National Provider Identifier (NPI): Understanding the Readiness of Other Health Plans, Steps to Facilitate a Smooth Transition to NPI-Only Medicare Bi

CMS encourages all health care providers to ensure they understand the readiness of other health plans with which they interact, especially if those health plans may be primary or secondary to Medicare. Medicare will only accept/send NPI-only transactions beginning May 23rd and providers need to understand from these other plans what will happen if they are unable to send/receive NPI-only transactions.

Important Information for Medicare FFS Providers
CMS is pleased to announce that Medicare is receiving more than 98% of claims with an NPI. The next milestone - May 23rd- requires providers to take the next step so they do not risk disruption in cash flow. Begin billing with NPI-only now to test how May 23rd will impact you.

CMS is concerned that the percentage of Medicare claims with NPI-only is not growing fast enough.

Steps to Facilitate a Smooth Transition to NPI-Only
1) Bill with Medicare legacy ID & NPI
· Once claims are successfully processed, move to Step 2.
2) Bill with NPI –Only
· Start with a small batch of claims. If, or when, the results are positive, begin sending a greater volume and move to Step 3.
· Billing with NPI-only also tests the ability to receive the NPI on 835 transactions.
3) Test NPI-Only on Other HIPAA Transactions
· CMS will require use of the NPI on the 270/271, 276/277 and NCPDP transactions. Providers should begin testing the use of the NPI on these transactions, in small quantities, prior to May 23rd to ensure a smooth transition. Also, be prepared to accept the NPI-only on the 835 remittance advice transaction.

Institutional Providers Submitting Taxonomy Codes to Identify Subparts –
UPDATE: Medicare is Using Alternative Data to Obtain NPI/OSCAR Match
On January 1, 2007, Medicare implemented change request (CR) 5243, which required the submission of taxonomy codes all claims submitted by institutional Medicare providers who submit claims for their primary facility and its subparts (such as psychiatric unit, rehabilitation unit, etc.).

The intent of CR 5243 was to enable Medicare to appropriately crosswalk a provider NPI to each of the provider's subparts through the reporting of taxonomy codes in the claims. Medicare has found that using taxonomy codes has been unsuccessful in obtaining a one-to-one match on the crosswalk for those providers having one NPI tied to multiple OSCAR/Certification numbers. As a result, the taxonomy code is no longer used as part of the crosswalk criteria that are used to attempt to match an NPI with an OSCAR/Certification Number. Currently, the fiscal intermediary shared system (FISS) uses these matching criteria to obtain a one-to-one match between an institutional Medicare provider’s NPI and its OSCAR/Certification Number:

§ First level of match: Type of bill (TOB) to OSCAR/Certification Number

If the system is unable to identify a valid match, the search will continue with the next level of match.



§ Second level of match: Revenue code to OSCAR/Certification Number

If the system is unable to identify a valid match, the search will continue with the next level of match.



§ Third and final level of match: Facility ZIP code on the claim This final level prompts the systems logic to limit the list of appropriate OSCAR numbers by matching the facility ZIP code on the claim against the ZIP code of the master address in the FISS provider address file.

Note: If the system is unable to make a valid match, the claim will suspend with reason code 32105, and the provider will receive an additional development letter (ADR) requesting the OSCAR number.

Action Required by Institutional Providers with Subparts

Providers are strongly encouraged to enumerate their subparts. The following documents may assist providers in answering additional questions on this subject.

§ CMS Medicare Subpart Expectations paper may be accessed on the CMS Web site athttp://www.cms.hhs.gov/NationalProvIdentStand/Downloads/Medsubparts01252006.pdf

§ Read NPI Fact Sheet titled “For Health Care Providers Who are Organizations” athttp://www.cms.hhs.gov/NationalProvIdentStand/Downloads/NPI_FactSheet_Org_Provi_web_07-03-07.pdf

§ Review the article titled “Information Regarding National Plan and Provider Enumeration System Errors, Using the NPI on Medicare Claims and 835 Remittance Advice Changes” available in the August 2007 Medicare A Bulletin athttp://www.floridamedicare.com/Part_A/Medicare_A_Bulletins/Archive/110043.pdf

§ Review Special Edition article http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0608.pdf

§ National Plan and Provider Enumeration System (NPPES) https://nppes.cms.hhs.gov/NPPES.


Encourage Clearinghouses to Allow Testing of NPI-Only
It has come to CMS’ attention that some clearinghouses may not allow important NPI-only testing prior to May 23rd. CMS encourages Medicare providers to work with their clearinghouses to allow use of the NPI-only to facilitate this testing. If you do not test, you will not be aware, in advance, of any problems that could prohibit Medicare from processing and paying claims.

Registration Available for NPI Roundtable
CMS subject matter experts will be available to address questions from the provider community on April 17, 2008 from 2-3:30PM ET. Participants are able to submit questions using the online registration system for this call. To register, visit http://www.cms.hhs.gov/NationalProvIdentStand/Downloads/listserv_wording_4-10-08_call.pdf on the CMS website.


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 athttps://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 "CMSCommunications" in the left column of the www.cms.hhs.gov/NationalProvIdentStand CMS webpage.