New CMS Claims Approval Policies Underscore the Importance of Verifying NPPES Data

March 11, 2008

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Important NPI Information Not Matching IRS Records

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.

If your 837P or CMS-1500 claim is rejected:

  • Check your record in the National Plan and Provider Enumeration System (NPPES).
    • Verify that the legacy identifier sent on the claim is reported in your NPPES record. If the legacy identifier is not there, it must be added.
    • Verify that the Legal Business Name (for a provider/supplier who is an organization) or the Legal Name (for a provider/supplier who is an individual or a sole proprietorship) is correct.
    • Verify that the correct Entity type was selected at the time of NPI application.
      • Individuals obtain an NPI as Entity Type 1
      • Organizations obtain an NPI as Entity Type 2 NPI

    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.

  • If the above validation is successful and your claims continue to be rejected, call the Customer Service Representative at your Medicare Contractor.
    • Have a copy of your NPPES record or your NPI Registry record in hand. A copy of your NPPES record can be printed from NPPES by going online and using the User ID and password selected when you applied for your NPI. If you obtained your NPI through the EFI alternative or submitted a paper NPI application, you should print your record from the NPI Registry. EINs and Social Security Numbers (SSNs) are not displayed in the NPI Registry.
    • Have the claim reject number and message.
    • Be prepared to give the following information:
      1. Legal Business Name of the organization or Legal Name of the individual
      2. Contractor Tracking Number (if known)
      3. Approximate date (month/year) when the CMS-855 enrollment application was submitted or last updated
      4. Provider/Supplier Tax Identification Number (EIN or SSN)
      5. National Provider Identifier (NPI)
      6. Medicare legacy Identifier
      7. Practice location on claim (where the is practice located; e.g., 100 Main St., New Orleans, LA)
      8. Contact Information where you can be reached if further discussion is needed

Some Clearinghouses Continue to Strip Information from Medicare Claims

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.

Physicians Are Encouraged to Test NPI-only—NOW

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).

  • If the claim is processed and you are paid, continue to increase the volume of claims sent with only your NPI.
  • If the Medicare NPI Crosswalk cannot match your NPI to your Medicare legacy number, the claim with an NPI-only will be rejected.
    • Go into your NPPES record and verify that the information you are sending on the claim is consistent with the information in NPPES.
    • If it is different, make the updates in NPPES and resend a small batch of claims 3–4 days later.
  • If your claims are still being rejected after updating your information, you may need to update your Medicare enrollment information to correct this problem.

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.

Visit the CMS NPI page for more information.