Medicare Fee for Service Legacy Provider IDs Prohibited on Form CMS-1500 Claims after NPI Required Date
Impact to You
Effective May 23, 2008, if you report a Provider Legacy Identifier on Medicare CMS-1500 or CMS-1450 (UB-04) claims, your contractors will return them as unprocessable.
What You Need to Know
Change Request (CR) 5858, from which this article is taken, announces that Provider Legacy Identifiers are not to be reported on Medicare CMS-1500 or Form CMS-1450 claims received on or after May 23, 2008 (the date at which the NPI is required to be reported on claims). After that date, claims containing Legacy Identifiers will be returned as unprocessable.
What You Need to Do
Make sure that your billing staffs are aware that effective May 23, 2008, only NPIs are to be reported on Medicare CMS-1500 and CMS-1450 claims.
Background
The Health Insurance Portability and Accountability Act (HIPAA) of 1996 required issuance of a unique national provider identifier (NPI) to each physician, supplier and other health care provider who conducts HIPAA standard electronic transactions. In accordance with this act, CMS began issuing NPIs on May 23, 2005.
Further, on April 2, 2007, the Department of Health and Human Services (DHHS) provided covered entities guidance regarding contingency planning for NPI implementation. In this guidance, as long as a health plan was compliant, meaning they could accept and send NPIs on electronic transactions, they could establish contingency plans to facilitate the compliance of their trading partners.
As a compliant health plan, on April 20, 2007, Medicare fee for service (FFS) established a contingency plan that followed this guidance. Since then, CMS has been allowing transactions adopted under HIPAA to be submitted with a variety of identifiers, including:
- NPI only
- Medicare legacy only (PINs, UPINs or National Supplier Clearinghouse number)
- NPI and legacy combination
CR 5858, from which this article is taken, announces that beginning on May 23, 2008, CMS requires the NPI to be submitted on the Form CMS-1500 and CMS-1450 paper claims, and legacy numbers will not be permitted on claims received on or after that date. Effective that date, Form CMS-1500 and CMS-1450 claims containing legacy identifiers will be returned as unprocessable, without appeal rights.
When returning these claims, your contractors will use an appropriate message and Remittance Advice Remark code, such as:
- N257 Missing/incomplete/invalid billing provider primary identifier.
Note: Contractors will not return claims in certain situations where an NPI is not required (e.g., foreign claims, deceased provider claims, and other situations as allowed by CMS in the future). Such claims will be processed with established procedures for such claims.
Additional Information
You can find more information about the prohibition of Medicare fee for service legacy provider IDs on Form CMS-1500 and CMS-1450 claims after the NPI required date by going to CR 5858 (PDF, 310 KB). You will find updated Medicare Claims Processing Manual (100-04), Chapter 26 (Completing and Processing Form CMS-1500 Data Set), Section 10.4 (Items 14-33 - Provider of Service or Supplier Information) as an attachment to that CR.
If you have questions, please contact our Provider Contact Center at our toll free number at (866) 332-7025 for Ohio and West Virginia or (888) 828-2092 for South Carolina.