NPI: An Industry Simplification?
The Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandated the adoption of a standard unique identifier for health care providers. This identifier is a number now commonly known as NPI (National Physician Identifier).
NPI is a unique 10-digit identification number issued to health care providers in the United States. The NPI will be used on each claim submitted to all payers. The implementation of this requirement was complex for the payers as their adjudication systems needed to be adjusted to receive this new number.
The initial NPI deadline for compliance was May 23, 2007, but just weeks prior to the deadline, CMS (Medicare) issued a contingency notice granting providers and payers an extra 12 months to work out compliance issues.
The Problem:
Even after CMS extended the NPI deadline, some payers still required that providers use their NPIs beginning on May 23, 2007; others recognized the extension and deferred the requirement to May 23, 2008. Some payers were not able to identify providers through their NPIs only; they, therefore, required that providers submit claims with both the NPI and legacy numbers – until their systems were updated. Check out a few more complex examples relating to NPI issue:
- Tufts required ONLY the NPI beginning on May 23, 2007.
- Medicare NY required ONLY the NPI beginning January 1, 2008.
- Medicaid NY, on the other hand, will not be able to accept the NPI on claims until October 2008.
- Medicaid of AR wants only the NPI when the claims are submitted electronically, except when their claims are submitted on paper, in which case they want only the legacy number (formerly known as the provider number).
To make things even more confusing, some payers still want the legacy number to appear on the claim after May 23, 2008 – if a legacy number is available. Why would a legacy number not be available? Well, with the advent of NPI some payers stopped issuing legacy provider numbers!
Even though the goal of NPI is simplification, the transition to NPI added many new numbers for our clients to obtain and monitor. Our clients are not only responsible for their providers’ NPI, but also the NPIs assigned to their medical groups, facilities, and referring providers.
The Solution:
To meet the new requirements, athenahealth developed new athenaNet functionality to recognize the NPI numbers. We also developed a set of NPI rules that work – regardless of the payer – to manage the claims that are submitted to Medicare A, DME, ASC as well as single provider claims. Here are examples of the new athenahealth rules relating to NPI:
- Rules that confirm that both the Type 1 and Type 2 NPIs have been entered into the provider and medical group number tables in athenaNet.
- Rules that confirm the NPI is a valid number format based on a standard algorithm.
- Rules that confirm the NPI has been verified against the national database.
- Rules that confirm the NPI is on file with the payers billed by each practice
The Process:
athenaNet rules will also assigning the non conforming NPIs to a responsible party for resolution. For example, if the NPI has not been entered into athenaNet, the practice’s MGRHOLD status would be assigned, notifying the practice manager of the issue. On the other hand, if the NPI has been entered into athenaNet but has not been verified through the national registry, the ATHENAHOLD status would be assigned and athenahealth’s enrollment services department will be notified.
Once again athenaNet Rules have managed a very complex issue in an efficient way helping our clients submit compliant, clean claims.