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Resolving Common NPI Problems

Palmetto GBA is rejecting claims that are submitted with valid NPIs that cannot be matched to existing Medicare Provider Transaction Access Numbers (PTANs). This match is also referred to as the 'internal crosswalk.'

The NPI/ PTAN combination may be used to identify the Billing, Pay-to or Rendering Provider (the Pay-to Provider is identified only if it is different from the Billing Provider). This applies to claims that are submitted by corporations formed by physicians and non-physician practitioners and by physicians and non-physician practitioners that submit claims directly to Palmetto GBA.

The purpose of this article is to identify common crosswalk issues we are encountering and to provide guidance in how to resolve these problems.

Problem 1: Mismatch in the National Plan and Provider Enumeration System (NPPES, or the NPI file) against our provider file (for your PTAN or legacy number).

Most of these problems relate to provider name and punctuation errors. You must enter your legal business name in NPPES, and it must be an exact match in both files.

Examples of Name Mismatches:
  • John K. Smith; John Kenny Smith
  • Dr. John K. Smith MD; John K. Smith M.D.
It is easier to make corrections in NPPES if the mismatched information is minor, as illustrated above. You may be able to make these changes in NPPES and avoid resubmitting a CMS-855 Enrollment Form. Please contact Palmetto GBA so that we may determine if you can make a minor correction to your NPPES information or if changes are needed in your CMS-855 Enrollment Form.

Note: The Provider Enrollment Chain and Ownership System (PECOS) does not recognize any character that is not a letter or number. Any punctuation or special characters such as $, @ or # are not recognized by PECOS and therefore the two files will not match.

Problem 2: The manner in which the provider is enrolled in NPPES and/or the information in our Provider Enrollment files.
 
Individual Providers (Entity Type 1)
  • In terms of NPI assignment, an individual is considered an Entity Type 1 and is eligible for a single NPI. As individuals, these health care providers cannot be subparts and cannot designate subparts. A sole proprietorship is a form of business in which one person owns all of the assets of the business and the sole proprietor is solely liable for all of the debts of the business. There is no difference between a sole proprietor and a sole proprietorship.
Helpful Tips
  • List all PTANs in NPPES with the corresponding state code
  • Include your existing legacy numbers (PTANs, including PIN and UPIN). Be sure to select the appropriate ‘Issuer’ type in the ‘Other Provider Identifier’ section of NPPES that corresponds with the specific type of ID you will be entering. For example: Medicare PIN, Medicare UPIN, Medicaid, etc.
  • It is best if you can make a match on Match Set 1 (1st step) of the Individual Recipe, which is listed below
  • Individual (Type 1) providers do not crosswalk using the address, so you do not need to change the address in NPPES to match your credentialing information on file with Palmetto GBA. Check your information in the NPPES to ensure that the NPI(s) were properly obtained. For example, if you are a solo provider, you should have an individual PTAN (previously known as a Provider Identification Number or PIN) and you should have obtained an NPI as an Individual (Entity type 1), not as an Organization (Entity type 2).
Individual Recipe (Type 1)

Recipe Name
Match Set
Legacy Field
NPPES
PTAN Individual
Match Set 1
Last Name (required)
Last Name (required)
Exact Match
 
SSN (required)
SSN (required)
 
Match Set 2
First Name (required)
First Name (required)
 
 
SSN (required)
SSN (required)
 
Match Set 3
DOB (required)
DOB (required)
 
 
TaxID(required)
SSN (required)
 
MatchSet 5
Last Name (required)
Last Name (required)
 
 
DOB (required)
DOB (required)
 
 
UPIN (required)
UPIN (required)
 
MatchSet 6
First Name (required)
First Name (required)
 
 
DOB (required)
DOB (required)
 
 
UPIN (required)
UPIN (required)
 
MatchSet 7
SSN (required)
SSN (required)
 
 
UPIN (required)
UPIN (required)
 
MatchSet 8
SSN (required)
SSN (required)
 
 
DOB (required)
DOB (required)

Note: This matching recipe is used for electronic and paper claims.
 
Organizations (Entity Type 2)
In terms of NPI assignment, an organization is considered an Entity Type 2. They are health care providers that are corporations or partnerships or other types of businesses that are considered separate from an individual by the state in which they exist. Subparts of such organization health care providers who apply for NPIs are also classified as Entity Type 2.
 
