On April 2, 2007, the Centers for Medicare & Medicaid Services (CMS) announced that it would allow contingency plans for entities that would not meet the May 23, 2007, deadline but who had demonstrated a good faith effort to meet the compliance date. These contingency plans were not to extend beyond May 28, 2008. In response, the Health and Human Services Commission (HHSC) and TMHP developed a phased approach for NPI compliance, which was detailed in the June 2007 National Provider Identifier (NPI) Special Bulletin, No. 205.
During the past two years, TMHP has been working towards full NPI compliance. The steps to meet compliance have included:
· Attestation: TMHP created a website for providers to report their NPI and related data beginning January 22, 2007.
· Dual Strategy: TMHP enabled providers to report their NPI on claim transactions beginning May 23, 2007.
· Contingency Period: HHSC and TMHP extended the May 23, 2007 NPI compliance date to March 1, 2008, by following the CMS contingency period guidelines.
· Electronic Data Interchange (EDI) Vendor Testing: All third-party billers that submit claims electronically are required to complete vendor testing with TMHP no later than December 1, 2007.
After this effort and in coordination with the provider community, HHSC/TMHP has determined that the contingency period will end February 29, 2008. After that point HHSC and TMHP will require an NPI on all covered transactions.
The following sections describe what actions providers must take to ensure NPI compliance.
Attestation
Before providers can submit any transactions to TMHP with an NPI, providers must report their NPI to TMHP. The NPI can be reported using the TMHP website at www.tmhp.com. To begin the online attestation, providers must login to their account and click Attest an NPI under the “I would like to…” heading on the right side of the webpage. Detailed instructions for online attestation can be found in the articles “Completing the Online Attestation Process” in the January 2007 National Provider Identifier (NPI) Special Bulletin, No. 202, on page 4, and “Provider Attestation Going on Now,” in the June 2007 National Provider Identifier (NPI) Special Bulletin, No. 205, on page 4.
By attesting their NPI to TMHP, providers gain access to:
· Eligibility verification.
· Claims status inquiry.
· Claims and appeals processing.
TMHP encourages all providers to verify that the attestation information submitted to TMHP is accurate for each Texas Provider Identifier (TPI). TMHP is actively verifying the following pieces of information with National Plan & Provider Enumeration System (NPPES) and within the TMHP provider database to ensure accuracy of transaction processing.
· Entity type: The NPI Final Rule (45 Code of Federal Regulations [CFR) Part 162) section 160.03 defines two categories of health-care providers for enumeration purposes. The “Entity Type Code” is a data element in the National Provider System (NPS) record for each health-care provider that indicates which of the following categories applies to the provider:
o Entity 1 is issued for providers who are individual persons, such as physicians, dentists, nurses, chiropractors, pharmacists, and physical therapists. These providers should have only one NPI.
o Entity 2 is issued for providers that are organizations and not individuals, such as hospitals, clinics, laboratories, ambulance companies, and provider groups. These providers have the option, and are encouraged by TMHP, an NPI for each subpart of their organization. Examples of subparts of an organization include:
§ Hospitals—outpatient department, surgical centers, psychiatric units, and laboratories.
§ DME supplier chains—corporate headquarters and separate physical locations.
· Active providers: To ensure transaction processing accuracy, TMHP has contacted providers that have attested to TPIs that are currently identified in the TMHP provider database as inactive providers. Providers should only attest to the TPIs that they are using.
· Duplicate information: TMHP is actively identifying all providers that have attested to more than two TPIs with the same NPI-related data, including: NPI, taxonomy code, physical address including ZIP+4, and benefit code (when applicable).
During the attestation process, the taxonomy code for group providers is automatically populated with the multi-specialty or single-specialty group taxonomy code associated with the TPI entered. Providers should continue the attestation process using the automatically populated taxonomy code. Group providers that complete the attestation for individual providers in their group must click the plus sign (+) to expand the list and reveal all of the performing providers in the group. The most appropriate taxonomy codes should be selected for performing providers according to their specific rendering-provider type.
Billing Agencies and Third Party Billers (TPBs)
Providers are responsible for ensuring that their TPBs are aware of and comply with the NPI requirements for proper claims adjudication. TPBs are required to complete NPI testing by December 1, 2007. Testing for NPI at TMHP began in May 2007. To verify that a vendor has completed the mandated EDI vendor testing, providers can refer to the EDI page on the TMHP website at www.tmhp.com. Vendors who have not completed NPI testing at TMHP must contact the TMHP EDI Help Desk at 1-888-863-3638.
Claims Submissions
Electronic Claim Submissions
All providers must submit an NPI for billing, performing, attending, ordering, facility, and referring providers. If an NPI is not included, the claim will be rejected.
Paper Claim Submissions (2006 ADA Dental Claim Form, CMS-1500, UB-04 CMS-1450, Family Planning 2017)
All providers must continue to submit their TPI and NPI for the billing and performing providers. All other provider fields on the claim form require an NPI only. If the NPI and TPI are not included in the billing and performing provider fields or if the NPI is not included on all other provider identifier fields, the claim will be denied.
