October 29, 2007 - By this date, all carriers, A/B MACs and DME MACs, will be rejecting claims where the NPI/legacy identifier combination used in claims cannot be validated against the NPI crosswalk. Informational edits will no longer be issued once this happens, but will be replaced by reject reports that will assist providers in determining why the claim is being rejected.
January 1, 2008 - As of this date, 837I electronic claims and UB04 paper claims without an NPI in fields identifying the primary provider (billing and pay-to) will be rejected. Legacy identifiers paired with NPIs in the primary provider fields on the claim will still be acceptable as will legacy-only numbers in secondary provider fields (see clarification below).
CMS has not yet announced the date by which an NPI will be required for primary provider fields on 837 professional electronic claims and 1500 paper claims processed by carriers, A/B MACs and DME MACs. This will occur prior to May 23, 2008; a specific date will be announced once available.
May 23, 2008 - In keeping with the Contingency Guidance issued on April 3, 2007, CMS will lift its NPI contingency plan, meaning that only the NPI will be accepted on all HIPAA electronic transactions (837I, 837P, NCPDP, 276/277, 270/271 and 835), paper claims and SPR remittance advice. 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.
Common Claims Problems/Errors Causing Rejections
According to Medicare, the following problems/errors are due to providers billing with incompatible NPI/legacy pairs:
- The type of NPI you use (Entity Type 1 or Entity Type 2) must match your Medicare enrollment PIN (individual or organization). When compatible NPI/legacy pairs are submitted on a claim, there is a much higher success rate for finding a match on the NPI crosswalk, thus further ensuring timely and accurate processing of your claim.
- Those who are enrolled with Medicare as individuals, but obtained an Organization (Entity type 2) NPI through NPPES (or vice versa) need to ensure their enrollment records are correct and their NPIs were obtained appropriately.
- On professional claims (837P and CMS-1500), the NPI/PIN combination should identify the Billing, Pay-to, and Rendering Provider (the Pay-to Provider is identified only if it is different from the Billing Provider). This includes claims that are submitted by corporations that physicians and non-physician practitioners have formed or by physicians and non-physician practitioners who bill Medicare directly. For more information, please refer to MLN Matters article SE0744 on the CMS website.
Other problems identified:
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Medicare states that providers need to take proactive action based on the Part B informational edits and reject reports. They remind providers to pay attention to the informational edits prior to October 30 and the reject messages thereafter.
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CMS has received reports of clearinghouses and billing services that may be stripping the NPI from the claim and later adding the NPI back on the remittance advice. If you suspect that your clearinghouse or billing service is stripping your NPI from claims, please contact your contractor to confirm that an NPI was not received.
Test Your Claims Now!
Medicare encourages submitters to send a small number of claims using NPIs only (no legacy identifiers) . If no claims are rejected, the submitter may gradually increase the volume. And remember, Medicare will require the NPI on paper claims - be sure to begin the testing process now even if you bill paper!
Upcoming WEDI NPI Audiocast :
Using the NPI Registry and the NPPES Downloadable File
The Workgroup for Electronic Data Interchange will host an NPI audiocast on October 31 st . Visit the WEDI website to learn more. Please note that there is a cost to participate in WEDI events.
Still Confused?
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 on the CMS website. Providers can apply for an NPI online or call the NPI enumerator to request a paper application at 1-800-465-3203.
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