NPI Requirements
September 1, 2006Beginning May 23, 2007 (May 23, 2008, for small health plans), the NPI must be used in lieu of legacy provider identifiers. Legacy provider identifiers include:
- Online Survey Certification and Reporting (OSCAR) system numbers
- National Supplier Clearinghouse (NSC) numbers
- Provider Identification Numbers (PINs)
- Unique Physician Identification Numbers (UPINs) used by Medicare
They do not include taxpayer identifier numbers (TINs) such as:
- Employer Identification Numbers (EINs)
- Social Security Numbers (SSNs)
Primary and Secondary Providers
- Primary providers include billing, pay-to, rendering, or performing providers
- Secondary providers include supervising physicians, operating physicians, referring providers, and so on
Crosswalk
During Stage 2, Medicare will utilize a Crosswalk between NPIs and legacy identifiers to validate NPIs received in transactions, assist with population of NPIs in Medicare data center provider files, and report NPIs on remittance advice (RA) and coordination of benefit (COB) transactions. Key elements of this Crosswalk include the following:
- Each primary provider’s NPI reported on an inbound claim or claim status query will be cross-walked to the Medicare legacy identifier that applies to the owner of that NPI
- The Crosswalk will be able to do a two-directional search, from a Medicare legacy identifier to NPI, and from NPI to a legacy identifier
- The Medicare Crosswalk will be updated daily to reflect new provider registrations
NPI Transition Plans for Medicare FFS Providers
| Stage | Medicare Implementation |
| May 23, 2005 – January 2, 2006: | Providers should submit Medicare claims using only their existing Medicare numbers. They should not use their NPI numbers during this time period. CMS claims processing systems will reject, as unprocessable, any claim that includes an NPI during this phase. |
| January 3, 2006 – October 1, 2006: | Medicare systems will accept claims with an NPI, but an existing legacy Medicare number must also be on the claim. Note that CMS claims processing systems will reject, as unprocessable, any claim that includes only an NPI. Medicare will be capable of sending the NPI as primary provider identifier and legacy identifier as a secondary identifier in outbound claims, claim status response, and eligibility benefit response electronic transactions. |
| October 2, 2006 – May 22, 2007:
(This is stage 2, the subject of CR4023) |
CMS systems will accept an existing legacy Medicare billing number and/or an NPI on claims. If there is any issue with the provider’s NPI and no Medicare legacy identifier is submitted, the provider may not be paid for the claim. Therefore, Medicare strongly recommends that providers, clearinghouses, and billing services continue to submit the Medicare legacy identifier as a secondary identifier. Medicare will be capable of sending the NPI as primary provider identifier and legacy identifier as a secondary identifier in outbound claim, claim status response, remittance advice (electronic but not paper), and eligibility response electronic transactions. |
| May 23, 2007 – Forward: | CMS systems will only accept NPI numbers. Coordination of benefit transactions sent to small health plans will continue to carry legacy identifiers, if requested by such a plan, through May 22, 2007. |
Claim Rejection
Claims will be rejected if:
- The NPI included in a claim or claim status request does not meet the content criteria requirements for a valid NPI
- An NPI reported cannot be located in Medicare files;
- The NPI is located, but a legacy identifier reported for the same provider in the transaction does not match the legacy identifier in the Medicare file for that NPI;
- Claims include the NPI but do not have a taxpayer identification number (TIN) reported for the billing or pay-to provider in electronic claims received via X12 837, DDE screen (FISS only), or Medicare’s free billing software.
X12 837 Incoming Claims and COB
During Stage 2, an X12 837 claim may technically be submitted with only an NPI for a provider, but you are strongly encouraged to also submit the corresponding Medicare legacy identifier for each NPI in X12 837 Medicare claims.
Use of both numbers could facilitate investigation of errors if one identifier or the other cannot be located in the Medicare validation file. When an NPI is reported in a claim for a billing or pay-to provider, a TIN must also be submitted in addition to the provider’s legacy identifier as required by the claim implementation guide.
Paper Claim Forms
The transition period for the revised CMS-1500 is currently scheduled to begin October 01, 2006 and end February 01, 2007. The transition period for the UB-04 is currently scheduled for March 1, 2007 – May 22, 2007.
Pending the start of submission of the revised CMS-1500 and the UB-04, providers must continue to report legacy identifiers, and not NPIs, when submitting claims on the non-revised CMS-1500 and the UB-92 paper claim forms.
Provider identifiers reported on those claim forms are presumed to be legacy identifiers and will be edited accordingly. “Old†form paper claims, received through the end of the transition period that applies to each form, may be rejected if submitted with an NPI.
Or, if they are not rejected—since some legacy identifiers were also 10-digits in length—could be incorrectly processed, preventing payment to the provider that submitted that paper claim.