If you are a health care provider who bills for services, you probably need an NPI number. If you bill Medicare for services, you definitely need an NPI number. Getting an NPI is easy and free. If you delay applying for your NPI, you risk your cashflow and that of your healthcare partners as well. As of May 23, 2008, an NPI number is required for all HIPAA Standard Transactions. This means:
• For all primary and secondary provider fields, only the NPI will be accepted and sent on all HIPAA electronic transactions, paper claims and SPR remittance advice.
• The reporting of Medicare legacy identifiers in any primary or secondary provider fields will result in the rejection of the transaction.
State Medicaid officials say some physicians “are experiencing a higher-than-usual rejection rate” of their claims because of national provider identifier (NPI) errors. The Texas Medicaid & Healthcare Partnership (TMHP) says clearinghouses and third-party software programs are submitting incorrect claims information. See their website at http://www.tmhp.com.
Physicians are receiving rejection notices that say the provider information “does not meet NPI requirements for a noncontingent submitter.” TMHP says physicians who get such a message should contact their software vendor or clearinghouse and ask them to review the TMHP EDI Companion Guides, call the TMPH at (888) 863-3638 or visit their website.
Modern Healthcare reported in late May that nationally “claims processors and claims-flow watchers report at least four-fold increases in rejected Medicare claims, similar or even higher rejection-rate spikes for Medicaid claims, and a doubling of rejection rates” for claims processed by Blue Cross and Blue Shield plans on May 23, the day the NPI requirement took effect. The publication quoted experts that 26 percent of Medicaid claims were rejected that day, compared with the normal 4 percent. They placed Medicare claims rejections at 24 percent, compared with the usual 6 percent, and Blue Cross rejections at 6 percent, compared with the normal 3 percent rate.
Texas physicians having NPI-related claims problems can e-mail the TMA Knowledge Center at knowledge@texmed.org, or call either (800) 880-7955 or (512) 370-1550 for assistance. TMA’s NPI Resource Center has the information you need to meet the federal NPI requirements.
TMA’s Payment Advocacy staff reminds physicians that their tax identification number is not a legacy identifier. It is necessary for tax purposes, so you should continue to submit it on your claims. However, some practice management software vendors and clearinghouses are removing the tax identi- fication number from claims. Check with your vendors to make sure this is not happening.
Physicians with NPI issues on Medicare claims may e-mail TrailBlazer Health Enterprises, the Texas Medicaid carrier, for assistance at npi.issues@trailblazerhealth.com.
Note that claims will be rejected if:
• The NPI included in a claim or claim status does not meet the content criteria requirements for a valid NPI, (i.e., begins with 1,2,3, or 4; 10 digits long with no special characters; check digit is correct).
• A submitted NPI report cannot be located in Medicare files.
• The NPI is located, but a legacy identifier reported for the same provider in the transaction does not match the legacy identifier in the Medicare file for that NPI.
• Claims include the NPI but do not have a taxpayer identification number (TIN) reported for the billing or pay-toprovider in electronic claims received via X12 837, DDE screen (FISS only) or Medicare’s free billing software.
• Claims that do not meet Medicare submission requirements, HIPAA implementation guide requirements, or Medicare program requirements for reasons unrelated to NPI.
For more information about NPI, access the following sources:
• CMS - http://www.cms.hhs.gov/NationalProvidentStand
• TMA - http://www.texmed.org/Template.aspx?id=5567
