MAL 528

Medical Assistance Letter (MAL) 528

June 7, 2007

To:                Individual APNs, Anesthesia Assistants and Incorporated Individual APN Practices

Trading Partners and Tape Intermediaries

Directors, County Departments of Job and Family Services

Medical Assistance Coordinators

From:            Helen E. Jones-Kelley, Director

Re:                Information Providers Must Know about the National Provider Identifier (NPI) in Order to Get Paid

NPI………………GET IT..........................SHARE IT........................USE IT

The purpose of this Medical Assistance Letter (MAL) is to inform individual Advanced Practice Nurses (APNs), Anesthesia Assistants and incorporated individual APN practices that are enrolled as providers in the Ohio Medicaid program and do business with ODJFS that they are required to obtain a National Provider Identifier (NPI) by May 23, 2007.  An NPI for APNs and Anesthesia Assistants is a unique, ten-digit, entity type 1 identifier that providers receive from the National Plan and Provider Enumeration System (NPPES).  Upon receipt of their NPI and until January 1, 2008, APNs that conduct business with Medicaid in an electronic format (i.e., submit EDI claims, receive electronic remittance advices and/or communicate electronically with trading partners and payers) must submit both their individual NPI number and their current individual Medicaid provider number (now referred to as the Medicaid legacy number or Ohio Medicaid legacy number) in accordance with the Ohio Medicaid EDI companion guide and/or the instructions contained in this MAL.*  This is to create an association between these two numbers.

APNs and Anesthesia Assistants MUST enumerate through NPPES, disclose their NPIs to ODJFS and bill using both the NPI and Medicaid legacy identifiers.  This MAL provides direction to providers on enumerating through NPPES, disclosing your NPI to ODJFS, and billing ODJFS using your NPI.*

APN claims received by ODJFS before January 1, 2008 that contain a valid Ohio Medicaid legacy number, or both a valid NPI and valid Ohio Medicaid legacy number in the required provider fields, will continue to be accepted and processed.  Claims submitted without an Ohio Medicaid legacy number (i.e., submitted only with an NPI number) prior to January 1, 2008 will be rejected or denied.*  APN claims submitted to ODJFS on or after January 1, 2008 will be denied if the APN's NPI number is not in the required field(s) on the claim.  APN claims submitted on or after May 23, 2008 will not require the Ohio Medicaid legacy number if ODJFS has a record of your NPI number and has linked the NPI to your Ohio Medicaid legacy number.

*         See special instructions for paper and tape claims (below in this MAL).

I.         How do I get an NPI?

Individual APNs can receive an NPI number by personally submitting an NPI application to NPPES.  Or, you may arrange for your employing health care entity or place of practice to obtain an individual provider number for you.  To obtain an NPI, providers should contact NPPES directly at http://nppes.cms.hhs.gov or by phone at 1-800-465-3203 (or 1-800-692-2326 (TTY)).  Providers can apply for an NPI electronically or by paper.

When you apply for your individual NPI, ODJFS encourages you to submit the following information with your NPI application:

·          Ohio Medicare legacy (PIN) number,

·          Ohio Medicaid legacy number,

·          taxonomy number,

·          social security number, and/or

·          IRS individual tax identification number (TIN).

It is also important that you make it clear that you are applying for an NPI for an individual APN (i.e., an entity type 1 NPI) by checking the box on the NPI application for "an individual who provides health care."  A listing of taxonomy codes for APNs can be found at

http://www.wpc-edi.com/codes/taxonomy.

II.        How must my NPI relate to my Medicaid legacy number?

If your practice received this MAL, you/your practice submitted claim(s) as an individual APN or as an incorporated individual APN practice to ODJFS at least once during the last twelve months.  When APNs are doing business with ODJFS as an individual APN or as an individual incorporated APN practice, ODJFS currently only issues an individual APN Medicaid legacy number and expects the billing provider, pay to provider, and rendering provider to be the same provider (the individual APN).

Services rendered by other practitioners employed by or under contract with the APN or APN's incorporated individual practice should be billed under the APN's NPI and/or the APN's Medicaid legacy number (when both numbers are required).  This directive applies as soon as an APN receives their NPI number and remains in effect after January 1, 2008.

