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Important NPI Update

The NPI is here.  The NPI is now.  Are you using it?

Health plans are progressing to transition to full NPI implementation.  Be sure to stay informed about the steps you need to take to bill correctly and test your NPI with all of the health plans with whom you do business.


National Plan and Provider Enumeration System (NPPES) FOIA-Disclosable Data to be Available on September 4, 2007

NPPES health care provider data that are disclosable under the Freedom of Information Act (FOIA) will be disclosed to the public by the Centers for Medicare & Medicaid Services (CMS).  In accordance with the e-FOIA Amendments, CMS will be disclosing these data via the Internet.  Data will be available in two forms:

  1. A query-only database, known as the NPI Registry.
  2. A downloadable file.


CMS has extended the period of time in which enumerated health care providers can view their FOIA-disclosable NPPES data and make any edits they feel are necessary prior to our initial disclosure of the data. CMS will be making FOIA-disclosable NPPES health care provider data available beginning Tuesday, September 4, 2007.  The NPI Registry will become operational on September 4 and the downloadable file will be ready approximately one week later.


CMS has posted several documents to help providers understand what the downloadable file will look like, including a “Read Me” file, Header File, and Code Value document for the downloadable file on the CMS NPI web page at


Important Information for Medicare Providers


Starting September 3, 2007, Medicare Carriers and DME MACs Will Begin Transitioning their Systems to Start Rejecting Claims when the NPI and Legacy Provider Identifier cannot be found on the Medicare Crosswalk

Since May 29, 2007, Medicare Fiscal Intermediaries, as well as Part B CIGNA Idaho and Tennessee, have been validating NPIs and Legacy Provider Identifier pairs submitted on claims against the Medicare NPI Crosswalk.  Between the period of September 3, 2007 and October 29,2007, all other Part B carriers and DME MACS will begin to turn on edits to validate the NPI/Legacy pairs submitted on claims.  If the pair is not found on the Medicare NPI crosswalk, the claim will reject.  Contractors have been instructed to inform providers at a minimum of 7 days prior to turning on the edits to validate the NPI/Legacy pairs against the Crosswalk.


If you are receiving informational edits today, we strongly urge you to validate that the NPPES has ALL of the NPI and legacy numbers you intend to use on claims and for billing purposes.  If NPPES is correct, and you continue to receive information edits, you should ask your contractor to validate the provider information in their system.  If the contractor information is not correct, you may be instructed to submit an enrollment form or CMS-855.  Please include ALL of your NPI/Legacy numbers in NPPES AND all of your NPIs that are to be used in place of your legacy on the CMS-855.  If the information is different in the two systems, there is a very good chance your claim will reject. NPPES data may be verified at on the web.


Medicare Efforts to Minimize Rejections and Suspensions

CMS CR5649, Transmittal number 1262 dated June 8, 2007, instructed Medicare Contractors to identify providers with the highest volume of rejections (or potential rejections/informational edits) due to invalid NPI information.  They were also instructed to identify providers who are not submitting their NPI.  Contractors have begun calling providers that fit these categories.  If you are contacted, you may be asked to validate your NPPES information or confirm that the information in the Contractor’s Provider file is correct.  If you are not submitting your NPI at this time, your Contractor will ask:  why you are not submitting it, the date you plan to submit it, and will ask you to send a small batch of claims using your NPI only, if possible.


Additionally, all Medicare providers could receive phone calls and/or letters from their contractors in the event that a claim suspends due to problems with mapping a provider’s NPI to a legacy provider identifier.   This could happen in the instance where one NPI is tied to several legacy identifiers.   If it is determined that the claim suspended due to incorrect data in the Contractors provider file or NPPES, the provider will be requested to either update their information in NPPES and/or submit an updated CMS-855 form.


If the provider does not respond within 14 calendar days to this communication, the Contractor will return the claim as unprocessable.  Conversely, if the provider does respond, it may furnish the Legacy number over the phone; however, the Contractor will ensure that it is in compliance with the Medicare Program Integrity Manual (Publication 100-08), chapter 10, section 17.2 regarding the release of information.


Reporting a Group Practice NPI on Claims

Medicare has identified instances where the Multi-Carrier System (MCS) is correcting billing or pay-to provider data on Part B claims submitted by group practices.  As of May 18, 2007, the MCS Part B claims processing systems no longer corrects claims submitted by group practices that are reporting the individual rendering Provider Identification Number (PIN) or individual rendering NPI in either the billing or pay-to provider identifier fields.  Groups should enter either their group NPI or group NPI and legacy PIN number pair in either of these fields.

Medicare has also reported instances of incorrect billing occurring with DME MAC’s.  Providers must ensure that if they enumerate as individuals in the National Supplier Clearinghouse (NSC), they must enumerate as individuals in NPPES. If they enumerate as organizations in NSC, they should do the same in NPPES.


Update to 835 Remittance Advice Changes in MLN SE0725

In MLN SE0725 Medicare described the 835 changes that would occur for the 835 Remittance Advice and that those changes would occur July 2, 2007 for DME MACS only.  The article also went on to note that Medicare would notify providers when the Part A Institutional and Part B Professional 835 would be changing.  Medicare 835 Electronic Remittance Advices will reflect the noted changes on Remittances for Part A and Part B, starting April 7, 2008.


Transcript for August 2nd Roundtable Now Available

The transcript for the August 2nd, Medicare FFS Q&A Session: Common Billing Errors, Roundtable is now available at  on the CMS NPI page.


Reminder: Recent MLN Matters Articles

Several recent Special Edition MLN Matters articles contain important billing information for Medicare providers and suppliers, including:


General Medicare Claims Processing Reminder

Unrelated to the NPI, Fee-for-Service Medicare claims can be rejected by contractors for a variety of reasons including:

  • incorrect billing information,
  • the provider has been terminated from the program
  • the beneficiary is not eligible for Medicare
  • the claim was sent to the wrong contractor

If a provider has questions about a claim rejected by an FI/carrier or MAC, the provider should contact the contractor directly.  It is never appropriate to direct the beneficiary, who received the service billed on the claim, to the 1-800-Medicare toll free line to resolve a claim rejection.


Still Confused?

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 on the CMS website.  Providers can apply for an NPI online at or can call the NPI enumerator to request a paper application at 1-800-465-3203.  Having trouble viewing any of the URLs in this message?  If so, try to cut and paste any URL in this message into your web browser to view the intended information.

Getting an NPI is free – not having one can be costly.
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