May 21, 2007
When Medicare unveiled its contingency plan for fee-for-service (FFS) providers that cannot meet the May 23, 2007 deadline to comply with National Provider Identifier (NPI) requirements, it triggered a lot of questions on the practical side, including plans to "fast track" required NPI use by certain providers.
The NPI is one of a series of identifiers required by HIPAA (the Health Insurance Portability & Accountability Act of 1996) to facilitate electronic healthcare data exchange. The NPI is a unique 10-digit numeric identifier that neither expires nor changes. It replaces all legacy provider identifiers now in use, such as UPINs, OSCARs, individual plan identifiers, etc. CMS began issuing NPIs on May 23, 2005, and affected entities had until May 23, 2007, to complete NPI implementation (small health plans had an additional year).
To answer some of the questions raised by the new NPI contingency plan for FFS providers that cannot meet the above deadline, the Centers for Medicare & Medicaid Services held a May 10 national roundtable, where a panel of agency officials discussed the plan in detail and fielded calls from the public. Summarized below are some of the key issues tackled.
When can we expect a notice on how CMS will make NPI data available, including crosswalks, to facilitate NPI exchange with trading partners?
At the outset of the national roundtable, CMS officials said they could not offer an update on this issue. The agency has said it would provide help for crosswalks between NPIs and legacy provider numbers. The notice on NPI data to be available from the National Plan/Provider Enumeration System (NPPES) is in regulatory clearance, the officials said, but it is expected to be released soon.
Government delay in issuing the NPPES notice has been a big impediment to NPI readiness, say lab groups and other providers. Access to a centralized database is essential, they say, to obtain NPIs and arrange for a smooth exchange of NPIs with trading partners. Currently, getting NPIs is time-consuming and costly, note industry groups. Providers must collect them by going from one trading partner to another.
How will CMS handle the phase-out of the UPIN registry during the transition to sole NPI use?
Also at the outset of the call, officials said they could give no update on this topic, except to note that guidance on the UPIN registry is expected shortly, "perhaps within the next week or so."
What should a contingency plan look like?
There is no checklist per se, said Larraine Doo, senior policy advisor in the CMS office of e-health, during the roundtable call. It is up to each provider to devise a plan that fits its situation and that of its trading partners.
If a complaint is received, she said, CMS would look at when you got NPIs, when you shared them with your trading partners, and what schedule you have set to test NPI software and data exchanges with your trading partners.
With regard to health information clearinghouses, CMS would look at dates set for testing, the flow of communications with clients regarding testing, and the time frame for completing crosswalks from legacy identifiers to NPIs.
When complaints involve vendors, CMS has no authority to intervene; however, if such a complaint is lodged, the agency could help in gaining cooperation from the vendor.
When should a group practice start using NPIs?
Right away. While the group handles HIPAA transactions and the employed physicians don’t, the group, as an employer, could require the doctors to obtain NPIs and use them to identify themselves as the rendering physician on the claims the group submits. Also, health plans can require enrolled physicians to obtain NPIs in order to participate. Medicare is one such health plan.
Part B contractors are no longer accepting group practice claims that report the individual rendering PIN or individual rendering NPI in either the billing or pay-to provider ID fields. The group should either enter its group NPI or its group NPI and legacy PIN number pair in either of these fields.
When will Medicare begin rejecting claims without an NPI in the primary billing provider field, and what is meant by a primary provider?
Primary providers are billing, pay-to, and rendering providers. When CMS judges that a sufficient number of claims contain the NPIs of these providers, it may start rejecting claims that do not contain these NPIs. That could be July 1 or soon after.
All other providers are defined as secondary. They include referring, ordering, supervising, facility, care plan oversight, purchase service, attending, operating, and "other" providers. Legacy numbers are acceptable for these providers until May 23, 2008.
If a secondary provider’s NPI is on a claim, it will only be edited to assure that it has 10 digits, that it begins with "1", "2", "3", or "4", and that the 10th position of the number is a correct check digit.
What is a "sufficient number" that would trigger required NPI use for primary providers?
At this time, there is no clear, defined number, CMS officials said. There is no specific statistic or number of claims in mind, they noted, adding that the determination of "sufficient number" will be based on other factors as well.
When will paper claims start being rejected?
Medicare will begin rejecting the old Part A paper form, the UB-92, after May 22, 2007, and will only accept the new UB-04.
Medicare will continue accepting the old CMS-1500 (12-90) form until July 1, 2007. Its use had been set for April 1, but was delayed when CMS discovered printing errors on the new form. Medicare will begin rejecting the CMS-1500 (12-90) as of July 1.
Both the new UB-04 and the new CMS-1500 (08-05) allow reporting of NPI and legacy provider numbers together. For NPI purposes, Medicare will treat paper claims, direct data entry claims, and claims submitted using CMS’s free billing software the same as electronic claims.
"Whatever date Medicare sets to start rejecting electronic claims that do not contain an NPI in the primary provider field will also be the date when Medicare starts rejecting paper, direct data entry, and free billing software claims without an NPI at the primary level," Marlene Biggs, NPI Medicare FFS lead in the CMS office of information services, told the roundtable audience.
What identifier should be used for referring/ordering providers from Canada or elsewhere outside the U.S.?
You may continue using their legacy numbers until May 23, 2008; as of then, however, they must have an NPI. Obtaining an NPI is not limited to providers practicing in the U.S., so encourage your referring/ordering providers outside the U.S. to apply for an NPI as soon as possible.
What should a provider do when it has the required NPIs, but the software for NPI exchange is not ready? Should you wait until you get all the software tested?
You should start testing with a small number and make certain it works on your end in particular, said CMS officials. Then you can move to a larger claims volume as more of the software becomes available.
Our hospice has made every effort to get NPIs from attending physicians, but we are having trouble doing so. What should we do now?
Continue your effort, and start using the NPIs you already have. But remember, the attending physicians would fall into the secondary provider group, so you may continue to use their legacy numbers until the 2008 end date, said CMS officials.
When a provider confronts an entity whose NPI contingency plan differs from the Medicare FFS guidance and files a complaint, what will CMS do?
CMS would look at the particulars of the case, such as the good-faith effort made by all parties, said Larraine Doo. All HIPAA-covered entities must implement policies that conform to HIPAA requirements for accepting NPIs.
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