by Legal & Regulatory Affairs and Communications Staff
May 23, 2007 — The Centers for Medicare and Medicaid Services (CMS) announced in April that the Medicare program will not require participating providers to use only their National Provider Identifier (NPI) when submitting Medicare claims effective May 23, 2007. Medicare providers may continue temporarily to use their existing identifier numbers (referred to as "legacy numbers" or "UPIN"), use their NPI, or submit both numbers on their claims.
CMS issued the policy following a decision by the U.S. Department of Health and Human Services (DHHS) to allow health plans to continue processing claims that do not have NPIs until May 23, 2008. The Health Insurance Portability and Accountability Act (HIPAA) rules had specified May 23, 2007 as the date by which health professionals covered under HIPAA needed to have and use their NPI. The federal government took its recent action out of concern that a significant number of health plans and providers were not ready to use NPIs.
It is unclear when this CMS policy will end and when providers will be required to use only their NPI. The CMS notice states that providers definitely will have to use their NPIs on all claims as of May 23, 2008. However, Medicaremay require exclusive use of NPIs at an earlier date, depending on whether a "sufficient number" of Medicare claims filed in coming months contain NPIs. The Centers for Medicare and Medicaid Services will notify providers before they begin rejecting claims that lack this identifier.
Private insurer requirements may vary
Rather than trying to change the HIPAA rules, CMS decided try to encourage health plans to allow providers to use their legacy numbers by promising not to impose penalties on insurers that continue processing claims submitted withthese numbers instead of with the NPI.
This leeway, however, does not preclude private insurers from requiring health professionals to submit claims as of May 23, 2007 using only their NPIs. If a private health plan has decided that it is ready to accept only NPIs, the insurer can deny claims — both electronic and paper — that do not have NPIs.
So it is crucial for you to check with all health plans you work with to learn their policy related to using NPIs versus provider legacy numbers in claims submission.
About the NPI
The NPI is a unique 10-digit number assigned to every health care provider who applies for it. The number is intended for use in identifying practitioners when they transmit health information electronically. Any private health insurer can mandate that health professionals who bill the insurer use an NPI, even if they submit claims by mail.
The APA Practice Organization strongly encourages practitioners who have not yet done so to obtain their NPI immediately.
IMPORTANT NOTE ABOUT USING THE CMS-1500 CLAIM FORM: As of June 1, 2007, health professionals who bill Medicare using paper claims must use the new CMS-1500 form. The new version, which indicates “Approved OMB-0938-0999 FORM CMS-1500 (08/05),” was redesigned to accommodate the inclusion of NPIs. Medicare will no longer accept the old version of the CMS-1500 form dated 12/90. If you use a billing company, be sure they have the updated claim forms and are prepared to use your NPI.