NFTL 07-05

Nursing Facility Transmittal Letter (NFTL) 07-05

August 9, 2007

TO:                Administrators of Nursing Facilities

Directors of County Departments of Job and Family Services

FROM:          Helen Jones-Kelly, Director

SUBJECT:    National Provider Identifier (NPI) Implementation and the ODJFS NPI Contingency Plan

PLEASE ROUTE THIS LETTER TO YOUR:

·    Billing Departments

·    Systems/Information Technology Departments

·    Billing Software Vendors

·    Billing Associates

·    Trading Partners

This transmittal letter is an update to NFTL 06-08 that we sent to you August 18, 2006. This NFTL has two primary purposes. First, this NFTL is to inform you of the Ohio Medicaid NPI Contingency Plan during the 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 will deny claims that are missing the plan's legacy number.

Second, this NFTL is to remind you of the importance of sharing your National Provider Identifier (NPI) with the Ohio Medicaid program's Long Term Care (LTC) Provider Enrollment Unit, and to provide you with Ohio Medicaid billing information regarding room and board and Medicare Part A claims. Instructions are provided for both the current dual identifier period tentatively scheduled to end December 31, 2007, and the period thereafter when NPIs are fully implemented. The transition to NPIs will affect your Medicaid enrollment, billing, and reimbursement.

I.         The ODJFS Contingency Plan

Federal law still requires providers of health care and health plans (except for small health plans defined in CFR 45 §160.103 as a health plan with annual receipts of $5 million or less) 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.

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) to be reported on claims. Failure to continue to send the Medicaid legacy identifier during the ODJFS dual identifier period will result in denial of claims.

The purpose of the dual identifier period is to give health plans and providers the opportunity to assure that 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.

Nursing facility claims for room and board and Part A co-insurance 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 denied.* Nursing facility claims submitted to ODJFS on or after January 1, 2008 will be denied if the nursing facility's NPI number is not in the required field(s) on the claim. This information is displayed in the table below:

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

Providers and trading partners will be notified in the event ODJFS decides that the ODJFS dual identifier period can end sooner than December 31, 2007, or if it 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.

II.        Obtaining and Sharing the NPI with Ohio Medicaid

According to federal regulation 45 CFR § 162.404, all eligible health care providers are required to obtain a ten-digit NPI number from the National Plan and Provider Enumeration System (NPPES) and to disclose the NPI upon request. After full implementation of the NPI, the NPI will be the only acceptable provider identifier. The Ohio Department of Job and Family Services (ODJFS) Ohio Medicaid program is requesting that you share your NPI with us.

In order for ODJFS to recognize your NPI number's association with your provider agreement, your NPI must be submitted to the LTC Provider Enrollment Unit as instructed in this section. Your NPI must be verified and entered into our provider enrollment system as soon as possible so that we can identify and process your claims with your NPI number once the use of the NPI is fully implemented. Effective January 1, 2008, NPI numbers are required for use in all HIPAA related transactions such as the 837 Institutional (837I) transaction. Failure to comply with these NPI enumeration and verification requirements could result in denied claims or delayed payments.

Steps You Must Take to Enumerate and Share Your NPI

Although the NPI is not required for electronic claims submission until January 1, 2008, in order to ensure that your Medicaid payment continues without interruption, we request that you do the following:

A.       Obtain an NPI number

The Centers for Medicare & Medicaid Services (CMS) has developed the National Plan and Provider Enumeration System (NPPES) to assign these unique identifiers. CMS has contracted with Fox Systems, Inc. to serve as the NPI Enumerator. The NPI Enumerator is responsible for dealing with health plans and providers on issues relating to unique identification. To learn more about the NPI and to obtain an NPI number, The NPI Enumerator may be contacted as follows:

·    web address: https://nppes.cms.hhs.gov/NPPES

·    email at customerservice@npienumerator.com or

·    phone 1-800-465-3203 (NPI Toll-Free) or 1-800-692-2326 (TTY)

·    mail at NPI Enumerator, PO Box 6059, Fargo, ND 58108-6059

When applying for an NPI number, be sure to reference your Medicare and Medicaid numbers in Section 3C: Other Provider Identification Numbers on the NPI Application/Update Form.

