Bulletin: March 08, 2006

National Provider Identifiers

By: Quadax, Inc.

Now that providers are able to apply for a National Provider Number (NPI), it is important to review some of the significant concepts and dates associated with this new mandate:

• The NPI will replace health care provider identifiers currently in use for standard health care transactions.
• The format will be 10 positions long: nine digits for the actual account number, plus one check digit.
• The NPI will be "intelligence free," meaning that logic cannot be built around the number.

Health plans with whom providers do business will provide instructions as to when they may begin using the NPI in standard transactions. In the meantime, the majority of payers will most likely use a crosswalk initially.

The Centers for Medicare and Medicaid Services (CMS), which is in charge of the NPI program, is currently seeking fast-track approval of a certification document that provider organizations can use to conduct bulk enumeration of the NPI. Providers can continue to apply for numbers individually, but most are waiting for bulk enumeration to be available. However, the issue of access to issued numbers has still not been addressed yet.

Revised CMS-1500

The National Uniform Claim Committee (NUCC) announced the release of the new version of the CMS-1500 Health Insurance Claim Form (version 08/05) that accommodates the reporting of the NPI. All of the revisions made to the form were either NPI-related or because a significant need for the change was identified. The revised 1500 has been submitted to the Office of Management and Budget (OMB) for approval for use with federal programs, such as Medicare. The revised form is currently available for testing and transition preparation purposes only and cannot be used for the official purpose of claims submission at this time.

Although not mandated by law, the NUCC recommended the following timeline for transitioning to the new version of the 1500 Claim Form:

• October 1, 2006: Health plans, clearinghouses, and other information support vendors should be ready to handle and accept the revised (08/05) 1500 Claim Form.
• October 1, 2006 - February 1, 2007: Providers can use either the current version or the revised (08/05) version of the 1500 Claim Form.
• February 1, 2007: The current version of the 1500 Claim Form is discontinued; only the revised form is to be used.  All rebilling of claims should use the revised form from this date forward, even though earlier submissions may have been on the current 1500 Claim Form.

Because the current 1500 Claim Form is due to expire with the OMB in March 2006, it will be renewed to allow its continued use during this transition period.
For additional information, visit http://new.cms.hhs.gov/NationalProvIdentStand/01_Overview.asp. Or you can complete an NPI application by directing your Web browser to: https://nppes.cms.hhs.gov/NPPES/StaticForward.do?forward=static.instructions. CMS has also produced an instructional Web tool, called the NPI Viewlet, for viewing at http://www.cms.hhs.gov/apps/npi/npiviewlet.asp. This tool, designed for all health care providers, offers an overview of the NPI, a walkthrough of the application, as well as live links to the National Plan and Provider Enumeration System's (NPPES) Web site. In addition, AdminaStar Federal has created a new link on the Intermediary Homepage, National Provider Identifier (NPI), to http://www.adminastar.com/Providers/Intermediary/NPI/NPI.htm.

UB-04

The UB-04 contains a number of improvements and enhancements that resulted from nearly four years of research, including better alignment with the electronic HIPAA ASC X12N 837-Institutional transaction standard. Below is a list of some of the key changes.

Additions:

• Unique fields for NPI and National Health Plan ID
• Accident State
• Diagnosis Indicator
• ICD – version qualifier (ICD-9/ICD-10)
• Pay-to-location
• PPS/DRG Code
• Code-Code Field

Deletions:

• Covered, Non-covered, Coinsurance & lifetime reserve days (converted to Value Codes)  
• Patient Marital Status
• Employment Status Code
• Employer Location
• Prior Payments – Patient
• Procedure Coding Method Used
• Provider/Representative Signature

Modifications

• Bill Type – expanded field size
• Condition Codes – added four new fields
• Occurrence Codes – added additional field
• HCPCS/Rate/HIPPS Rate Codes – expanded field size for additional modifiers
• Treatment Authorization Number – expanded field size
• Diagnosis Fields – added nine new fields – expanded size to 8 characters
• Procedure codes – expanded field size by one.

The UB-04 is scheduled to replace the UB-92 beginning with bills created on March 1, 2007 in accordance with the following transition:

• March 1, 2007: Receivers (i.e. health plans and clearinghouses, like Quadax) must be able to receive the new UB-04 electronic format. Submitters (i.e. health care providers such as hospitals, skilled nursing facilities, hospice, and other institutional claim filers) can begin using the UB-04.
• March 1 to May 22, 2007: Providers can use either the UB-04 or UB-92 forms/data set specifications.
• May 23, 2007: The UB-92 is discontinued; only the UB-04 form and data set specifications can be used. All rebilling of claims must use the UB-04 from this date forward, even though earlier submissions may have been on the UB-92.

For more information regarding the UB-04, direct your Web browser to: www.nubc.org/INFORMATION_ON_UB-04.pdf.

Finally, please remember to inform Quadax when you begin submitting NPI so the appropriate changes can be made to the mapping tables and submission issues are avoided.