The Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandated the adoption of standard unique identifiers for health care providers, as well as the adoption of standard unique identifiers for health plans. They become mandatory on May 23, 2007.
The purpose of these provisions is to improve the efficiency and effectiveness of the electronic transmission of health information. The Centers for Medicare & Medicaid Services (CMS) has developed the National Plan and Provider Enumeration System (NPPES) to assign these unique identifiers.
CMS has contracted with Fox Systems, Inc. to serve as the NPI Enumerator. The NPI Enumerator is responsible for dealing with health plans and providers on issues relating to unique identification.
Changes in the HCFA 1500 form to accommodate the NPI number took place January 1, 2007. Until March 30, 2007, using NPI number on the HCFA form is optional but as of April 2, 2007, using NPI becomes mandatory.
Getting an NPI is free – Not Having One Can Be Costly: If you delay applying for your NPI, you risk your cash flow.
- Enumerate: Enumeration is mandatory for both individual providers and organizations and subparts. When applying for your NPI, CMS urges you to include your legacy identifiers, not only for Medicare but for all payors. If reporting a Medicaid number, include the associated State name. This information is critical for payors in the development of crosswalks to aid in the transition to the NPI.
- Update: Make sure to upgrade your software, HIPAA Transactions, CMS1500, UB04, and/or Dental claim form changes.
- Communicate: Notify your payers once you have obtained your NPI number. As outlined in the Federal Regulation (The Health Insurance Portability and Accountability Act of 1996 (HIPAA)) you must also share your NPI with other providers, health plans, clearinghouses, and any entity that may need it for billing purposes — including designation of ordering or referring physician.
- Collaborate: Check the readiness of your payment partners (such as health plans, TPAs, clearinghouses, etc…)? Not all payers are ready to accept the NPI number at this time. Use both your existing (legacy) number and the NPI number when submitting electronic claims.
- Test: Test transactions well before the deadline. Make sure to test HIPAA Transactions, e.g., 837 Claims, 835 Remittance Advice, and, if you submit paper claims, verify that the data is printed in the correct fields. The new HCFA form has new fields for identifier numbers on lines 17b, 32a and 33a.
- Educate: Focus on staff working on insurance verification of eligibility and claim denial or underpayment follow up.
- Implement: Once you obtain your NPI, it might take about 120 days to do the remaining work to use it. This includes working on your internal billing systems, coordinating with billing services, vendors, and clearinghouses, testing with payers.