Health Information Compliance Alert

Published on Fri May 11, 2007 PDF

If you're not careful, claim rejections could start this summer.

If your to-do list includes managing Medicare's new NPI, get cracking or you could open your business up to enforcement actions and unpaid claims--starting this summer.  

Officials speaking at a Centers for Medicare & Medicaid Services Special Open Door Forum on the National Provider Identifier (NPI) Contingency Plan on May 10 noted a number of dates that will be vital to NPI use and compliance.

Background: In April, CMS announced that it would extend  the NPI deadline for a year, in   light of covered entities' lack of readiness. The contingency plan began May 23 and is in effect until May 22, 2008, but that doesn't  mean you can stop worrying about the new identifier.

Urgent: "At this point, any covered entity that is noncompliant, and has not implemented a contingency plan, is at risk for enforcement action," CMS warns.

For information on getting an NPI, go to www.nppes.cms.hhs.gov.

Get started: Those who have an NPI should begin testing the new identifier right away, CMS recommends.

Tips Help You Avoid Rejected Claims

Alert: Even with the contingency plan's extensions, CMS may start rejecting claims submitted without an NPI in primary provider fields as early as July 1, officials stressed at the forum.

"As soon as the number of claims submitted with an NPI for primary providers ... is determined sufficient ... Medicare will begin rejecting claims that do not contain an NPI for primary providers," CMS says in April 24 MLN Matters article MM5595.

The crucial fields are "billing, pay-to and rendering providers," CMS explains.

Paper jam: Providers must use the NPI on both paper and electronic claims. CMS will also treat claims filed using direct data entry and Medicare's free billing software the same as electronic claims for purposes of NPI compliance.

If you file paper claims, be sure you're using the right form. For example, if you use CMS form 1500, be sure you have the new version--version 805--on hand. If you are using the old version, 1290, your claims will be rejected starting July 1.

Paper claims filed on UB 92 began rejecting May 22. Beginning May 23, providers should have replaced the UB 92 with the new NPI-friendly UB-04.

Remember: The contingency plan spelled out in CMS' April 24 Change Request 5505 applies only to Medicare fee for service. You may soon have other dates and requirements to keep in mind as other health plans release contingency plans of their own.

Providers should look for contingency plan information "from various health plans they bill and with whom they conduct any HIPAA transaction," said a CMS official speaking at the forum. That includes CMS' other health plans, such as Medicare Advantage, Medicare Part D and state Medicaid plans.

Look For Referring Docs' NPIs

You finally have a date that you can expect a National Provider Identifier directory for referring physicians' NPIs. CMS says it will issue the NPI information June 28 as part of the National Plan and Provider Enumeration System (NPPES) data.

More information is at www.cms.hhs.gov/NationalProvIdentStand/Downloads/DataDisseminationNPI.pdf

Providers have until May 2008 to include referring docs' new numbers. Until then, providers can include "secondary" providers' legacy numbers, including UPINs, on Medicare claims.

Until the to-be-announced NPI deadline, providers can include NPIs, legacy numbers or a combination of NPIs and old numbers on their claims, CMS says in April 24 Change Request 5595.

Resources: More NPI instructions and resources are at www.cms.hhs.gov/NationalProvIdentStand.

The MLN Matters article is at www.cms.hhs.gov/MLNMattersArticles/downloads/MM555.pdf. The CR is at www.cms.hhs.gov/Transmittals/downloads/R1227CP.pdf.