APNs must submit only the individual (entity type 1) NPI assigned to them with the Ohio Medicaid legacy number that was issued to them as an individual APN.  Only one NPI number can be associated with your individual Ohio Medicaid legacy number.  An individual APN's NPI should never be submitted to ODJFS with an individual Medicaid legacy number that belongs to another APN.

III.       How do I bill ODJFS using the NPI?

The billing instructions contained in this MAL are for APNs who do business with ODJFS as individual APNs or as incorporated individual APN practices who have not obtained a group (entity 2 type) NPI.  If you do business with ODJFS only as a member of a group practice or other provider-based practice, use the appropriate billing instructions as contained in MAL 529.

Instructions for submitting the NPI by an individual APN are also contained in the ODJFS EDI 837 Professional Companion Guide, which is available at:

http://jfs.ohio.gov/OHP/providers/npi.stm (see the box titled "Trading Partner").

Billing NPI on EDI 837 Professional Claims

The information in this section is technical but is intended to assist you in making the appropriate arrangements with your trading partner to receive your NPI number and to submit your NPI number on your EDI claims and other transactions.  A copy of this MAL will also be issued to each EDI trading partner doing business with ODJFS.

The NPI number must be entered in the primary identifier field on ASCII X12 837 health care transactions. The APN's NPI must be sent with the XX qualifier in the NM108 and the NPI in the NM109 of the 2010AB (for the pay to provider information) loop and/or 2010AA (for the billing provider information) loop.  Prior to January 1, 2008, the APN's Medicaid legacy provider number must also be sent with the 1D qualifier in the secondary identification qualifier location REF01 and the Medicaid legacy number in the secondary identification location REF02 of loops 2010AB and/or 2010AA.  The EDI standard does not require the rendering provider loop to be completed if the rendering provider is the same as the pay to provider.  For individual practices participating in Medicaid, the rendering and

pay to provider are always the same.  Do not send NPI information in the NM108 and NM109 nor the Medicaid legacy information in the REF01 and REF02 of the rendering provider loops (2310B or 2430B respectively).

Billing on Paper Claims or by Tape

*  Special Instructions for Paper and Tape formats

ODJFS is no longer accepting tape formats.

Beginning May 23, 2007, ODJFS will start to accept the Center for Medicare and Medicaid Services (CMS) 1500 (08/05) paper form (also referred to as the new CMS 1500).  Providers may continue to send the CMS 1500 (12-90) paper form (also referred to as the old CMS 1500).

Providers using the old CMS 1500 must submit a Medicaid legacy number wherever a provider number (identifier) is required on the claim.  Submitting an NPI number on the old CMS 1500 will cause the claim to reject or may cause the claim to pay inappropriately.

Providers submitting the new CMS 1500 must submit both the NPI and the Medicaid legacy number (identifier) in accordance with the ODJFS New CMS 1500 (08/05) Billing Instructions.

IV.      If my sole proprietary APN practice (practices owned by one APN) is incorporated, do I use my individual NPI number?

Although this is not currently allowed under the Ohio Medicaid program, many other health plans allow sole proprietary practices to be a group practice (of one member).  The NPI provisions allow any sole proprietary practice that is incorporated to obtain an entity type 2 (group/organization) NPI and, if the sole proprietary practice is not incorporated, the practice is not eligible for a group/organization (entity type 2) NPI.  When the sole proprietary practice is entitled to obtain an entity type 2 NPI, the NPI provisions require the individual APN that owns the practice and each APN employed by or under contract with the practice to also obtain an individual (entity 1) APN NPI number.

You may obtain your group (entity type 2) NPI number from NPPES as instructed in Section I of this MAL.  It is important that you make it clear that you are seeking the group NPI by checking the box for "an organization that renders health care."  Please submit as the primary taxonomy for the group practice either the taxonomy number 193400000X (if you are a single specialty practice) or the taxonomy number 193200000X (if you are a multi-specialty practice).

