National Provider Identifier Instructions For Medicare Part B Electronic Submissions

Effective March 1, 2008, First Coast Service Options, Inc. (FCSO) began the next stage of the acceptance of the National Provider Identifier (NPI) submitted on an ASC X12N ANSI 837 4010A1 transactions. NPIs must be submitted for primary providers.

Background

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 required issuance of a unique National Provider Identifier (NPI) to each physician, supplier, and other provider of health care. A number of articles have been issues in recent months to educate and remind physicians, suppliers, and other providers on the NPI and the application process. If you have not applied for an NPI, you may do so via the Internet at https://nppes.cms.hhs.gov.

Effective with this stage of the NPI implementation, primary providers may submit the NPI number alone, or with the legacy provider identifier and the NPI. FCSO strongly suggests you start submitting small files with the NPI only. Once your claims are processing correctly, it is recommended that you begin removing the legacy provider numbers. This will prepare you for the end of contingency.

Impacts

When groups or organizations submit claims, and the billing and the pay-to providers are different individuals or entities, the pay-to information must always be reported in the 2010AB loop and the billing provider information in the 2010AA loop.

The NPI will not be accepted on pre-HIPAA transactions, such as the X12 270 version 3051 or any proprietary electronic eligibility format currently supported.

The following requirements must be met when an NPI is submitted on an 837 or 276 version 4010A1 transaction.

It is imperative that when submitting your NPI numbers that they are associated correctly. Examples:

• If the billing provider is a group, Limited Liability Corporation (LLC), Professional Association (PA), or other corporate entity, identify the billing and rendering providers. It is imperative that you submit the group type 2 organization NPI in the 2010AA Billing Provider Loop, which relates to box 33 on the paper claim when printed. Then you must also submit the individual NPI in the 2310B Rendering Provider Loop, which relates to box 24J when the claim is printed. Not placing the correct NPI number in the correct loop will result in your file being rejected at pre-pass.

• If the billing provider is an independent laboratory, Ambulatory Surgical Center (ASC), Independent Diagnostic Testing Facility (IDTF), ambulance supplier, or solo practitioner, the NPI should only be sent in the 2010AA Billing Provider Loop, which relates to box 33 on the paper claim when printed. You should not send a 2310B rendering provider loop. Your claim will not be rejected, however you will received development letters or denials that will prolong your payments.

X12 837 Professional Electronic Claim, Version 4010A1 NPI Edits

• The NPI should be submitted on the 837 4010A1 claim in the following provider loops: 2010AA, 2010AB, 2310A, B, C, D or E, or 2420A, B, C, D, E or F.

• When submitting an NPI, the NM108 must contain the XX qualifier and the NM109 of that same segment must contain the NPI, which is a 10-byte numeric identifier (containing no special or alpha characters).

• When the NPI is submitted in either the billing loop (2010AA) or pay-to-provider loop (2010AB), you should also submit an REF segment to indicate the Employee Identification Number (EIN) or Social Security Number (SSN.) The number sent in the REF segment must match the number Medicare has registered for this provider.

• When indicating the EIN or the SSN, the REF01 must contain the EI qualifier (for the EIN) or SY (for the SSN), and the REF02 must contain the actual EIN or the SSN.

X12 276/277 Claim Status and Response, Version 4010A1 NPI Edits

• The NPI must be submitted on the X12 276 version 4010A1 claim status request in the 2100C loop.

• While the Medicare legacy provider number is no longer required; it is recommended that when submitting an NPI, in the 276 that you submit two iterations of the 2100C loop - one for the NPI and one for the Medicare legacy provider number. It is also recommended that you submit a few small files with NPI only. Once these files are processing correctly, we recommend that you remove the legacy provider numbers and send NPI only.

• Within the first 2100C loop, NM108 must contain the XX qualifier and the NM109 of that same segment must contain a 10-byte numeric NPI identifier (containing no special or alpha characters).

• Within the second 2100C loop, NM108 must contain the SV qualifier and NM109 must contain the Medicare legacy provider number.

• When both the NPI and the provider legacy identifiers are submitted in a 276 version 4010A1 claim status request transaction both will be reported back on the 277 version 4010A1 response transaction.

Any 276 version 4010A1 claim status request submitted on or after January 1, 2006, not meeting the requirements above specified will be rejected. Additionally, if a 276 is submitted with more than three iterations of the 2100C loop, or has entries of the same qualifier (XX, SV or FI) more than once in NM108 of the 2100C loop iterations, it will be rejected by the standard system.

Two of the 276 format verification edits are:

• HR2100CBNM10904 is set to fail if the 2100C NM108 is XX and the 2100C NM109 value is not present in the crosswalk file.

• HR2100CBNM10905 is set to fail when the NPI PIN combination is not on the crosswalk file. The NPI is located in the 2100C NM109 where the 2100C NM108 is XX and the PIN is in the 2100C NM109 where the 2100C NM108 is SV. Note: Edit will only fail when there is a 2100C NM108 of XX and a NM108 of SV.

X12 835 Electronic Remittance Advice (ERA), Version 4010A1 NPI Changes

• The header information of the 835 will remain the same as it is today. The payee TIN (EIN/SSN) will be returned at the payee level as the Payee ID (1000B loop) and the REF segment will contain the Medicare legacy identifier with the 1C qualifier.

• The NPI will be reported, if submitted, at the claim level in the 2100 loop NM109 with qualifier XX. If the NPI is not submitted, the Medicare legacy Identifier will be reported as it is today, in the REF segment of loop 2100 with the 1C qualifier.

• If the service level provider is different than the claim level provider and an NPI is submitted, it will be reported in the REF segment of loop 2110 with the HPI qualifier. If an NPI is not submitted and the service level provider is different than the claim level provider, the Medicare Legacy Identifier will continue to be reported as it is today in the REF segment of loop 2110 with the 1C qualifier.

Standard Paper Remittance (SPR) Advice & Medicare Remit Easy Print (MREP)

• The Header information will contain the Medicare Legacy Identifier as it does today.

• The rendering provider NPI will be displayed at the detail service level.