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When, If Ever, Do You Get a New NPI Number and Other NPI Questions

Questions

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What is a NPI again?

The National Provider Identifier (NPI) is a Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification Standard. The NPI is a unique identification number for covered health care providers. Covered health care providers and all health plans and health care clearinghouses must use the NPIs in the administrative and financial transactions adopted under HIPAA. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number). This means that the numbers do not carry other information about healthcare providers, such as the state in which they live or their medical specialty. The NPI must be used in lieu of legacy provider identifiers in the HIPAA standards transactions.

As outlined in the Federal Regulation, The Health Insurance Portability and Accountability Act of 1996 (HIPAA), covered providers must also share their NPI with other providers, health plans, clearinghouses, and any entity that may need it for billing purposes.

When should you get a new NPI?

The National Provider Identifier (NPI) is meant to be a lasting identifier, and is expected to remain unchanged even if a health care provider changes his or her name, address, provider taxonomy, or other information that was furnished as part of the original NPI application process. There are some situations, however, in which an NPI may change such as when health care provider organizations determine they may need a new NPI due to, for example, certain changes of ownership, the conditions of a purchase, or a new owner’s subpart strategies. There also may be situations where a new NPI is necessary because the current NPI was used for fraudulent purposes.

A health care provider (or the trustee/legal representative of a health care provider) should deactivate its NPI in certain situations, such as retirement or death of an individual, disbandment of an organization, or fraudulent use of the NPI. To deactivate an NPI, a health care provider (or the trustee/legal representative of a health care provider) must complete a CMS-10114 and mail it to the NPI Enumerator.

Does the NPI replace the tax ID number?

The billing provider’s tax ID number and NPI are always required on claims. Any other providers identified on the claim, such as rendering provider or service facility, must be identified with their NPI only. Their tax ID number should not be included.

For eligibility, claim status inquiry, referral and precertification, only the NPI (no tax ID number) is used.

How does a rendering physician report their National Provider Identifier (NPI) on a claim that includes Physician Quality Reporting Initiative (PQRI) or Electronic Prescribing Incentive Program (eRx) quality-data codes (QDCs)? What if he/she is part of a group and the group NPI is used on the claim?

Your individual National Provider Identifier (NPI) must be included on the claim line items for the quality-data codes (QDCs) you submit as well as the line items for the services to which the QDC is applicable. The PQRI/eRx QDC must be included on the same claim that is submitted for payment at the time the claim is initially submitted in order to be included in PQRI analysis.

If a group NPI is used at the claim level, the individual rendering physician’s NPI must be placed on each line item, including all allowed-charge and quality-data line items. See the PQRI Implementation Guide for a sample CMS-1500 claim. This is available as a download from the Measures/Codes section of the CMS PQRI website. For eRx, see the Claims-Based Reporting Principles for eRx, available on the CMS eRx website.

If a health care provider with a National Provider Identifier (NPI) moves to a new location, must the health care provider notify the National Plan and Provider Enumeration System (NPPES) of its new address?

Yes.  A covered health care provider must notify the NPPES of the address change within 30 days of the effective date of the change. We encourage health care providers who have been assigned NPIs, but who are not covered entities, to do the same. A health care provider may submit the change to NPPES via the web or by paper. If paper is preferred, the health care provider may download the NPI Application/Update Form (CMS-10114) from the Centers for Medicare & Medicaid Services’ forms page or may call the NPI Enumerator (1-800-465-3203) and request a form.

What happens when you join a group?

In Section 4B of the CMS-855I, the NPI of the Group should be entered if it has been issued to the Group. If you are joining a group, the group is responsible for providing you with their current Provider Identification Number (PIN) and the NPI, if they have been issued.

If you are a solo physician with an incorporated practice, how many NPIs should you have?

An individual is eligible for only one NPI. In the above example, there are two health care providers: the physician and the corporation. The physician would obtain an NPI (Entity Type Code 1, Individual). The corporation would obtain an NPI (Entity Type Code 2, Organization). Generally, the corporation’s NPI would represent the Billing and Pay-to Providers and the physician’s NPI would represent the Rendering, Referring/Ordering, Attending, Operating and/or Other Providers. These physicians should ensure that their enrollment records with the health plans to whom they will be sending claims are up to date, that those health plans are aware of the assigned NPIs, and that the NPIs are used in a way that is compatible with their enrollment.

I do not submit healthcare claims to Medicare; do I need a National Provider Identifier (NPI)?

