| |
Enforcement
of the Compliance Date, Clarifying Medicare's Key Implementation
Dates, Testing Medicare Claims & More!
January
2008
Industry-Wide
Enforcement of the NPI Compliance Date
The
compliance date for the NPI for all HIPAA covered entities except
small health plans was May 23, 2007. (Small health plans have until
May 23, 2008 to comply.) In guidance provided on April 2, 2007,
CMS announced that, through May 23, 2008, it would not impose penalties
on covered entities that deploy contingency plans to facilitate
the compliance of their trading partners. On May 24, 2008, CMS will
lift its enforcement-leniency policy. Complaints will be investigated
as they are today, but penalties will be a legitimate resolution
if the entity does not demonstrate compliance or corrective action.
CMS will continue to employ a complaint-driven approach to enforcement.
For example, if a complaint is received alleging a failure to comply
with the NPI requirements, CMS will contact the entity to secure
evidence of compliance and the contingency plan that had been in
place. If violations are identified, enforcement actions will take
place.
This
notice does not prohibit covered entities from lifting contingency
plans prior to May 24, 2008.
In
sum, no later than May 24, 2008, all covered entities are expected
to be using the NPI in a compliant manner, and all contingency plans
should be lifted.
NPPES
and the NPI Enumerator: Misconceptions & Facts
In
conversations and correspondence with health care providers, health
plans, and others within the health care industry, it is very clear
that there are misconceptions concerning the National Plan and Provider
Enumeration System (NPPES) and the NPI Enumerator. Below we have
listed some common misconceptions and the facts that correct those
misconceptions.
| Misconception
|
|
Fact |
| NPPES
sends data directly to the Medicare provider enrollment system |
|
NPPES
does not send data to the Medicare provider enrollment system
or to the provider enrollment system of any health plan. As
explained in the NPI Final Rule, applying for enrollment in
a health plan is a completely separate process from the process
of applying for an NPI.
|
NPPES
sends data directly to the Medicare claims system.
|
|
NPPES
does not send data to the Medicare claims system or to the claims
system of any health plan. Medicare extracts certain NPPES data
and uses those data in its Medicare NPI Crosswalk. That Crosswalk
is used in processing Medicare Part A and Part B claims. Other
health plans are also free to use NPPES data to help process
their claims.
|
NPPES
is part of the Medicare provider enrollment system.
|
|
Obtaining
an NPI is required in order for a health care provider to enroll
in Medicare; however, the NPPES does not function as a part
of the Medicare provider enrollment system. Medicare requires
a health care provider to have an NPI and to furnish that NPI
on the Medicare provider enrollment application form (CMS-855).
In addition, once a health care provider submits a CMS-855 to
Medicare, Medicare compares the NPI and certain other information
on the CMS-855 to certain information in that health care provider’s
record in NPPES. If the information being compared does not
match, the health care provider must correct whichever information
(NPPES or CMS-855) is incorrect in order for the enrollment
process to continue.
|
| Obtaining
an NPI guarantees payment to the health care provider by a health
plan. |
|
As
explained in the NPI Final Rule, obtaining an NPI does not guarantee
payment to the health care provider by Medicare or by any other
health plan. NPI assignment simply establishes the uniqueness
of an enumerated health care provider amongst all other enumerated
health care providers. Most health plans will not pay a health
care provider that is not enrolled in that health plan.
|
NPPES
verifies licenses and credentials that are reported by health
care providers when applying for NPIs.
|
|
NPPES
does not verify licenses or credentials. NPPES verifies only
two things: (1) It verifies a health care provider’s Social
Security Number if the health care provider is an individual
who furnished his/her SSN when applying for the NPI; and (2)
Using special software, it verifies that the health care provider’s
business mailing and practice location addresses are legitimate
Postal Service addresses, but not that the health care provider
is actually associated with or located at either of those addresses.
Licensure and credentials must be verified by health plans as
part of their enrollment processes. It is possible, under certain
circumstances, that the NPI Enumerator may contact health care
providers who have submitted applications, updates, or deactivations
to verify information that was furnished in order to properly
process those actions. Health care providers are reminded that
the information they send to NPPES must be true, correct, and
complete, in accordance with the Certification Statement of
the NPI Application/Update Form (paper form and web-based form).
|
NPPES
is a Medicare system.
