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Will Washington DSHS require providers to use the NPI when billing claims?

On and after May 23, 2007 and until implementation of the new ProviderOne system, DSHS will require providers to submit both the NPI along with their current Medicaid provider number on all HIPAA transactions (837, 270, 276, 278) and paper claims (CMS-1500, UB-04 and ADA 2006).

  • DSHS will continue to only return the Medicaid Provider Number on outbound HIPAA transactions (835, 277U, 271, 277, and 278) and the paper remittance advice until ProviderOne implementation.

The new ProviderOne system is tentatively scheduled to be in production in December 2008. To learn more about the ProviderOne Project please visit the website.

What should providers do to prepare for this?

Providers and their clearinghouses/software vendors/billing agents need to ensure their billing systems will continue to support the inclusion of the NPI in addition to the Medicaid provider number on and after May 23, 2007 and until the ProviderOne system is implemented.

How will the NPI rule affect DSHS Pharmacy providers who submit claims through the new ProviderOne Pharmacy System?

Upon implementation of the new ProviderOne Pharmacy System, which is tentatively scheduled for May 19, 2008, DSHS will require pharmacy providers to provide the pharmacy and prescriber NPIs on all electronic prescription drug claims

Until then, pharmacy providers are required to continue to submit the NCPDP/NABP number, Prescriber DEA or Prescriber Medicaid Provider Number on all prescription drug claims through the legacy Point of Sale (POS) system.

Will Washington DSHS require the NPI on paper and electronic claims?

Yes, DSHS will require providers to submit the NPI and Medicaid provider number on both electronic and paper claims.

When will DSHS accept the new UB-04 , CMS 1500 version 08/05 and 2006 ADA Dental paper claim forms?

What is a Taxonomy Code?

The Healthcare Provider Taxonomy Code (HPTC) is a unique, 10-digit, alphanumeric code that allows a provider to identify their specialty category.  Providers applying for their NPI will be required to submit their taxonomy information.  Providers may have one or more than one taxonomy associated to them. 

In addition, DSHS currently does not require providers to submit their taxonomy codes on electronic or hardcopy claims.

What is a Covered Entity?

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), a Covered Entity is a health plan, a health care clearinghouse, or a health care provider who conducts transactions in electronic form via HIPAA transactions.

A health care provider is defined as an individual or organization that provides medical or other health services that furnishes, bills, or is paid for health care in the normal course of business. This includes:

  • Physicians and other practitioner groups
  • Institutions such as hospitals
  • Laboratories
  • Nursing homes
  • Dental providers
  • Suppliers such as pharmacies and medical supply companies and
  • Any health care provider who transmits any health information in electronic form in connection with a standard HIPAA transaction

Exception: Non-health care workers (atypical providers) such as transportation services, home and vehicle modifications, billing personnel, or housekeeping staff, who support the provision of health care are not eligible to obtain a NPI.

What is an NPI?

The National Provider Identifier (NPI) is a unique identification number mandated under the Administrative Simplification portion of HIPAA for health care providers.

What is the purpose of NPI?

The NPI is a single identification number that will be assigned to health care providers. It is intended to improve the efficiency of the health care system and help to reduce fraud and abuse.  The intent of the NPI is to eliminate the need for payers and providers to keep numerous identifiers and in turn simplify transaction processing between these entities. 

Who is required to apply for an NPI?

With the exception of atypical providers, Washington Department of Social and Health Services (DSHS) requires all health care providers (individual, organization, and subparts of an organization) submitting electronic and paper claims to obtain an NPI.

What is a subpart of an organization?

A subpart is any component of a provider organization that furnishes health care. It may also consist of separate physical locations of an organization.

  • Washington DSHS is aligning with Medicare's recommendation on subpart enumeration. This recommendation can be found at the following links:

http://www.cms.hhs.gov/NationalProvIdentStand/Downloads/Medsubparts01252006.pdf

http://www.cms.hhs.gov/MLNMattersArticles/downloads/se0608.pdf

What will the NPI look like?

The NPI will be a unique, ten digit, numeric identifier that will include one check digit in the tenth position to ensure accuracy. The NPI will contain no imbedded intelligence. In other words, a provider's state, region, specialty, or any other information can not be derived from their NPI.

What is the NPPES?