Yes. NPIs are required by the NPI Final Rule to be used to identify health care providers in HIPAA standard transactions (including claims) that are conducted with any health plan, not just with Medicare. So even if you do not submit claims to Medicare, but submit HIPAA standard claims transactions to some other health plan, you are required to use an NPI in those transactions, and should be doing so as of May 23, 2007. Additionally, many health plans are requiring that providers use NPIs on paper claims. Providers should check with any health plan with whom they conduct business to determine their policy on the use of the NPI for paper claims.
*Questions and Answers excerpted from the CMS website.

Where can you look up NPIs?

https://nppes.cms.hhs.gov/NPPES/NPIRegistryHome.do
http://nynpi.com/
http://www.npinumberlookup.org/
http://www.npinumberlookup.org
http://www.npivalidator.com/
http://npidb.org/
http://www.hmedata.com/npi.asp
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The Dog Days of PECOS: CMS Publishes the Short Form (Paper) for PECOS, plus Consultant David Zetter Walks You Through It Online

NOTE: The date has been changed to July 5, 2011 has been delayed indefinitely.

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Many managers have told me they know their providers are in PECOS but they’re not on the list OR they never enrolled their providers but they are on the list OR they’ve sent their paperwork and have not heard back for 2, 4, 6 weeks – should they be worried?  The CMS website says “It is possible that it could take 45-60 days, sometimes longer, for Medicare enrollment contractors to process enrollment applications,” so I guess we all need to chill out a little.

The massive undertaking of qualifying every single healthcare professional who refers/orders or provides medical services to Medicare patients in order to sift out those who would lie about providing goods and services is fraught with confusion, miscommunication and misunderstanding.  That’s okay, though, because CMS says no checks for services or goods will be withheld due to providers not being listed in PECOS, at this time. They know it’s a mess and it will take quite a while to get everyone straightened out, on the list and able to get checks from CMS if and only if their name is on the list.

Below is the CMS fact sheet published last week.

The Doctor, by Sir Luke Fildes (1891)

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Medicare Enrollment Guidance for Physicians that Infrequently Receive Reimbursement from the Medicare Program

Traditionally, most physicians have enrolled in the Medicare program to furnish covered services to Medicare beneficiaries.  However, with the implementation of Section 6405 of the Affordable Care Act, some physicians will need to enroll in the Medicare program for the sole purpose of certifying or ordering services for Medicare beneficiaries. These physicians do not send claims to a Medicare contractor for the services they furnish.

In the process of implementing the provisions contained in the Affordable Care Act, we have become aware of several unique enrollment issues for certain types of physicians or practitioners. Specifically, we have modified the process of enrollment to accommodate the special circumstances of the following individual physicians and practitioners:

  • Physicians employed by the Department of Veterans Affairs
  • Physicians employed by the Public Health Service
  • Physicians employed by the Department of Defense Tricare program
  • Physicians employed by Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs) or Critical Access Hospitals (CAHs)
  • Physicians in a Fellowship
  • Dentists, including oral surgeons

This document provides guidance to those practitioners.

Q: How can I verify whether I am already enrolled in PECOS?

A: If a physician is concerned or uncertain about whether s/he is actually enrolled in the Provider Enrollment, Chain and Ownership System (PECOS), s/he can  review the Ordering and Referring file found in the download section of the “OrderingReferringReport” tab (click here) on the Medicare Provider and Supplier Web Site.

Providers and suppliers can check with the ordering or referring physician to see if the physician is currently seeing Medicare patients and the physician’s claims are being paid. Until we advise otherwise, your orders and referrals will not be rejected due to the lack of an approved enrollment record in PECOS.

Q: I am a physician employed by the Department of Veterans Affairs, Department of Defense Tricare program, by the Public Health Service, an FQHC, an RHC, or a CAH.  Do I need to enroll in PECOS to order and refer items or services for Medicare beneficiaries?

A: Yes, but we have abbreviated the enrollment process and documents for physicians employed by the Department of Veterans Affairs, the Public Health Service, the Department of Defense Tricare program, an FQHC, an RHC, or a CAH. However, because this is a unique solution to enrollment for a specific set of physicians, our systems will not accommodate the abbreviated forms on-line. Therefore, any physician employed by the Department of Veterans Affairs, the Public Health Service, the Department of Defense Tricare program, an FQHC, an RHC, or a CAH, who is not already enrolled in PECOS, must use the paper enrollment application process
and do the following:

Complete the following sections of the paper CMS-855I, “Medicare Enrollment Application for Physicians and Non-Physician Practitioners” and mail the completed form to the designated Medicare enrollment contractor:

  • Section 1  Basic Information (they would be a new enrollee)
  • Section 2  Identifying Information (section 2A, 2B, 2D and if appropriate 2H and 2K)
  • Section 3  Final Adverse Actions/Convictions
  • Section 4C/4E  Practice Location Information (same as section 2B)
  • Section 13  Contact Person
  • Section 15  Certification Statement (must be signed and dated””blue ink recommended)
  • Section 17  Supporting Documentation (cover letter stating the provider is only enrolling to order and refer services to a beneficiary)

Note: Physicians who are employed by the Department of Veterans Affairs, the Public Health Service, the Department of Defense Tricare program, an RHC, FQHC, or CAH are not required to include the Electronic Funds Authorization Agreement (CMS-588) or the Medicare Physician and Supplier Agreement (CMS-460) with the enrollment form.

