Important - Medicaid Claims Requirement

NPI Compliance Deadline Arrives

The big day for National Provider Identifier (NPI) compliance is almost here. As of May 23, 2008, payors will only accept electronic or paper claims that contain an NPI in all required fields. Claims that contain older “legacy” identifiers will be rejected.

Physicians who successfully met Medicare’s earlier compliance date are on track to meet the NPI-only deadline onMay 23. Still, there are pitfalls that could lead to rejected claims.

Know your NPI “P’s and Q’s”

There are four NPI uses that physician practices need to be familiar with.

• Personal (Type 1)

• Corporate (Type 2)

• Referring physician

• Facility

Most payors will require that these four items be used in paper and electronic claims.

Personal and corporate NPIs

The physician’s individual NPI must be entered in the appropriate “rendering provider” field on paper and electronic claims. When applicable, corporate NPIs must also be entered in the “billing field” on paper and electronic claims.

Incorporated physicians, including incorporated physicians in solo practice, need to register for a corporate NPI in addition to their individual NPI. Claims for incorporated physicians will be rejected if the corporate NPI is not also included on claims.

Referring physician NPI

The “referring physician NPI” is simply the individual NPI of any physician who refers a patient to a specialist. Specialist physicians who bill for consultation or evaluation and management (E/M) visits must include the referring physician’s name and NPI on the claim.

What if the referring physician’s NPI is unknown? Billing staff may look up any referring physician’s NPI by visiting the NPI Enumerator at https://nppes.cms.hhs.gov.

Facility NPI

Only hospitals have “facility NPIs.” The facility NPI should be entered in the appropriate field on paper and electronic claims. Use care when including a facility NPI in a claim: Many hospitals have
separate NPIs for different facilities (e.g., outpatient surgery, off-site surgical center, etc.)

Physician practices that use software vendors or third-party billers should contact those entities to verify that claims systems have been updated to accurately reflect individual, corporate, referral, and facility NPI requirements.

Medicaid Claims Requirement - IMPORTANT 1. DHFS requires individual NPIs only to identify the billing physicians. 2. Do not use corporate NPIs when billing DHFS for medical services. 3. Continue to use the current single digit payee identifier on claims to designate     the payee. In other words ... if you want to get paid, do not use corporate NPIs when billing Medicaid.

Contact: Division of Health Policy Research and Advocacy, 800-782-4767 ext. 1470 or advocacy@isms.org