|
|
NPPES
is not a Medicare system; it belongs to no health plan. It is
maintained by CMS for the health care industry in general, in
accordance with the NPI Final Rule and as part of CMS’
delegated HIPAA authority. Health care providers who apply for
NPIs are not required to furnish any information about their
enrollment in any health plan. In an optional field, health
care providers may report legacy identifiers that health plans
have assigned to them in the past. This field, “Other Provider
Identification Numbers,” can capture the legacy identifiers
and the issuers of those identifiers (i.e., the names of the
health plans that assigned them). The information in this field
is used by health plans to help them locate their enrolled providers
in NPPES in order to know of their NPI assignments. For this
reason, Medicare providers are urged to report their Medicare
legacy identifiers in this field.
|
The
NPI Enumerator can update the Medicare claims and enrollment
systems.
|
|
The
NPI Enumerator cannot view, update, or interact with the Medicare
claims or the Medicare enrollment systems, nor can it do so
with any health plan’s claims or enrollment systems.
|
The
NPI Enumerator can view and update/change the Medicare NPI Crosswalk.
|
|
The
NPI Enumerator cannot view or update/change the Medicare NPI
Crosswalk. The NPI Enumerator can assist providers with certain
aspects of updating their NPPES records, and some of that information
in those NPPES records could be used by Medicare in the Medicare
NPI Crosswalk.
|
The
NPI Enumerator serves Medicare providers and supports Medicare
operations, not other providers or health plans.
|
|
The
NPI Enumerator operates under contract to CMS in accordance
with the NPI Final Rule and as part of CMS’ delegated HIPAA
authority. The NPI Enumerator serves the entire health care
provider community for NPI purposes, not just Medicare providers.
The functions of the NPI Enumerator are not specific to any
health plan.
|
CMS
has posted information that lists the specific duties and responsibilities
of the NPI Enumerator in a recent MLN Matters article located at
www.cms.hhs.gov/MLNMattersArticles/downloads/SE0751.pdf
on the CMS Web site. An article that further clarifies the functions
of NPPES and the NPI Enumerator is in development; this article
will be announced once available.
Important
Information for Medicare Providers
Medicare’s
Key Dates
There
are two key dates remaining for 2008 in Medicare's NPI implementation
plan. There is also some confusion as to the difference between
the implementation steps for March 1 and May 23. The chart below
indicates the implementation steps for each date; as well a new
column to help further clarify the difference between these two
dates.
Date
|
Implementation
Steps |
Key
Point |
March
1, 2008
|
Medicare
FFS 837P and CMS-1500 claims must include an NPI in the primary
provider fields on the claim (i.e., the billing, pay-to, and
rendering provider fields).
–
You may continue to submit NPI/legacy pairs in these fields
or submit only your NPI on the claim. You may not submit claims
containing only a legacy identifier in the primary provider
fields.
–
Failure to submit an NPI in the primary provider fields will
result in your claim being rejected or returned as unprocessable.
–
Until further notice, you may continue to include legacy identifiers
only for the secondary provider fields.
|
Claims
with only legacy identifiers in the primary provider fields
will be rejected.
|
May
23, 2008
|
In keeping with the Contingency Guidance issued on April 2,
2007, CMS will lift its NPI contingency plan, meaning that only
the NPI will be accepted and sent on all HIPAA electronic transactions
(837I, 837P, NCPDP, 276/277, 270/271 and 835), paper claims
and SPR remittance advice. (Note that this date is one day earlier
than that mandated by the National Enforcement Policy)
–
This also includes all secondary provider fields on the 837P
and 837I. The reporting of legacy identifiers will result
in the rejection of the transaction.
–
CMS will also stop sending legacy identifiers on COB crossover
claims at this time.
|
If
the claim contains a legacy identifier in any field, it will
be rejected.
|
Only
4 Months Until May 23 - Test NPI-only claims NOW
While
Medicare is receiving well over 90% of claims containing an NPI
in primary provider fields, there is a very small percent of claims
submitted with NPI- only. Until you submit claims with an NPI-only,
you will not have a preview of what your experience will be on May
23. The time for correcting problems, should there be any, is
getting short. CMS urges that ALL Medicare providers test NOW so
that problems can be resolved prior to May 23. For example, if there
is a problem that requires a change in your Medicare enrollment
information, you will need to act immediately.
How
to test - After Medicare providers have submitted claims containing
both NPIs and legacy identifiers and those claims have been paid,
Medicare urges these providers to send a small batch of claims now
with only the NPI in the primary provider fields. If the
results are positive, begin increasing the number of claims in the
batch.
(Reminder: For institutional claims, the primary provider fields
are the Billing and Pay-to Provider fields. For professional claims,
the primary provider fields are the Billing, Pay-to, and Rendering
Provider fields. If the Pay-to Provider is the same as the Billing
Provider, the Pay-to Provider does not need to be identified.)
Remember, if you test and your claims are processed successfully,
you can approach the May 23 date with confidence. If you do not,
you may face unanticipated cash flow problems.
