First the facts on what has taken place so far in the 2011 EHR Incentive Programs.
As of June 30th, the total of Medicare EHR Incentive Program payments is over $94 million.
As of June 30th, over $166 million has been paid in Medicaid EHR incentives since the program began in January. In May and June, four states launched Medicaid EHR Incentive Programs – Indiana, Ohio, Pennsylvania, and Washington, bringing the total states with Medicaid EHR Incentive Programs to 21. More states will launch in July.
There are 68,001 active registrations of eligible professionals and eligible hospitals for the Medicare and Medicaid EHR Incentive Programs.
If your group hasn’t received a check and hasn’t registered for the Medicare or Medicaid Incentive Program, then this blog post is for you! For anyone who is really just beginning their EHR journey, today’s presentation clarified previous information given by CMS, as well as giving listeners new information about the programs.
Note: see my latest post on registering and attesting for the EHR Incentive Program here.
Registration opens on January 3, 2011 for the Medicare and Medicaid EHR Incentive Programs
Register as soon as possible after January 3, 2011.
You can register before you have a certified EHR, but you will have to have an EHR when you attest.
You can register even if you do not have an enrollment record in PECOS.
A link to the Incentive Registration will be available here when it is published.
Not all states will be ready to participate in the Medicaid program on January 3rd. Information by state is here.
What do you have to have to register?
A National Provider Identifier (NPI) All eligible professionals, eligible hospitals, and critical access hospitals (CAHs) must have a National Provider Identifier (NPI) to participate in the Medicare and Medicaid EHR Incentive Programs.
An enrollment record in the Provider Enrollment, Chain and Ownership System (PECOS) All eligible hospitals and Medicare eligible professionals must have an enrollment record in PECOS to participate in the EHR Incentive Programs. Eligible professionals who are only participating in the Medicaid EHR Incentive Program are not required to be enrolled in PECOS. If you do not have an enrollment record in PECOS, you should still register for the Medicare and Medicaid EHR Incentive Programs.
CMS Identity and Access Management (I&A) User ID and Password
Eligible Professionals: Eligible professionals can use the same User ID and Password they use for the National Plan and Provider Enumeration System (NPPES). This is also the same User ID and Password that is used to access PECOS. If you do not have an active User ID and Password for NPPES or PECOS, request them here. You will need your type 2 NPI, your Taxpayer Identification Number (TIN), and your address from IRS Form CP-575. You will also need to mail a copy of IRS Form CP-575 as directed.
Hospitals/Critical Access Hospitals: Authorized Officials can use the same User ID and Password they use to access PECOS. If you do not have an Authorized Official with access to PECOS, request a User ID and Password here. You will need your type 2 NPI, your Taxpayer Identification Number (TIN), and your address from the IRS Form CP-575. You will need to mail a copy of the IRS Form CP-575 as directed. Additional hospital staff will need to request access to the “EHR Incentive Programs” application here and be approved by the Hospital’s Authorized Official.
What else do you need to know about registration?
Hospitals that are eligible for EHR incentive payments under both Medicare and Medicaid should select “Both Medicare and Medicaid” during the registration process, even if they plan to apply only for a Medicaid EHR incentive payment by adopting, implementing, or upgrading certified EHR technology. Dually-eligible hospitals can then attest through CMS for their Medicare EHR incentive payment at a later date, if they so desire. It is important for a dually-eligible hospital to select “Both Medicare and Medicaid” from the start of registration in order to maintain this option.
Hospitals that register only for the Medicaid program (or only the Medicare program) will not be able to manually change their registration (i.e., change to “Both Medicare and Medicaid” or from one program to the other) after a payment is initiated and this may cause significant delays in receiving a Medicare EHR incentive payment.
Eligible professionals eligible for both the Medicare and Medicaid EHR Incentive Programs must choose which incentive program they wish to participate in when they register.
Before 2015, an eligible professional may switch programs only once after the first incentive payment is initiated. Most eligible professionals will maximize their incentive payments by participating in the Medicaid EHR Incentive Program.
