. If the legacy identifier is not there, it needs to be added.
o Validate that the Legal Business Name (for a provider/supplier who is an organization) or the Legal Name (for a provider/supplier who is an individual or a sole proprietorship) is correct.
o Validate that the correct Entity type was selected at the time of NPI application. Individuals obtain an NPI as Entity Type 1. Organizations obtain an NPI as Entity Type 2 NPI.
(Note: If you enumerated through the EFI alternative or submitted a paper NPI application, you should use the NPI Registry to check the content of your NPPES record. Make sure to have the Customer Service Representative at your Medicare contractor verify your Employer Identification Number (EIN) because the NPI Registry does not display EINs.)
If the above validation is successful and your claims continue to reject, call the Customer Service Representative at your Medicare Contractor.
o Have a copy of your NPPES record or your NPI Registry record in hand. A copy of your NPPES record can be printed from NPPES by going online at https://nppes.cms.hhs.gov and using the User ID and password selected when you applied for your NPI. If you obtained your NPI through the EFI alternative or submitted a paper NPI application, you should print your record from the NPI Registry at https://nppes.cms.hhs.gov/NPPES/NPIRegistryHome.do . EINs and Social Security Numbers (SSNs) are not displayed in the NPI Registry.
o Have the claim reject number and message
o Be prepared to give the following information:
1. Legal Business Name of the organization or Legal Name of the individual
2. Contractor Tracking Number (if known)
3. Approximate date (month/year) when the CMS-855 enrollment application was submitted or last updated
4. Provider/Supplier Tax Identification Number (EIN or SSN)
5. National Provider Identifier (NPI)
6. Medicare legacy Identifier
7. Practice location on claim (i.e., where is the practice located (e.g., 100 Main St., New Orleans, LA)
8. Contact Information where you can be reached if further discussion is needed
Some Clearinghouses Continue to Strip Information from Medicare Claims
It has come to CMS' attention that some clearinghouses continue to strip NPIs, as well as other information, from Medicare claims. If your clearinghouse continues to strip your NPI from your claims for any reason, notify your Medicare Contractor immediately so that CMS can work with your clearinghouse to resolve the issue.
In some cases, clearinghouses are stripping the SY qualifier and the SSN from claims that contain an NPI. Based on business requirement 4320.17 (outlined in Transmittal number 204, dated February 1, 2006), the qualifier SY is an acceptable qualifier for use on Medicare claims. See below block for specific details. You should share this information with your clearinghouse if you suspect they are stripping the SY qualifier and the SSN from your claims.
4320.17: Shared systems shall reject as non-compliant with the implementation guide any 837 version 4010A1 claim that contains XX in NM108, the NPI in NM109, and 1C or 1G as applicable in REF01of the same loop, but which lacks another REF01 in the billing or pay-to-provider loop with the EI (Employer Identification Number) qualifier and number or the SY (SSN, applies to carriers & DMERCs only) qualifier and number to convey the taxpayer identifier.
TEST NPI-only NOW
If you have been submitting claims with both an NPI and a Medicare legacy number and those claims have been paid, you need to test your ability to get paid using only your NPI by submitting one or two claims today with just the NPI (i.e., no Medicare legacy number). If the Medicare NPI Crosswalk cannot match your NPI to your Medicare legacy number, the claim with an NPI-only will reject. You can and should do this test now! If the claim is processed and you are paid, continue to increase the volume of claims sent with only your NPI. If the claims reject, go into your NPPES record and validate that the information you are sending on the claim is consistent with the information in NPPES. If it is different, make the updates in NPPES and resend a small batch of claims 3-4 days later. If your claims are still rejecting, you may need to update your Medicare enrollment information to correct this problem. Call your Medicare carrier, FI, or A/B MAC enrollment staff or your DME MAC. Have a copy of your NPPES record or your NPI Registry record available. The contractor telephone numbers are likely to be quite busy, so don't wait.
Need More Information?
Still not sure what an NPI is and how you can get it, share it and use it? As always, more information and education on the NPI can be found through the CMS NPI page www.cms.hhs.gov/NationalProvIdentStand on the CMS website. Providers can apply for an NPI online at https://nppes.cms.hhs.gov or can call the NPI enumerator to request a paper application at 1-800-465-3203. Having trouble viewing any of the URLs in this message? If so, try to cut and paste any URL in this message into your web browser to view the intended information.
Note: All current and past CMS NPI communications are available by clicking "CMS Communications" in the left column of the www.cms.hhs.gov/NationalProvIdentStand CMS webpage.
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