Please make sure your NPPES Application contains all of the following vital pieces of information:

·    Provider's doing business as (DBA) or facility name

·    Provider's legal name (e.g., corporation, partnership, or limited liability company)

·    Provider's facility address, (street, city, state, zip code)

·    Provider's nine-digit federal Employment Identification Number, (EIN)

·    Provider's seven-digit Ohio Medicaid provider number (sometimes referred to as the Medicaid legacy number)

·    Provider's six-digit Medicare number

·                [Note  Ohio facilities' Medicare numbers usually begin with "36". Following the implementation of the NPI, the Medicare/Medicaid Provider Number will continue to be issued to certified providers and used on all survey and certification transactions and resident assessment transactions.

·                In order to distinguish its role from that of the NPI, the Medicare Provider Number has been renamed the Centers for Medicare & Medicaid Services (CMS) Certification Number (CCN)]

·    Provider's primary taxonomy codes

·    Provider's secondary taxonomy codes (if applicable).

NPPES will process your application and provide an email notice containing your ten-digit NPI number. That notice will also contain the data elements listed above, only if you provide them to NPPES on your application.

B.       Report Your NPI and Verification Data to ODJFS

1.        Forward the email notice that you received from NPPES that relays your assigned NPI number and associated verification data (see section A above) to NF_NPI@odjfs.state.oh.us. If you received a paper or fax notice from NPPES, scan the notice and send it as an attachment to this same email address.

2.        In the forwarding subject line, include the heading "NPI Reporting," and the name and seven-digit Ohio Medicaid number of the nursing facility to which the NPI is assigned.

3.        If the NPPES confirmation letter omits the information listed in section A1, above, provide that information in the body of the email to the LTC Provider Enrollment Unit. The missing information can also be hand-written on the NPPES letter, but you must initial and date any data items added to the letter. We also highly recommend that you amend your application with NPPES to provide them with these data elements.

4.        To assist in providing a smooth NPI transition, you must also supply the following information in the e-mail:

·                Provider's Ohio Department of Health four-digit identification number

·                Provider's Ohio Department of Health license number (if applicable)

·                Provider's phone number with area code.

·                Provider's trading or billing partners

·                Provider type (e.g., NF, SNF/NF, ICF-MR)

5.        The LTC Provider Enrollment Unit will send a confirmation notice back to the email address you use to submit your NPI.

III.       Billing Instructions

As of the date of this NFTL, December 31, 2007 is the end of the "dual identifier" period. January 1, 2008 is the date when all claims submitted to Ohio Medicaid for nursing facility (NF) services must use the NPI on the 837I transaction. Do not submit your Medicaid legacy number using the qualifier 1D after the dual identifier period is over.

A.       Dual Identifier Period

ODJFS is currently conducting a dual identifier period similar to Medicare's. The NPI should be submitted in addition to the Medicaid provider (legacy) number. To include both numbers on the 837I, follow these instructions:

1.        Loop Occurrences

If you submit only Loop 2010AA, Billing Provider Information, report the NPI, SSN or EIN, and the Medicaid provider number in this loop.

If you submit both Loop 2010AA, Billing Provider Information, and Loop 2010AB, Pay to Provider Information, and the billing and pay to provider are the same, report the same NPI, SSN or EIN, and the Medicaid provider number in both loops.

If you submit both Loop 2010AA, Billing Provider Information, and Loop 2010AB, Pay to Provider Information, and the billing and pay to provider are different, submit the NPI, SSN or EIN, and the Medicaid provider number of the provider to be paid in Loop 2010AB, Pay to Provider.

2.        Segment Usage

a.        The NM1 Segment Usage:

Use the qualifier XX in the primary identification qualifier location NM108, and use the NPI number in the primary identification location NM109.

b.        The REF Segment will be used twice:

For the first occurrence of the REF segment, continue to use your Medicaid provider number with the 1D qualifier in the secondary identification qualifier location REF01, and the Medicaid provider number in the secondary identification location REF02.

For the second occurrence of the REF segment, use your Social Security Number (SSN) or Employer Identification Number (EIN) with SY or EI in the secondary identification qualifier location REF01, and the EIN or SSN in the secondary identification location REF02.

3.        Coinsurance Claims:

a.        Submitted directly to ODJFS:

For coinsurance claims submitted directly to Ohio Medicaid, use both the NPI and your Medicaid provider number.

b.        Automatic cross-overs:

For coinsurance claims that automatically cross over to ODJFS, the NPI of the provider that is submitted to Medicare is the NPI that will be sent to ODJFS. Continue to report the Medicaid provider number associated with the NPI submitted on the claims.