The Electronic Health Record (EHR) Information Center is open to assist the EHR Provider Community with inquiries.
Hours of operation are:
8:30 a.m. ”“ 4:30 p.m. (Central Time) Monday through Friday (except federal holidays)
1-888-734-6433 (primary number) or 888-734-6563 (TTY number)
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.
On May 28, 2010, CMS in Change Request 6842 notified Medicare Part A & B Administrative Contractors (A/B MACs) of their responsibility to facilitate a “One-Time Mailing” to all physicians and non-physicians who are currently enrolled in Medicare but who do not have an enrollment record in PECOS.
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This mailing is to take place no later than 30 days after the date of the issuance (May 28th), therefore no later than June 28, 2010, leaving only six business days before the July 6 date for PECOS enrollment.
Additionally, the Change Request states:
A provider education article related to this instruction will be available at http://www.cms.hhs.gov/MLNMattersArticles/ shortly after this CR is released. You will receive notification of the article release via the established “MLN Matters” listserv. Contractors shall post this article, or a direct link to this article, on their Web site and include information about it in a listserv message within one week of the availability of the provider education article. In addition, the provider education article shall be included in your next regularly scheduled bulletin. Contractors are free to supplement MLN Matters articles with localized information that would benefit their provider community in maintaining Medicare provider enrollment data correctly.
As of Tuesday evening when I posted this article, the MLN Matters article referred to had not been published.
Interestingly, there is no mention of the July 6, 2010 date that is the so-called compliance date for all providers to have an enrollment record in PECOS. As of the last CMS open door forum (my notes here) there was a lack of clarity surrounding the July 6, 2010 date versus the original January 1, 2011 date. The speaker would not definitively say that providers without a PECOS enrollment record as of July 6, 2010 would not receive Medicare payments. Given the short time frame between the MAC letters and the July 6 date, one would assume providers will have a grace period before CMS shuts off reimbursement for services rendered and/or refuses stimulus money for meaningful use of an EMR.
[Physician/Non-Physician Practitioner Name and Correspondence Address]
Dear Physician/Non-Physician Practitioner:
Our records indicate that you do not have an enrollment record in the Medicare Provider Enrollment, Chain and Ownership System (PECOS) because you enrolled in Medicare prior to the implementation of PECOS and you have not submitted any updates to your Medicare enrollment information in the past 6 (or more) years. PECOS is the enrollment system for Medicare providers and suppliers.
There are three important reasons why you should take the necessary action to establish an enrollment record in PECOS as soon as possible. First, updating your Medicare enrollment record will assist us in ensuring payment accuracy for the services you furnish to Medicare beneficiaries. Second, you will need an approved enrollment record in PECOS to continue to order or refer items or services for Medicare beneficiaries. Finally, in accordance with the American Recovery and Reinvestment Act of 2009, Title XIII, known as the “HITECH Act,” incentive payments may be made by Medicare and Medicaid to enrolled “eligible professionals” and certain hospitals that meet the HITECH requirements. More information on Medicare HITECH incentive payments can be found at http://www.cms.hhs.gov/Recovery/11_HealthIT.asp under “Related Links Outside CMS” on the CMS web site. The Centers for Medicare & Medicaid Services (CMS) will use the PECOS enrollment records to verify Medicare enrollment for HITECH incentive payments. Therefore, you will not be eligible to receive incentive payments from Medicare for meaningful use of certified electronic health records if your enrollment information is not maintained in PECOS by CMS.
Since you do not have a current Medicare enrollment record, it is imperative that you immediately begin the process to establish your enrollment record in PECOS. CMS expects you to do this as soon as possible after receiving this letter. If you have already submitted an enrollment application within the last 60 days, and your enrollment application has been accepted for processing by the carrier or A/B MAC, you need not take any additional actions based on this letter.
