MAL 529

Medical Assistance Letter (MAL) 529

June 7, 2007

To:                Group Advanced Practice Nurses

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 providers enrolled and billing as Advanced Practice Nurse (APN) group practices in the Ohio Medicaid program that they are required to obtain a National Provider Identifier (NPI) by May 23, 2007.  An NPI for group practices is a unique, ten-digit, entity type 2 identifier received from the National Plan and Provider Enumeration System (NPPES).  This MAL also provides information on applying for your NPI, disclosing your NPI to ODJFS, and using your NPI when submitting claims to ODJFS.

APN group practices will also be required to use the unique (entity type 1) NPI numbers for each individual APN providing/rendering services for the group practice on claims* submitted to ODJFS if the individual APN has been issued an individual Medicaid legacy number.  The group practice should work with the individual APNs in the group to determine if the group will obtain the individual APN numbers from NPPES for the practice's APNs or the individual APNs will independently obtain their own individual APN numbers from NPPES and then share the numbers with the group practice.  For every Ohio Medicaid provider/billing number you currently have and use today for your Medicaid business, your practice must have a corresponding, unique NPI number.

After receiving the APN group NPI and the individual APN NPI numbers and until January 1, 2008, all APN group practices conducting 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 group NPI number and their current group Medicaid provider number (now referred to as the Medicaid legacy number or the Ohio Medicaid legacy number) in accordance with the Ohio Medicaid EDI companion guide and/or the instructions contained in this MAL.  In addition, they must submit both the individual APN's NPI number and the corresponding individual 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.  Until January 1, 2008, claims received by ODJFS from APN group practices will continue to be accepted and processed if the claims contain a valid Medicaid legacy number or both a valid NPI and valid Ohio Medicaid legacy number in the required provider fields.  Prior to January 1, 2008, claims submitted without an Ohio Medicaid legacy number (i.e., claims submitted only with an NPI number) in the required provider fields will be rejected or denied.*

APN claims submitted to ODJFS on or after January 1, 2008 will be rejected and/or denied if the group and/or individual 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.

APNs and APN group practices must:

·          enumerate through NPPES,

·          receive their NPI, and

·          disclose their NPI to ODJFS immediately.

APNs and APN group practices must be ready to submit both their NPI(s) and Medicaid legacy numbers on claims.*

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

I.         How do I get an NPI?

APN group practices can receive an (entity type 2) NPI number for the APN group practice and an individual (entity type 1) APN provider number for each APN in the group practice by submitting an application to NPPES.  To obtain a National Provider Identifier, 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 APN group practice NPI, ODJFS encourages you to submit the following information with your NPI application: Ohio Medicare legacy (PIN/UPIN) number, Ohio Medicaid legacy number, taxonomy number, and employer identification number (EIN).  It is also very important to make it clear on the NPI application when you are applying for an NPI for the group practice and when you are applying for an individual NPI for one of the APNs in your practice.

If you are applying for a group NPI, check the box on the NPI application 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).  Other APN taxonomy numbers may be given as secondary taxonomy numbers to further describe the practice and the type of specialty services provided by the practice.

If you are applying for an NPI for an individual APN in the group (i.e., an entity type 1 NPI), check the box on the NPI application for "an individual who provides health care."  Please submit as the primary taxonomy number for the individual APN the taxonomy code that best describes the APN's specialty.  You may submit more than one APN taxonomy number.

A listing of taxonomy codes for APNs can be found at  http://www.wpc-edi.com/codes/taxonomy.

II.        How do I bill ODJFS using the NPI?

If your practice received this MAL, at least once during the last twelve months you/your practice submitted claim(s) as a group practice.

Billing NPI on EDI 837 Professional Claims

The information in this section is technical but is intended to assist your practice 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 NPI (entity type 2) assigned to the group practice must be sent with the XX qualifier in the NM108 and the group (entity type 2) 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 Medicaid legacy provider number assigned to the group practice must also be sent with the 1D qualifier in the secondary identification qualifier location REF01 and the group Medicaid legacy number in the secondary identification location REF02 of loops 2010AB and/or 2010AA.  The rendering provider loop (2310B loop) must also be completed and contain information about the individual APN

who rendered the service.  Group APN practices must submit the (entity type 1) NPI assigned to the individual APN that provided the service in the NM109 of 2310B with the qualifier value of XX in the NM108 of the 2310B loop and submit the Medicaid legacy number assigned to the individual APN in the REF02 of the 2310B loop with a 1D qualifier in the REF01 of the 2310B loop.  When a group practice submits claims, the pay to numbers should always belong to the group and the rendering provider number must always be a valid individual APN or other valid individual practitioner that can provide Ohio Medicaid covered services under an APN group practice.  Only one individual (entity type 1) NPI number can be associated with a (unique) 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 or another individual, group or organizational entity.

Instructions for submitting NPI on claims for an APN group 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 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 submitting 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.

III.       Is the APN group practice required to get an NPI?

The Code of Federal Regulations, CFR 45, Subpart D, Section 162.410 (a) (1) through (a) (6), requires APNs and APN group practices to obtain NPI numbers, to use their NPI 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 transactions sent to and received from any health plan (i.e., Medicaid, Medicare or any other health plan).  ODJFS must also comply with the federal regulations.

IV.      Is the APN group practice required to share with ODJFS the NPI numbers assigned to the group and the individual APNs that practice in the group?

Yes, the group practice must disclose the NPI number assigned to the group to ODJFS.  The group practice must also disclose the NPI numbers assigned to each individual APN that practices in the group to ODJFS, unless the individual APN has independently disclosed his or her individual NPI number to ODJFS.

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.

V.       Is the group practice required to share the NPI numbers assigned to the group practice or assigned to the individual APNs in the group with other entities?

Yes, APNs and APN group practices must disclose their NPI, when requested, to any entity that needs the NPI to identify that APN/APN group practice in a standard transaction.  This includes disclosing your NPI to Medicaid, Medicare, other health plans, and any other provider that needs to identify the APN on transactions.

Pharmacies will need the appropriate individual NPI to submit as the prescribing provider on pharmacy 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 DME claims. You are required to share the appropriate NPI with them.

VI.      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.

VII.     Has ODJFS deployed a contingency plan?

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

VIII.    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