As of May 23, Medicare FFS will require and send NPI-Only in ALL provider identifier fields for all HIPAA and paper transactions where a provider identifier is required. If you send Medicare a transaction with a Medicare legacy identifier in any of the provider fields, your claim will be rejected. These transactions include all electronic and paper claims (837I, 837P, NCPDP, DDE and paper CMS-1500 and UB-04), the 276/277 claims status transaction, the 270/271 eligibility transaction, 835 remittance advice and SPR paper remittance.
If your billing software is set up to continue to send both the NPI and the legacy identifier, and your clearinghouse or billing service will not be stripping the legacy identifier from your claim as of May 23, the responsibility falls to the provider to send in the Medicare claim with NPI-only, i.e., NO legacy identifiers.
NPIs for Secondary Providers
If the entity that is required to be identified in the secondary provider field (i.e., the ordering/referring/attending/operating/supervising/purchased service/other/service facility provider or prescriber) does not furnish an NPI, the billing provider must attempt to obtain that NPI in order to enter it on the claim. The billing provider may use the NPI Registry (https://nppes.cms.hhs.gov/NPPES/NPIRegistryHome.do) to obtain the secondary provider’s NPI or it may need to directly contact the ordering/referring/attending/operating/supervising/purchased service/other/service facility or prescriber in order to obtain the NPI.
If the billing provider has exhausted all possibilities of finding the NPI of the ordering/referring/attending/operating/supervising/purchased service/other or prescriber, Medicare FFS is permitting the billing provider (in the X12N 837 transactions) or the service provider (in the NCPDP 5.1 transaction) to use their own NPI as the identifier for those secondary providers. Medicare will reject claims if Medicare policy requires a secondary identifier and there is no NPI present.
For service facility location loop, if the billing provider is still unable to obtain the NPI of the entity, no identifier should be reported in that loop.
Need More Information?
Still not sure what an NPI is and how you can get it, share it and use it? As always, more information and education on the NPI can be found through the CMS NPI page www.cms.hhs.gov/NationalProvIdentStand on the CMS website. Providers can apply for an NPI online at https://nppes.cms.hhs.gov or can call the NPI enumerator to request a paper application at 1-800-465-3203.