You can submit your enrollment application in one of two ways:
(1) Use Internet-based PECOS
”¢ Step 1. Before you begin, be sure you have a National Provider Identifier (NPI) and have created a User ID and password in the National Plan and Provider Enumeration System (NPPES). You will need the NPPES User ID and password in order to access Internet-based PECOS. If you need help creating an NPPES User ID and password, or if you are not sure you ever created them or cannot remember what they are, you may contact the NPI Enumerator for assistance at 1-800-465-3203.
”¢ Step 2. Read the documents that are available about Internet-based PECOS on the CMS Provider/Supplier Enrollment web page www.cms.hhs.gov/MedicareProviderSupEnroll/
”¢ Step 3. Once you have completed and submitted your enrollment application using Internet-based PECOS, be sure to print the Certification Statement, sign and date it, and mail it, along with any required supporting documentation, to the carrier or A/B MAC whose name and mailing address will be displayed to you by the system.
Note: If you reassign some or all of your Medicare benefits to a group practice, there will be two Certification Statements to print, sign and date, and one of them will also need to be signed and dated by an Authorized Official of the group practice. The carrier or A/B MAC cannot process your web-submitted enrollment application without having the signed and dated Certification Statement(s) in hand.
(2) Complete the paper Medicare enrollment application (CMS-855I) as an initial application.
”¢ Step 1. Complete the CMS-855I (if you reassign benefits to a clinic or group practice other than your own, complete a CMS-855R as well), sign and date (blue ink recommended) and mail the application(s), along with any required additional supporting documentation, to the Medicare carrier or A/B MAC. These forms are downloadable from the CMS Provider/Supplier Enrollment web page (shown above) or the CMS forms page www.cms.hhs.gov/cmsforms or you may request the necessary forms from the carrier or A/B MAC.
”¢ Step 2. Once the paper application has been received by the carrier or A/B MAC, the carrier or A/B MAC will begin to process your enrollment application. If additional information is needed by the carrier or A/B MAC to complete the processing of your enrollment application, they will contact you.
You are strongly urged not to delay in establishing your Medicare enrollment record within PECOS, especially if you plan on applying for incentive payments under the HITECH program. The carriers and A/B MACs are expected to process your enrollment application within 60 days as long as you submit your enrollment application before September 1, 2010.
If you need information about Medicare enrollment or how to use Internet-based PECOS, visit the
CMS Provider/Supplier Enrollment web page at: www.cms.hhs.gov/MedicareProviderSupEnroll/
If you need assistance with your NPPES User ID and password, contact the NPI Enumerator at 1-800-465-3203.
If you have questions about this letter, contact [carrier or A/B MAC phone number/contact person].
CMS held a two-hour Open Door Forum today and there was so much good information shared that I thought I’d pass my notes from the call along to you.
New EFT Form
The revised EFT (Electronic Funds Transfer) authorization form 588 is available here (pdf.) The old form will still work for a few months longer before it becomes invalid.
Changes to the Medicare Program Integrity Manual
The Program Integrity Manual (publication 100-08) will have revisions related to the changes in provider enrollment. The online-only manual here will have content moved from Chapter 10 to Chapter 15 and the provider enrollment information will be easier to understand. 🙂
The Question on Everyone’s Lips
How do I know if I’m listed in PECOS (Provider Enrollment and Chain/Ownership System) and how do I know if others are listed in PECOS? A new downloadable file is now available here (12,000 pages!) and everyone listed in this Ordering/Referring file has approved enrollment status. Anyone not appearing on this list is not in approved status, or has opted completely out of the Medicare program.
Advanced Diagnostic Imaging
Beginning in January 2012, all diagnostic magnetic resonance imaging (MRI), computed tomography (CT), and nuclear medicine imaging such as positron emission tomography (PET) must be performed in a facility accredited by the American College of Radiology (ACR), The Joint Commission (TJC) or the Intersocietal Accreditation Commission (IAC) for the technical component of the test to be reimbursed by Medicare. This rule does not apply to x-rays, ultrasound, fluoroscopy, mammography or DEXA scans and does not apply to any professional component.
Hospitals not enrolled in PECOS or not receiving EFT (Electronic Funds Transfer) will be contacted by CMS in an attempt to get all hospitals revalidated.