Q: I am a  physician in a fellowship program.  Do I need to enroll in PECOS?

A: If you are a physician in a fellowship, and licensed in the State, you can enroll in Medicare for the sole purpose of ordering or referring items or services for Medicare beneficiaries. To enroll as a “referring and ordering physician-only” you would need to complete the abbreviated enrollment application form in the same way as other physicians (VA, DoD, PHS, FQHC, RHC CAH) who are enrolling to order and refer only (see previous question.) If you elect to enroll to order and refer only, you would not be enrolled in Medicare for the purpose of providing Medicare services to Medicare beneficiaries. In order to provide covered services to Medicare beneficiaries, a physician would need to complete the full enrollment application either on-line or in hard copy.

Q: I am an Oral Surgeon or Dentist. How do I Enroll in PECOS?

A: Dentists, including oral surgeons, must enroll in the Medicare program to receive reimbursement for services furnished to Medicare beneficiaries or to order covered items or services for Medicare beneficiaries. Oral surgeons would complete the same paper forms, or on-line application, as any other practitioner enrolling in PECOS.
If you elect to enroll as a “referring and ordering physician-only”, you would need to complete the abbreviated enrollment application form in the same way as other physicians (VA, DoD, PHS, FQHC, RHC CAH) who are enrolling to order and refer only (see previous two questions.)  If you elect to enroll to order and refer only, you would not be enrolled in Medicare for the purpose of providing Medicare services to Medicare beneficiaries.

In order to provide covered services to Medicare beneficiaries, a dentist, including oral surgeons, would need to complete the full enrollment application either on-line or in hard copy.

Note:  In completing the enrollment application portion dealing with specialty, oral surgeons would check the “oral surgery (dentist only)” box found in section 2 of the Medicare enrollment application and any other dentist would check the box titled, “Undefined Physician Type” and specify that they are a dentist in the space provided.  In the near future, we will revise the Medicare enrollment application to add “Dentist” as a physician specialty.

Internet-based PECOS

Physicians and practitioners who are employed by the Department of Veterans Affairs, the Defense Department, the Public Health Service, an RHC, FQHC, or CAH must complete the paper enrollment application that has been modified and shortened to accommodate the special situation of these professionals. All other physicians and practitioners who furnish services to Medicare beneficiaries must enroll in the Medicare program to receive reimbursement and order/refer in the Medicare program.  For those physicians and practitioners using the on-line process, we have developed a document that will help you through the PECOS enrollment process.   It will be easier to complete the process if you review this document before you begin the enrollment process.

  • The document titled, “Internet-based PECOS — Getting Started Guide for Physicians and Non-Physician Practitioners” can be found here.
  • Although you are permitted to complete your enrollment application in hard copy, it will be easier and quicker if you use the Internet-based Provider Enrollment, Chain and Ownership System (PECOS) to complete the Medicare enrollment process.  The Internet-based PECOS application is completed via the web here.
  • After submitting an enrollment application via Internet-based PECOS, you must:
    • Print, sign and date (blue ink recommend) the Certification Statement(s), and
    • Mail the Certification Statement(s) and applicable supporting documentation to the designated Medicare contractor (no later than 7 days after you complete the online portion.)
    • NOTE: The Medicare contractor will not be able to begin to process your enrollment application until it receives a signed and dated Certification Statement.

 

Additional Medicare Enrollment Information

To ask a provider enrollment question, contact the Medicare contractor for your State. Medicare provider enrollment contact information for each State can be found here.

To report Internet-based PECOS navigation, access, or printing problem with Internet-based PECOS, contact the EUS Help Desk at 1-866-484-8049 or send an e-mail to the EUS Help Desk to EUSSupport@cgi.com

For additional information regarding the Medicare enrollment process, visit the website here. Of course, if you have any additional questions about the Medicare enrollment process, you can contact the designated Medicare contractor for your state.

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If you haven’t started yet but plan to use the online process to enroll your providers or yourself, here’s a really excellent SlideShare presentation by David Zetter that steps you through the enrollment process by showing screen shots of each step.  You can contact David Zetter here.

PECOS Enrollment Process