Important NPI Enrollment Information

Past Medicare Enrollment Practices May Have Contributed to the Use of Incompatible NPI/PIN Combinations. One reason a claim will reject is if the NPI and PIN used in combination on the claim does not identify the same entity. For example, the NPI in the ÒBilling ProviderÓ field might be the corporationÕs NPI, but the PIN used in combination with it might be the physician/practitionerÕs PIN. This pairing may be the result of variations in past Medicare enrollment and PIN assignment procedures. For example, Medicare carriers may have combined the enrollment of a physician/ practitioner and his/her corporation into a single enrollment; or, a sole proprietorship may have been enrolled as a corporation because the sole proprietorship was issued an Employer Identification Number (EIN) by the IRS.

These and similar situations may require physician/practitioners who are experiencing claims rejections to ensure their Medicare enrollment information, and that of their corporations (if they are incorporated), is correct. This may require the completion of the appropriate CMS-855 Medicare Provider Enrollment Application.

If Your Claims Are Rejected

• Check Medicare Reject Report messages.
• If you use billing companies, clearinghouses, and administrative staff, check to find out if they have been contacted by Medicare carriers or A/B MACs concerning problems in matching NPI/PIN combinations to the Medicare NPI crosswalk.
• Check your information (and that of your corporation, if you formed one) in the NPPES to ensure that the NPI(s) were properly obtained. For example, if you are have a sole proprietorship, you should have an individual PIN and you should have obtained an NPI as an Individual (Entity type 1), not as an Organization (Entity type 2).
• Ensure that the NPPES data (for you and your corporation, if you formed one) are correct, and that the NPPES record(s) contains the Medicare legacy identifier(s) that was assigned to the provider (physician/practitioner or the corporation) to whom the NPPES record belongs. For example, a physician/practitioner applying for an NPI would list his/her Medicare PIN in the Ã’Other Provider IdentifiersÓ section of the NPI application, but would not list the PIN of the group in which he/she is a member. Medicare uses this information in building the Medicare NPI crosswalk and incorrect reporting will flow into the NPI crosswalk and cause problems down the road. To view or edit your NPPES record, go here on the CMS web site. For assistance, call the NPI Enumerator at 1-800-465-3203.
• If the NPI(s) was properly obtained and the NPPES information is correct and you continue to get informational NPI edits: Ensure that your (and your corporationÕs, if you formed one) Medicare enrollment information is up to date.