PECOS (pronounced “pay-cose”)
CMS recommends that anyone with questions or just getting started in PECOS read the “Getting Started Guide”, of which there are two versions, both available here in pdf form. One is for providers and one is for suppliers of DMEPOS (Durable Medical Equipment, Prosthetics, Orthotics, and Supplies.) You need to know your corporate structure before getting started because the business must enroll before the providers can assign benefits to the business. The 855I is for individual/solos providers and the 855B is for non-individuals (multiple owners) billing Medicare Part B and assigning benefits to a legal entity/corporation. Dentists and pediatricians who order or refer services for Medicare patients are required to have an enrollment record in the PECOS. Residents and interns are exempt from the enrollment requirement, but an attending physician needs to be identified on the claim when a service is ordered or referred. The main page for enrollment is https://www.cms.gov/MedicareProviderSupEnroll/
Two Ways to Get Into PECOS
One is to complete the paper form in BLUE INK (and if time is of the essence CMS suggests that you use the paper form) and let the MAC enter it into PECOS for you. The other is to use the internet-PECOS system directly, and sign, date and mail the certification statement to complete the process. Submit the participation form or EFT form if required. The certification form for the paper process is NOT the same as the certification from for the internet-PECOS process.
What is the 30-day rule?
The 30-day rule states that you can bill for services provided to Medicare patients up to 30 days prior to your filing date. The filing date is the date your enrollment is accepted, not the date you mailed it. Online it will say “Status Approved”, and you will receive an email, and then a letter confirming it. You will appear on the Ordering/Referring file on the CMS website.
What happens to payments for patients that were referred by a provider not enrolled on PECOS?
Even though you are enrolled, if the referring physician is not enrolled, you will not be paid for that patient’s services. However, if that referrer becomes enrolled, you can resubmit the claim and it will be paid.
What happens on July 6, 2010? When does this happen?
July 6, 2010 The compliance date for Part A providers (hospitals, skilled nursing homes and home health agencies) and Part B providers (physicians, ambulance) must be enrolled in PECOS as ordering/referring physicians for payments to be made has been delayed indefinitely!
What happens on July 13, 2010?
DMEPOS (pronounced “demmy-pos”) providers must be enrolled in PECOS to receive Medicare payments.
What should be done if a provider leaves a group?
The provider or his Authorized Official (CEO, CFO, Manager) should file a 855R or make the change in PECOS as soon as possible.
Why do provider offices still request UPINs from our office?
Unclear. UPINs were no longer required as of May 23, 2008. The NPI is the only number accepted on Medicare claims.
Should the information submitted on a 855 be the same information in PECOS?
Yes, if it isn’t, contact the Help Desk. Their toll-free number is 1-866-484-8049 and their e-mail address is firstname.lastname@example.org.
For more information on the nuts and bolts of PECOS, see my post here.
Recovery Audit Contractors (RACs) will pursue corrections of Medicare claims by auditing for overpayments and underpayments under Part A or B of the title XVIII of the Social Security Act. Health care providers will be affected as Medicare has recently contracted with RACs for 2009 and beyond. RACs will audit every United States and Peurto Rico health care provider who files with Medicare. The audit and recovery plan is expected to be in place by (more…)
UPDATE on July 4, 2009: I’ve been having problems with the links in this article and I’ve found that the HITTG website has vanished! I’ve not been able to find out where it went. If anyone has any information, please let me know.
Until recently you could download one directory during every update cycle completely free of charge.
I wish we could keep doing that, but here’s what happened:
Literally hundreds of downloads were being taken “against the rules,” that is, people were creating multiple accounts and downloading multiple states every month. That cost us serious bandwidth problems, and slowed down our site for everyone. Eventually, it crashed our site, broke some stuff, and threw us offline for quite awhile.
We put about 45 hours of work each month into processing the data, turning it into software, and uploading it so you can access it. Unfortunately, so few people were buying our non-free products that we were frankly losing money.