If your practice is an incorporated individual practice that has received, or plans to receive, an entity type 2 (group/organization) NPI, you may not submit that (entity type 2) NPI number on a claim to ODJFS until you have been issued a corresponding group Medicaid legacy number by ODJFS.  Once you have received your (entity type 2) NPI for your practice, you may request a group Medicaid legacy number from ODJFS by contacting the Provider Enrollment Unit at  P.O. Box 1461 Columbus, Ohio 43216-1461 or by phone at 1-800-686-1516.

Until you receive your group Medicaid legacy number from ODJFS, you must continue to bill as instructed in Section III of this MAL using only your individual NPI and Medicaid legacy number.  Once you receive your group Medicaid legacy number you must bill in accordance with the instructions contained in MAL 529.

V.       Why am I required to get an NPI?

The Code of Federal Regulations, CFR 45, Subpart D, Section 162.410 (a) (1) through (a) (6), requires APNs to obtain an NPI, to use it on all standard transactions where a provider identifier is required, and to disclose their NPI, when requested, to any entity that needs the NPI to identify that APN in a

standard transaction, including standard transactions sent to any health plan (i.e., Medicaid, Medicare or any other health plan).  ODJFS must also comply with the federal regulations.

VI.      Am I required to share my NPI number with ODJFS?

Yes, the APN must disclose to ODJFS the NPI number that has been assigned to the APN.  If you do not disclose your NPI to ODJFS, ODJFS will not be able to recognize you as a valid Medicaid provider.  This could cause your claims to deny.

Instructions on how to disclose your NPI information to ODJFS can be obtained under "SHARE IT!" from the following site:

http://jfs.ohio.gov/OHP/providers/npi.stm.

VII.     Am I required to share my NPI with other entities? 

Yes, as stated in Section V above, you are required to disclose your NPI, when requested, to any entity that needs the NPI to identify the APN in a standard transaction.  This includes disclosing your NPI to Medicaid, Medicare, other health plans and other health care providers.

Pharmacies will need your NPI to submit as the prescribing provider on claims; hospitals and long term care facilities (LTCF) may need your NPI to submit as a provider on hospital and LTCF claims; durable medical equipment (DME) suppliers will need your NPI to submit as the ordering provider on claims.  You are required to share your NPI with them.

VIII.    I heard that the date for NPI implementation has been extended.  Is that true?

No, the law still requires providers of health care and health (except small) plans to be in compliance with the NPI regulations on May 23, 2007.  However, for a 12 month period, CMS will not impose penalties on covered health plans that deploy contingency plans (in order to ensure the smooth flow of payments) if they have made reasonable efforts to become compliant and to facilitate the compliance of their providers and trading partners.

IX.      Has ODJFS deployed a contingency plan?

Yes, ODJFS has deployed a contingency plan as detailed in this MAL.

X.       What is meant by a dual identifier period?

A dual identifier period is the time period in which a health plan can require both the NPI and the plan's legacy (or proprietary) number on claim formats and may deny claims that are missing the plan's legacy number.

The purpose of the dual identifier period is to give health plans and providers the opportunity to assure the provider will get paid without interruption once NPI is fully implemented.  It is in the provider's best interest to have a significant volume of claims that have both identifiers and have been submitted early enough for ODJFS to assist the provider in correcting any NPI-related billing problems, prior to the end of the ODJFS dual identifier period.

As a part of ODJFS' NPI contingency plan, ODJFS has extended its dual identifier period to December 31, 2007.  During this extended period ODJFS requires both the Medicaid legacy identifier and the national provider identifier (NPI).  Failure to continue to send the Medicaid legacy identifier during the ODJFS dual identifier period will result in non-payment or the rejection of claims.

Providers and trading partners will be notified in the event ODJFS believes the ODJFS dual identifier period can end sooner than December 31, 2007, or needs to be extended to the CMS approved date of May 23, 2008.

ODJFS appreciates the attention of the providers in this matter, and as a result of their cooperation anticipates a successful transition to NPI enumeration.

Questions pertaining to this MAL should be addressed to:

Bureau of Plan Operations

The Provider Services Section

P.O. Box 1461

Columbus, Ohio 43216-1461

Toll free telephone number 1-800-686-1516

You can also obtain information about NPI as it pertains to the Ohio Medicaid program at http://jfs.ohio.gov/OHP/providers/npi.stm

NPI………………GET IT..........................SHARE IT........................USE IT