B.       Post NPI Dual Identifier Period

Because Ohio Medicaid's nursing facility rates are specific for each enrolled facility, in addition to the facility's NPI, the facility's seven-digit location number (the legacy number) must be submitted on the 837I effective January 1, 2008. This ensures that the correct rate is paid to each facility. Below are the instructions to include both numbers on the 837I - the NPI as the provider identifier and the location number as the facility identifier. Do not submit your Medicaid legacy number using the qualifier 1D after the Dual Identifier Period is over.

1.        Loop Occurrences

a.        If you submit only Loop 2010AA, Billing Provider Information, report the NPI, SSN or EIN, and the facility location number in this loop.

b.        If you submit both Loop 2010AA, Billing Provider Information, and Loop 2010AB, Pay to Provider Information, and the billing and pay to provider are the same, report the same NPI, SSN, or EIN, and the facility location number in both loops.

c.        If you submit both Loop 2010AA, Billing Provider Information, and Loop 2010AB, Pay to Provider Information, and the billing and pay to provider are different, submit the NPI, SSN, or EIN, and the facility location number of the provider to be paid in Loop 2010AB, Pay to Provider.

d.        If you also submit Loop 2310E, Service Facility Name, submit the NPI, SSN, or EIN, and the facility location number of the provider to be paid in this loop.

Note: Loops 2010AA and 2010AB apply to all claims while Loop 2310E applies to a single claim. In the ODJFS system, the pay to provider information reported in Loop 2310E will overwrite the pay to provider information reported in 210AA and 2010AB for the claim in which it is included.

2.        Segment Usage

a.        The NM1 Segment Usage:

Use the qualifier XX in the primary identification qualifier location NM108, and report the NPI in the primary identification location NM109.

b.        The REF Segment is used two times:

(1)      In the first occurrence of the REF segment, use the LU qualifier in the secondary identification qualifier location REF01 to report your facility location number (legacy number) in the secondary identification location REF02.

(2)      In the second occurrence of the REF segment, use the SY or EI qualifier in the secondary identification qualifier location REF01, and report your Social Security Number (SSN) or Employer Identification Number (EIN) in the secondary identification location REF02.

3.        Coinsurance Claims:

a.        Submitted directly to ODJFS:

Submit coinsurance claims directly to Ohio Medicaid using both the NPI and the facility location number using the LU qualifier as indicated above.

b.        Automatic cross-overs:

To insure that automatic coinsurance crossovers price correctly, we strongly recommend that you use the same NPI when submitting those claims that you use for Medicaid room and board billing. Report the facility location number using the LU qualifier as indicated above.

If the NPI number you submit to Medicare is different from the one you submit to Medicaid for room and board, please provide the Medicare NPI number to LTC Provider Enrollment Unit in the manner described in section A above.

IV.      Future Role of the Medicaid Provider Number (legacy number)

Post NPI implementation, the Medicaid legacy number will continue to be issued to certified NF providers and will continue to be requested for cost reports and other reporting purposes.

V.       Resources

To learn more about the NPI and to obtain an NPI number, visit the NPI Enumerator website at

https://nppes.cms.hhs.gov/NPPES

To submit your NPI to the LTC Provider Enrollment unit, forward the NPPES email notice or scanned hard copy NPPES notice that relays your assigned NPI number and associated verification data to

NF_NPI@odjfs.state.oh.us

For information regarding taxonomy codes, access The Washington Publishing Company at:

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

·    In the forwarding subject line, include the heading "NPI Reporting," and the name and seven-digit Ohio Medicaid number of the nursing facility to which the NPI is assigned

For questions about the assignment of NPI numbers relating to Ohio Medicaid nursing facilities,

1)        send an email to

NF_NPI@odjfs.state.oh.us

In the forwarding subject line, include the heading

"NPI Assignment Question"

OR

2)        call the LTCF Provider Enrollment Unit at (614) 466-9088.

For questions about billing the Ohio Medicaid program using the NPI, please use this email address:

NFDIRECTBILL@odjfs.state.oh.us.

Thank you for your attention to this matter. With your cooperation, we anticipate a successful transition to use of the NPI.