Those two things, taken together, meant that if we were going to keep doing NPIdentify Desktop — the best NPI directory on the planet — we would have to start charging a little bit for it, both to prevent the download avalanche, and to hopefully at least break even.
We’re truly sorry! But the good news is that we’ve reduced the price, so for those of you that have been paying for multiple states, now you’ll be paying far less! For those who were, well, shall we say “fibbing,” you’ll be paying a little bit more. It’s still the best NPI directory out there, and it’s still the least expensive, with all of the others running at least $39 per state!
Here’s my original article:
I had the pleasure of interviewing Marti Jensen of HITTG Consulting recently. Marti was kind enough to answer lots of questions about himself, the company, and their new product NPIdentify.
As most of you know, the transition to requiring NPIs on claims last year was one of the more chaotic and troublesome times for medical practices in recent memory. To lay the foundation for understanding the NPI (National Provider Identifier), and what NPIdentify does, here’s what the 2006 CMS NPI Fact Sheet states:
The Health Insurance Portability and Accountability Act (HIPAA) of 1996 requires the adoption of a standard unique identiï¬er for health care providers. The NPI Final Rule issued January 23, 2004 adopted the NPI as this standard.
Describing the NPI, the fact sheet goes on to say:
The NPI is a 10-digit, intelligence free numeric identiï¬er (10 digit number). Intelligence free means that the numbers do not carry information about health care providers, such as the state in which they practice or their provider type or specialization. The provider’s NPI will not change and will remain with the provider regardless of job or location changes.
Marti Jensen is HITTG’s Chief Operating Officer and has an impressive list of accomplishments. Marti describes himself as a “student of the Internet,” and his group as one that takes resources and makes them more accessible to users. In the case of NPIdentify, users are typically physician offices, billers and billing companies, software vendors and healthplans. Creating this product, Marti explained that CMS provides the NPI information for free, so HITTG’s job was to fashion the information into a database that is easy to search. This is especially helpful as the entire CMS file cannot be imported into Excel due to its size.
NPIdentify not only provides NPIs, it also provides UPINs and:
Provider name, including AKA
Type of provider (organization, male, female)
Practice location address
Zip code, 3, 5 or 9 digits
State License Code and licensing state
Taxonomy Code (the 9-digit numbers assigned under the HIPAA provisions to health care providers, to digitally encode their specialty in order to facilitate electronic billing) and specialty/subspecialty description
Other Identifiers, including:
Medicare NSC (National Supplier Clearinghouse for DME)
Other Medicare IDs
Date provider updated the information
Marti’s group HITTG (Healthcare IT Transition Group, Inc.) describes itself like this:
HITTG was originally formed in 1993 as Computer Quality Associates, Inc., and, from its first day, worked almost exclusively in healthcare information technology. Ten years later, its HIPAA Transition Weblog became a respected independent voice amidst the difficulties of implementing the HIPAA standards. HITTG now publishes theHIT Transition Weblog and HITSync eMagazine, devotes substantial resources to healthcare IT standards development on the national level, and serves clients in varied capacities within healthcare IT.
I have to tell you that one of the things I really like about HITTG is their mission, which says the group “…works with organizations to reduce the cost and improve the quality of healthcare through the development and implementation of robust IT standards.”
I do not, however, care for their acronym. I just can’t remember it! I’m sure they’d rather we all just remember NPIdentify and find them from there, but I’d rather they do something interesting by calling themselves something like Shaboom!, HealthLookup or NeedGovNum.
Now that I’ve criticized their name, where could they take their gig from here?
All practice management and billing software should integrate HITTG products as standard issue.
One of the most hit and miss mailing lists ever are those for doctors – how about a “Where are they now?” ability to get a fast mailing list customizable by specialty, location, etc. I don’t know of a list that keeps up with docs moving locations and practices. (I do believe Marti told me they could produce mailing lists for specific needs for a reasonable price, but you’ll have to speak with him about that.)
How about a list from the insurance department by state of all plans operating in a state and any other gritty information we could could get about them?