Helpful Tips
  • List all Medicare PTANs in NPPES with the corresponding state code
  • Organizations Only: When entering your Provider Type, we strongly recommend that you select 'Medicare PIN' to enter your Medicare numbers. Other or Unspecified, may cause NPI not to crosswalk.
  • It is best if you can make a match on MatchSet 1 (1st step) of the Organization Recipe, which is listed below
  • You can include your UPIN and other IDs. Be sure to select the appropriate ‘Issuer’ type in the ‘Other Provider Identifier’ section of NPPES that corresponds with the specific type of ID you will be entering. For example: Medicare PIN, Medicare UPIN, Medicaid, etc.
  • List your primary location – zip codes will be matched with up to nine digits
  • We recommend that Medicare PTAN prefixes are not entered into NPPES (e.g., PTAN = JO9912451, enter as 9912451)
  • Organizations (Type 2 providers) do crosswalk using the address, so be sure that the zip code and address match in both the NPPES and our provider enrollment files.
You are encouraged to verify that the NPI/legacy identifier combination is valid on NPPES Web site prior to submission of Medicare claims.
 
Organization Recipe (Type 2)

Recipe Name
Match Set
Legacy Field
NPPES
PTAN Organization
Exact Match
MatchSet 1
Provider ID
Other Provider ID (of type Medicare)
 
 
Tax ID
EIN
 
MatchSet 2
Provider Name
Legal Business Name
 
 
Tax ID
EIN
 
 
Practice Zip code (9)
Practice Zip code (9)
 
MatchSet 3
Provider Name
Legal Business Name
 
 
Tax ID
EIN
 
 
Practice Address
Practice Address
 
 
Practice Zip code (5)
Practice Zip Code (5)
 
MatchSet 4
Provider Name
Legal Business Name
 
 
Tax ID
EIN
 
 
Practice Zip code (9)
Practice Zip code (9)
 
MatchSet 5
Provider Name
Legal Business Name
 
 
Tax ID
EIN
 
 
Practice Address
Practice Address
 
 
Practice Zip code (5)
Practice Zip Code (5)

Note: This matching recipe is used for electronic and paper claims.

More Helpful Tips
  • Electronic claim submitters: check Medicare Reject Report messages
  • Ensure that the NPPES data are correct and that the NPPES record(s) contains the Medicare legacy identifier(s) that was assigned to the provider to whom the NPPES record belongs. For example, a physician/practitioner applying for an NPI would list his/her Medicare PIN in the 'Other Provider Identifiers' section of the NPI application, but would not list the PIN of the group in which he/she is a member. Medicare uses this information in building the Medicare NPI crosswalk and incorrect reporting will flow into the NPI crosswalk and cause problems down the road. To view or edit your NPPES record, go to the CMS Web site. For assistance, call the NPI Enumerator at (800) 465-3203.
  • If the NPI(s) was properly obtained and the NPPES information is correct:
    • Contact Palmetto GBA to compare information in NPPES ensures that your Medicare enrollment information is up to date
    • If you need to re-enroll or update the enrollment information on file, please complete the appropriate CMS 855 application form. Contact Palmetto GBA so that we may determine if your information can be corrected in NPPES before taking this step.
    • Please make sure the Taxpayer Identification Number (TIN) for use by Medicare in reporting your income to the IRS on the 1099 form is correct and up-to-date.
Keep in Mind
  • In most cases, you will not need to complete a new CMS-855 application
  • After correcting information in NPPES, it may take several days for the information to be updated in GPNet (for EDI claims) and MCS (the claims processing system)
  • We recommend that you wait approximately four to five business days before resubmitting your claims 
  • We recommend that you submit two or three claims to verify that the updates have correctly mapped on the crosswalk before submitting a large volume of claims
Questions?  We Are Here to Help!

Your Location
Type of Question
Contact Number
Jurisdiction 1
Your current provider enrollment information, completing CMS-855 applications or to collapse your PTANs
Provider Contact Center:
(866) 931-3901
Problems with claim denials or rejections
Provider Contact Center:
(866) 931-3901
Ohio or West Virginia
Your current provider enrollment information, completing CMS-855 applications or to collapse your PTANs
Provider Enrollment Support Line:
(866) 308-5439
Problems with claim denials or rejections, or customer service related questions
Provider Contact Center:
(866) 332-7025
South Carolina
Your current provider enrollment information, completing CMS-855 applications or to collapse your PTANs
Provider Contact Center:
(888) 828-2092
Problems with claim denials or rejections, or customer service related questions
Provider Contact Center:
(888) 828-2092

 

 

last updated on 10/02/2008
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