MLN Matters Number: MM6093 Revised
Related Change Request (CR) #: 6093
Related CR Release Date: October 15, 2008
Effective Date: May 23, 2008
Related CR Transmittal #: R270PI
Implementation Date: September 26, 2008
(FISS implementation date is November 3, 2008)
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Note: This article was revised on October 19, 2008, to reflect changes to CR 6093, which CMS revised on October 15, 2008, to include the FISS in the business requirements. The FISS implementation date was also added. The CR release date, transmittal number, and the Web address for accessing CR6093 were also revised. All other information remains the same.
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Provider Types Affected: All Medicare providers who submit claims to Medicare Carriers, Medicare Administrative Contractors (MACs), Durable Medical Equipment Medicare Administrative Contractors (DME MACs) and/or Fiscal Intermediaries (FIs) in which a secondary provider must be identified.
Provider Action Needed: This article is based on CR 6093 and outlines the need to use NPIs to identify secondary providers in Medicare claims beginning May 23, 2008.
Background: The Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandate the adoption of a standard unique health identifier for each health care provider. The NPI final rule, published on January 23, 2004, establishes the NPI as this standard. All health care providers and entities covered under HIPAA must comply with the requirements of the NPI final rule (45 CFR Part 162, CMS- 0045-F).
Effective May 23, 2008, paper and electronic Medicare claims must contain NPIs to identify health care providers in their role as health care providers. (NPIs do not replace Taxpayer Identification Numbers, which identify health care providers in their role as taxpayers.)
Medicare claims always identify primary providers. Primary providers are the Billing and Pay-to Providers and, for non-institutional and non-pharmacy claims, the Rendering Provider.
Some Medicare claims also need to identify one or more secondary providers. A secondary provider could be a health care provider who ordered services for a Medicare patient or who referred a Medicare patient to another health care provider (ordering/referring providers); an attending, operating, supervising, purchased service, other, or service facility provider; or a prescriber (the latter only in retail pharmacy drug claims).
Prior to May 23, 2008, health care providers who ordered/referred were identified by Unique Physician Identification Numbers (UPINs). UPINs were assigned to physicians as defined in section 1861(r) of the Social Security Act, and to nurse practitioners, clinical nurse specialists, physician assistants, licensed clinical social workers, clinical psychologists, and certified nurse midwives—the only practitioners who are permitted by law to order/refer in the Medicare program. Medicare ceased assigning UPINs in June 2007 as part of the implementation of the NPI.
Note: CR6093 does not alter existing requirements for capturing the name and address, when required, of secondary providers or instructions that address the specific practitioner types that must be reported in certain referral and “incident to” situations. CR6093 instruction addresses only the reporting of the identifier for secondary providers, when required.
Key Points of CR6093
- When an identifier is reported on a paper or electronically submitted claim for a secondary provider (ordering, referring, attending, operating, supervising, purchased service, other, or service facility provider [in the X12N 837 claims transactions] or for prescriber [in the NCPDP 5.1 retail drug claim transactions]), that identifier must be an NPI.
- If the secondary provider (the ordering, referring, attending, operating, supervising, purchased service, other, or service facility provider [in the X12N 837 claims transactions] or for prescriber [in the NCPDP 5.1 retail drug claim transactions]) does not furnish its NPI at the time of the order/, referral, purchase, prescription, or time of service, YOU as the billing provider need to know that NPI in order to use it in your claim.
- You may use the NPI Registry or you may need to contact the ordering, referring, attending, operating, supervising, purchased service, other, service facility, or prescriber in order to obtain that NPI. While the Implementation Guides for the X12N claims transactions permit the reporting of the Social Security Number (SSN) for some secondary providers if there is no NPI, the Centers for Medicare & Medicaid Services (CMS) does not believe you will be successful in having secondary providers disclose their SSNs.
- If you are unable to obtain the NPI of the entity to be identified as the service facility provider, or if that entity has not obtained an NPI, NO identifier is to be reported in that loop.
- If you are unable to obtain the NPI of the ordering, referring, attending, operating, supervising, purchased service, other, or prescriber, you (the Billing Provider) must use YOUR NPI as the identifier for that secondary provider.
- Claims will not be paid if the secondary providers (with the exception of the service facility provider) are not identified by NPIs. No NPI is necessary for the service facility provider.
Additional Information: For complete details regarding this Change Request (CR) please see the official instruction (CR6093) issued to your Medicare Carrier, DME MAC, MAC or FI. That instruction may be viewed by going to http://www.cms.hhs.gov/Transmittals/downloads/R270PI.pdf on the CMS website.
If you have any questions, please contact our provider service center at our toll-free number, 1-888-355-9165. If you need claims status or eligibility, please call the Interactive Voice Response (IVR) at 1-877-288-7600.
Disclaimer: This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2007 American Medical Association.