November 2007 Newsletter
Watch for New NPI Edits on Claims
As we progress towards the full implementation of HIPAA standards for National Provider Identifiers (NPIs), payers are instituting edits to verify that claims include the correct NPIs. Depending on the payer and the error type, the edits may cause claims to reject, or frontend responses and remittance messages may contain informational errors.
NPI Crosswalk Edits
On October 31, 2007, Medicare systems began validating whether the NPI and legacy numbers (such as the Medicare Provider Identification Number (PIN)), on claims match those in the NPI Crosswalk. If the NPI/PIN combination on a claim does not match an NPI/PIN combination in the NPI Crosswalk, the claim will reject.
A major reason for mismatched numbers and rejections is confusion over which entity is identified by the NPI: the corporation or the individual. Physicians, including solo practitioners, may have an individual NPI (Entity type 1) and, if incorporated, a corporation/organization NPI (Entity type 2). The NPI/PIN combination will not be found in the Crosswalk, for example, if the Billing Provider NPI is for the corporation but the PIN used in combination with it is for the individual physician. Generally, the corporation’s NPI represents the Billing and Pay-to Providers and the individual’s NPI represents the Rendering, Referring/Ordering, Attending, Operating and/or Other Providers.
The Crosswalk may not have the correct numbers linked if the PIN supplied on the NPI application was for the wrong entity type. Incorrect pairings of NPI/PIN may be the result of past Medicare enrollment and PIN assignment procedures. For example, Medicare carriers may have combined the enrollment of a physician and his/her corporation into a single enrollment, or a sole proprietorship may have been enrolled as a corporation because it was issued an Employer Identification Number (EIN) by the IRS. If a physician is billing as an individual and as a corporation, both entity types must now be enrolled in Medicare and receive separate NPIs linked to the appropriate PINs.
NPI Edits from Other Payers
To process NPIs on claims, payers may require that providers’ NPIs are also registered with them. Anthem is now reporting informational errors if the NPIs for Pay-to or Rendering physician are not registered with Anthem.
Other payers will be introducing edits to require NPIs on claims according to their own schedules. Claims will begin rejecting in the near future if NPI information is not present and correct.
What You Should Do
The following are some actions you should take to prevent or correct NPI errors:
- Monitor your claims, frontend responses, and remittances for NPI-related errors and rejections.
- Register your NPIs with all applicable payers.
- Verify that the NPPES has all the NPIs and legacy numbers you intend to use for billing and that the correct numbers are linked. Update the NPPES with any legacy numbers (Medicare IDs, PIN, UPIN) that were not included when you applied for your NPI.
- If your remittance advice contains informational errors, correct the problems now before claims begin to reject. Contact the payer to determine how your NPIs are linked to the legacy numbers.