WPS Update

III.  NATIONAL PROVIDER IDENTIFIER (NPI) CLAIM UPDATE

Suspended claims with NPI issues are being submitted multiple times.

WPS Medicare is finding that claims suspended within our system for NPI issues are being submitted multiple times. Before re-filing a claim, allow sufficient time for the claim to reach Medicare, for Medicare to process the claim and for the Provider Remittance Notice (PRN) to reach you. If you do not submit claims electronically or receive your remittance notice electronically, you must allow time for mail processing and delivery.

WPS Medicare recommends that you wait 60 days before re-filing any claim. This allows 45 days past the payment floor for any development that may occur on a claim.

Claim processing time cannot be shorter than the "payment floor" which is 14 days for electronic claims and 29 days for paper claims. This is the minimum amount of time that must elapse from the date Medicare receives the claim until the date Medicare issues a payment. Actual processing time can take longer on some claims. Also, before re-filling, always carefully review your PRN to reconcile your records, or access the Interactive Voice Response (IVR) system or C-SNAP for claim status.

Do not automatically re-file claims to Medicare Part B without first obtaining the status of the original claim. If your software automatically re-files claims, please disable this software capability, or reset your system to wait a sufficient amount of time after the claims have reached the payment floor. It is not appropriate to use an automatic re-filing system as an alternative to bookkeeping.

IV.   NATIONAL PROVIDER IDENTIFIER (NPI) – THINGS TO CONSIDER

Effective May 23, 2008, you were required to submit your claims with an NPI only. However, the Medicare claims processing system must match the NPI you submitted on your claim to the correct Provider Transaction Access Number (PTAN)/Provider Identification Number (PIN), otherwise known as your legacy number, so payment can be made to the appropriate provider.

If you have one NPI for each of your PTANs/PINs, there should be little disruption to your claims processing timeliness due to the NPI to PTAN/PIN matching process. For purposes of clarification, organizations may have multiple NPIs. An individual person will only have one NPI.

If you choose to have one NPI that corresponds to multiple PTANs/PINs, this may result in additional manual review and development to match your NPI to the correct PTAN/PIN. However, in the situation of one NPI that corresponds to multiple PTANs/PINs, we recommend you bill your corresponding taxonomy code for each rendering provider to reduce the likelihood of delays in processing due to manual review and development. In addition, it may be possible to collapse multiple PTANs/PINS (legacy numbers) into one PTAN/PIN to create a one to one match with your NPI. Additional information on collapsing multiple PTANs/PINs can be found at http://www.cms.hhs.gov/MLNMattersArticles/
Refer to "2008 MLN Matters Articles," article MM5906.

Following is some additional information to consider on the options for NPI enumeration. We hope you find this information helpful in making informed decisions that are in your best interest.

Enumerating Option #1 – One NPI to one PTAN/PIN Advantages

• Improved Claims Processing Timeliness, otherwise delayed by the NPI to PTAN/PIN matching process.

• Less risk of matching NPI to wrong PTAN/PIN, resulting in claims being processed and paid incorrectly.

• Fewer claims suspended due to the NPI to PTAN/PIN matching process.

• Fewer claims developed for additional information due to the NPI to PTAN/PIN matching process.
  
  
• Fewer denied claims due to the NPI to PTAN/PIN matching process.

Disadvantages

• Applying for and managing multiple NPI numbers

Enumerating Option #2 – One NPI to many PTANs/PINs Advantages

• Fewer NPI numbers to apply for and manage.

Disadvantages

• Potential for delays in Claims Processing Timeliness due to the NPI to PTAN/PIN matching process.

• Increased risk of matching NPI to wrong PTAN/PIN, resulting in claims being processed and paid incorrectly.

• Increase in number of claims suspending due to the NPI to PTAN/PIN matching process.

• Increase in number of claims developed for additional information due to the NPI to o PTAN/PIN matching process.

• Potential for increased denials on claims due to the NPI to PTAN/PIN matching process.

If you are interested in making changes to your NPI enumeration, you may contact the NPI Enumerator at 1-800-465-3203 or review information on how to apply for an NPI at https://nppes.cms.hhs.gov/NPPES/Welcome.do.

More information on the NPI can be found through the Centers for Medicare & Medicaid Services (CMS) NPI page http://www.cms.hhs.gov/NationalProvidentStand on the CMS Website.

If you have questions regarding your Medicare legacy numbers, please contact Provider Enrollment at: IL/MI/WI          877-908-8476