The National Plan and Provider Enumeration System (NPPES) was developed by the Centers of Medicare and Medicaid Services (CMS) to assign the NPI to eligible health care providers. The NPPES will also store the information about enumerated providers.

In addition, CMS contracted with FOX Systems to be NPI enumerator. As the enumerator, FOX Systems will be responsible for the following:

  • Process NPI applications and updates 
  • Maintain a helpdesk to assist with the NPI application process and resolve any issues
  • Handle data requests

How do providers get an NPI?

NPIs will be issued by the NPPES. There is no cost to apply and providers may apply for an NPI in one of three ways:

  • Effective May 2005, providers may apply through an easy web-based application process at https://nppes.cms.hhs.gov
  • Effective July 2005, providers may prepare a paper application and send it to Fox Systems. Providers may also call Fox Systems for a copy. The phone number is 1-800-465-3203 or TTY 1-800-692-2326
  • Effective April 2006, the Electronic File Interchange (EFI) process was made available to providers. EFI allows a health care provider or group of providers to have a particular organization (EFIO) apply for the NPI on their behalf.  In other words, rather than having a provider or group of providers submit a paper or web NPI application, the EFIO obtains an NPI for them via the submission of an electronic file.
  • DSHS will not bulk enumerate on behalf of their providers
  • Providers must furnish any updates to the NPPES within 30 days of the change if any of the required data submitted on the application changes

When do providers have to apply for their NPI?

Providers may apply for an NPI through the NPPES as early as May 23, 2005. To ensure a smooth transition, DSHS strongly encourages all providers to apply early so they can adequately test their systems. In addition, DSHS will require providers to submit their NPI information as part of the mandatory registration process into the new ProviderOne (MMIS) system. The registration process is tentatively scheduled to be available Spring 2007.

How will the NPI be used?

The NPI must be used in connection with the electronic transactions identified in HIPAA, which includes the following:

  • 837 - claim submission
  • 835 - remittance advice
  • 277 - unsolicited remittance advice for suspended claims
  • 270/271 - eligibility inquiry and response
  • 276/277 - claim status inquiry and response
  • 278 - referral and authorization

In addition, the NPI may be used by providers:

  • To identify themselves in HIPAA-compliant healthcare transactions or on related correspondence
  • To identify other healthcare providers in healthcare transactions or on related correspondence

The NPI may also be used by:

  • Health plans to process transactions and communications with providers
  • Health plans to coordinate benefits with other health plans
  • Electronic patient record files to identify treating providers in the medical record
  • The Department of Health and Human Services (HHS) to cross reference providers in fraud and abuse files and other program integrity files

What numbers will the NPI replace?

The NPI will replace other identifying numbers currently used such as:

  • Medicaid provider number
  • Medicare provider number
  • CHAMPUS number
  • UPIN number
  • All other payers's unique provider numbers (e.g. Blue Cross and Blue Shield number)

The NPI will not replace numbers used for purposes other than general identification, such as:

  • Social Security Number
  • DEA number
  • Taxpayer ID number
  • Taxonomy number
  • State license number

Will a provider's NPI ever change?

In most cases no. If a healthcare provider is deceased, their NPI will be deactivated. If a provider goes out of business, the NPI will also be deactivated. The deactivated NPI will never be issued to other health care providers. Movement of a provider from one geographical area of the country to another will not affect their NPI.

Does the NPI replace the Tax Identification Number (TIN)?

No. The NPI is not designed to replace the provider's TIN, nor is the NPI designed to correspond to the TIN.

Is there any relationship between NPI and the Unique Physician Identification Number (UPIN)?

The NPI will replace the UPIN in the Medicare program by May 23, 2007.

What if a provider has numerous health plan IDs, will each health plan require an additional NPI?

The NPI is the single provider identifier that will replace each of the different health plans's numerous identifiers. The NPI regulation requires each of the health plans to use the NPI as the sole identifier for each provider. The provider needs only to apply once for an NPI.

Where can I learn more about NPI?

http://www.cms.hhs.gov/NationalProvIdentStand - Medicare NPI Policy and Recommendations

http://www.cms.hhs.gov/apps/npi/npiviewlet.asp - NPI Tutorial

https://nppes.cms.hhs.gov/ - NPI Application and Enumeration

http://www.wedi.org/   - Provider Based NPI Workgroups and Analysis (Subparts)