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May 23

Today is NPI compliance day

Today, all medical groups and other providers must submit reimbursement claims and other transactions — electronic and paper — to Medicare and private health insurers with National Provider Identifiers (NPIs).

If your billing software is set up to send both NPIs and legacy identifiers, and your clearinghouse or billing service will not strip legacy identifiers from your claims starting May 23, your group is responsible for submitting claims with only NPIs. Legacy identifiers are no longer permitted.

Action steps

Here are some action steps provided by the Medical Group Management Association (www.mgma.com):

  • Ensure that you have fully enumerated your providers with a Type I NPI and your organization (and any subparts) with a Type II NPI.
  • Contact your clearinghouse to find out if it participated in CMS’ May 7 Legacy Free Day testing exercise, and if so, it results.
  • If claims were rejected during this exercise, ask your clearinghouse for an explanation. Resolution might require changes to the National Plan and Provider Enumeration System data or the 855 Medicare enrollment record.
  • If your clearinghouse did not participate in Legacy Free Day testing, send a few test claims to it with only NPIs in primary provider fields.
  • If you submit directly to health plans, send a small number of NPI-only test claims to them.
  • If the entity that must be identified in the secondary provider field does not furnish an NPI, your practice, as the billing provider, must attempt to obtain that NPI to enter it on the claim form. 
  • If you have exhausted all possibilities, the Medicare fee-for-service plan allows the billing provider to use its own NPI as the identifier for secondary providers. However, we remind you that Medicare and commercial health plans will reject claims if Medicare or the plan’s policy requires a secondary identifier and there is no NPI present. We recommend that you contact your Medicare contractor and commercial health plans to determine whether the NPI is required for secondary providers.
  • If the billing provider is still unable to obtain the NPI of the entity, no identifier should be reported in the service-facility location loop.
  • After May 23, health plans may deny pharmacy claims and/or pharmacies may refuse to fill prescriptions lacking the prescriber’s NPI. To ensure that patients receive their prescriptions, providers should include their NPIs on all prescriptions.

If you are concerned that your clearinghouse, payer, or your own billing system is not ready for NPI-only claims, you may wish to establish a line of credit with your financial institution.

About Reed Tinsley, CPA

As a top advisor to physicians, I help increase practice profits by delivering hands-on, expert medical accounting/tax support, practice counsel, and revenue-building strategies. Read more →