Medicare
DMEPOS Suppliers: If Your Claims Are Rejecting!
Medicare
DMEPOS suppliers may be experiencing claims rejections if they did
not obtain their NPIs properly, if they are not properly enrolled
in Medicare, or both. For example, if a DMEPOS supplier who is a
sole proprietorship enrolled with the National Supplier Clearinghouse
(NSC) as an organization and furnished an Employer Identification
Number (EIN) instead of a Social Security Number (SSN), but obtained
a National Provider Identifier (NPI) as an Entity type 1 - Individual,
the Medicare NPI Crosswalk will be unable to link that DMEPOS supplier's
Medicare legacy identifier (the NSC number) to its NPI. This is
because the NSC number and the NPI identify different entity types--one
identifies an organization and the other an individual. When a linkage
between a Medicare legacy identifier and an NPI used in a claim
does not exist in the Medicare NPI Crosswalk, the claim will reject.
DMEPOS suppliers should contact the DME MAC if they do not understand
the error message they received.
If
the rejection was due to the inability of the Medicare NPI Crosswalk
to link the NPI to the NSC number, the DMEPOS supplier should check
the NPPES record to ensure the appropriate Entity type (1 = Individual;
or 2 = Organization) is reflected in that record. Individuals (including
sole proprietorships) obtain NPIs as Entity type
1. Organizations obtain NPIs as Entity type 2. If the NPPES record
shows the appropriate Entity type, the DMEPOS supplier should contact
the NSC to ensure the enrollment record is correct. If the NPPES
record does not show the appropriate Entity type, the DMEPOS supplier
needs to take action to ensure the appropriate Entity type is selected.
If assistance is necessary, the NPI Enumerator (1-800-465-3203)
can explain to the DMEPOS supplier how this is done.
Once
the NPPES record is correct, the DMEPOS supplier needs to ensure
that it is properly enrolled in Medicare. The NSC, once contacted,
will ask appropriate questions to determine if the DMEPOS supplier
is, in fact, a sole proprietorship, and if so, properly reflected
as such in the enrollment record. The NSC will assist the DMEPOS
suppliers in correcting their enrollment records.
DMEPOS
suppliers who are sole proprietorships should be aware of the following:
- A
DMEPOS supplier who is a sole proprietorship obtains an Entity
type 1 (Individual) NPI.
- When
enrolling in Medicare (form CMS-855S) with the NSC, a DMEPOS supplier
who is a sole proprietorship furnishes his/her SSN as the Taxpayer
Identification Number (TIN).
- The
Legal Name of the sole proprietorship business is the sole proprietor’s
name.
- It
is possible for the sole proprietorship to have a “doing
business as” (dba) name. The dba name can be reported on
the CMS-855S and in the NPI application (in the “Other Name”
field). A dba name, however, is not a Legal Name.
- It
is possible that the sole proprietorship requested and received
an Employer Identification Number (EIN) from the IRS if the sole
proprietorship has employees. This EIN will protect the sole proprietor’s
SSN from appearing in claims and on W-2s.
- Medicare
will treat the EIN as the TIN for purposes of claims processing,
but the SSN must still be reported on the CMS-855S.
- When
Medicare reports tax information to the IRS for that EIN, the
IRS will link that EIN to the sole proprietor’s SSN.
Additional
Information on Reporting a National Provider Identifier (NPI) for
Ordering/Referring and Attending/Operating/Other/Service facility
for Medicare Claims
Visit
www.cms.hhs.gov/MLNMattersArticles/downloads/MM5890.pdf
for a recently released MLN Matters Article on the topic of reporting
NPIs for order/referring and attending/operating/other/service facility
for Medicare claims.
CMS to Host National NPI Roundtable on February 6
CMS
will host a national NPI Roundtable on Wednesday, February 6 from
2:30 p.m. – 4 p.m. ET. This call will focus on the status of
the Medicare implementation and a related question and answer session.
Registration details are available at www.cms.hhs.gov/NationalProvIdentStand/Downloads/listservwording2-6-08npicall.pdf
on the CMS Web site.
WEDI to Host NPI Audiocast
The
Workgroup for Electronic Data Interchange (WEDI) will host an audiocast
to discuss NPI implementation from an industry-wide standpoint.
The audiocast will be held on February 21, 2008. Visit www.wedi.org/npioi/index.shtml
for registration details. Please note there is a charge to participate
in WEDI events.
Need More Information?
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 Web site. 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.
|
|
|
720
Light Street, Baltimore, MD 21230
TEL:
(410) 727-7800• FAX: (410) 752-8295
EMAIL:
MOA@assnhqtrs.com
|
|
