Get your NPI number NOW

April 18, 2008

After May 23, only this identifier will get your Medicare claims paid.

Key Points

The 10-digit National Provider Identifier is meant to simplify electronic claims submission. But for many physicians, switching to this federally mandated number could require some complicated-and fast-footwork to comply with a deadline little more than a month away.

The landmark HIPAA legislation from 1996 created the NPI to replace a grab bag of identifiers that doctors have used with various third-party payers. It's required not only for electronic claims, but for all electronic transactions covered by HIPAA, such as remittance advice, queries on eligibility and claims status, and authorization requests. The NPI eventually will also become the standard identifier for e-prescribing, CMS says.

One crucial deadline for implementing the NPI has already passed. As of March 1, doctors are required to put the NPI in the primary-provider fields of electronic Medicare claims, although they're free to include their old "legacy" identifier, such as a Medicare Provider Identification Number (this deadline didn't apply to claims processed by private insurers). CMS claims data from early February suggest that providing both identifiers is what most physicians have done.

The deadline was originally set for May 2007, but CMS gave the healthcare industry more time to gear up for the NPI era. Are you ready?

Test the waters without delay

If you've submitted your NPI and legacy numbers in tandem and gotten paid, you should have no trouble switching to the national identifier alone. But you need to make sure, advises Cynthia Hughes, a coding and compliance specialist with the American Academy of Family Physicians. To play it safe, submit a few claims to Medicare before May 23 using only the NPI as a test.

If your test claims get paid, slowly increase the volume of those bearing only the NPI. If they're rejected, study the rejection message from Medicare to determine why. Typically, the problem will stem from a discrepancy between the information on your NPI application and your Medicare enrollment information, which is associated with your legacy number. To troubleshoot this problem, make sure the information in your NPI application is accurate and that it matches what appears on your claim. You can review your application by visiting the website of Medicare's National Plan and Provider Enumeration System (NPPES) at https://nppes.cms.hhs.gov/NPPES/Welcome.do.

Verify that the Medicare legacy number listed on the NPI application is correct and that you applied for the right NPI. If you're a sole proprietor, you need an individual identifier, not one intended for a corporation or other organizational structure. Once you fix any problems, then resubmit the claims.

If your NPI data is on the mark and you still get rejected, then contact your Medicare carrier-not CMS-to ensure that your enrollment information is accurate, particularly if your status has changed. If you started off as a sole proprietor but then incorporated, say, you need an organizational NPI in addition to an individual one. However, if your Medicare enrollment file still shows you as a sole proprietor, the discrepancy will trigger a denial. To clear up such problems, you may need to re-enroll with Medicare, a process that could take up to six months, says Cynthia Hughes.

Since your NPI also will replace identifiers used by your private payers, you'll need to send each of the health plans you contract with test claims bearing only the national identifier. Visit the website of each insurer for instructions.