Appeals
All appeal requests submitted on paper require a completed claim form along with a copy of the Remittance and Status (R&S) report. For claims that were submitted before the end of the contingency period, providers have the option to submit the appeal request on paper as a TPI-only claim. Providers that choose to appeal the claim with NPI information will be required to continue submitting a TPI along with the NPI until the claim is finalized. Refer to the June 2007 National Provider Identifier (NPI) Special Bulletin, No. 205 for detailed information regarding appeals.
All electronic appeals will require NPI-only information when submitted to TMHP.
Medicare Crossovers
Medicare does not require a taxonomy code for Part B claims. As a consequence, some claims submitted to TMHP from Medicare for payment of coinsurance and deductible may not include the taxonomy code needed for accurate processing by TMHP.
To ensure timely payment for claims that are sent to TMHP from Medicare, providers should include their primary taxonomy code on all claims including Part B submitted to Medicare. Providers should also verify that their physical address for Medicare matches their physical address for their TPI enrolled with TMHP.
All paper Medicare crossover claims must include an attached claim form and must be submitted with an approved Medicare form, including the TMHP Medicare Remittance Advice Notice (MRAN) template, Medicare Remit Easy Print (MREP), or PC-Print. All other Medicare forms will be returned to the provider at the address listed on the claim. For more information on these forms, refer to the June 2007 Texas Medicaid Bulletin, No. 205, and the September/October 2007 Texas Medicaid Bulletin, No. 208.
Correspondence Changes
The following correspondence changes will go into effect with the NPI full compliance implementation.
Paper R&S Reports
All paper R&S reports will contain both the billing TPI and NPI. The benefit code, when applicable, will also be included. (For further information on the benefit codes, see the January 2007 National Provider Identifier (NPI) Special Bulletin, No. 202.)
Electronic R&S Reports
All electronic R&S reports will contain the billing NPI only. The benefit code, when applicable, will also be included. (For further information on the benefit codes, see the January 2007 National Provider Identifier (NPI) Special Bulletin, No. 202.)
Paper Checks
The provider’s billing NPI will replace the TPI as the provider number. The benefit code, when applicable, will also be included. (For further information on the benefit codes, see the January 2007 National Provider Identifier (NPI) Special Bulletin, No. 202.)
Electronic Funds Transfer (EFT)
The provider’s billing NPI will replace the TPI as the provider number. The benefit code, when applicable, will also be included.
Prior Authorization Requirements
The NPI and TPI are required for all authorization and pre-certification requests. Requests received without this information will be rejected or returned.
Prior authorization forms that do not include the NPI will be rejected or returned.
Forms and Letters
Some forms were revised to accommodate NPI and other related data. The forms became available on the TMHP website on July 23, 2007, and are also available through the TMHP fax-back option by calling the Automated Inquiry System (AIS) at 1-800-925-9126, and selecting Option 1, then Option 6. CSHCN Services Program providers can call 1-800-568-2413 and select Option 1, then Option 4.
Forms that do not include an NPI will be rejected or returned.
TMHP Toll-free Lines and AIS
Effective March 1, 2008, providers will be asked for their NPI and TPI when they speak to a representative at the TMHP Contact Center. Providers will also be required to use their NPI when accessing AIS. Providers that have not attested to their NPI with TMHP or have not received an Atypical Provider Identifier (API) will not have access to AIS.
NPI Information and Help
TMHP Website
A webpage dedicated to NPI is available on the TMHP website at the following address: www.tmhp.com/C13/NPI Announcements.
This page is updated on a continuing basis as more information about NPI becomes available.
Other Resources
The following websites may also be helpful:
· National Plan and Provider Enumeration System: https://nppes.cms.hhs.gov
The NPI Enumerator assigns NPIs and assists health plans and providers with issues relating to unique identification.
· CMS: www.cms.hhs.gov
The CMS website includes educational materials on NPI and its implementation, as well as the application process. This resource provides answers to common NPI questions.
· National Uniform Claim Committee (NUCC): www.nucc.org
The NUCC website contains information about standardized data sets for transmitting claim and encounter information.
· National Uniform Billing Committee (NUBC): www.nubc.org
The NUBC website helps define the data content associated with each of the electronic transactions mandated in the Health Insurance Portability and Accountability Act (HIPAA) of 1996.
· Washington Publishing Company (WPC) Taxonomy Code Sets: www.wpc-di.com/taxonomy/more_information
The Health Care Provider Taxonomy Code Sets allow single providers (individuals, groups, or institutions) to identify their specialty category. Providers may have one or more associated codes.
· ZIP Code Lookup (ZIP+4): http://zip4.usps.com/zip4/welcome.jsp
The ZIP+4 code is used by TMHP during the crosswalk process to identify the provider’s specific TPI that is associated with the NPI submitted.