The Centers for Medicare and Medicaid Services (CMS) recently discovered a significant problem in the National Provider Identifier (NPI) filing system. A number of instances were found where the Legal Business Name (LBN) and/or Employer Identification Number (EIN) of an organization health care provider assigned an NPI did not match IRS records. In some cases, this mismatch was due to individual health care providers who erroneously applied for NPIs as organizations, and who reported their Social Security Numbers in the EIN field.
As a first step in improving the quality of information held in the National Plan and Provider Enumeration System (NPPES), CMS now requests that organization health care providers verify their LBN and EIN within NPPES. This is especially important if the organization health care provider experiences any Medicare claims processing issues.
March 1, 2008, was the deadline for all 837P and CMS-1500 claims to have an NPI or NPI/legacy pair in the required primary provider fields. Failure to include an NPI will now be cause for rejecting a claim.
Note: If you enumerated through the EFI alternative or submitted a paper NPI application, you should use the NPI Registry to check the content of your NPPES record. Make sure to have the Customer Service Representative at your Medicare contractor verify your Employer Identification Number (EIN), because the NPI Registry does not display EINs.
CMS has also discovered that some clearinghouses continue to strip NPIs, as well as other information, from Medicare claims. If your clearinghouse continues to strip your NPI from your claims for any reason, notify your Medicare Contractor immediately so that CMS can work with your clearinghouse to resolve the issue.
In some cases, clearinghouses are stripping the SY qualifier and the Social Security Number from claims that contain an NPI. Based on business requirement 4320.17 (outlined in Transmittal number 204, dated February 1, 2006), the qualifier SY is an acceptable qualifier for use on Medicare claims. See the table below for specific details. You should share this information with your clearinghouse if you suspect they are stripping the SY qualifier and the SSN from your claims.
|4320.17||Shared systems shall reject as non-compliant with the implementation guide any 837 version 4010A1 claim that contains XX in NM108, the NPI in NM109, and 1C or 1G as applicable in REF01of the same loop, but which lacks another REF01 in the billing or pay-to-provider loop with the EI (Employer Identification Number) qualifier and number or the SY (SSN, applies to carriers & DMERCs only) qualifier and number to convey the taxpayer identifier.|
If you have been submitting claims with both an NPI and a Medicare legacy number, and those claims have been paid, test your ability to receive payment using only your NPI by submitting one or two claims today with just the NPI (i.e., no Medicare legacy number).
Call your Medicare carrier, FI, or A/B MAC enrollment staff, or your DME MAC. Have a copy of your NPPES record or your NPI Registry record available.