National Provider Identifier NPI

National Provider Identifier NPI PowerPoint PPT Presentation


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National Provider Identifier NPI

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1. National Provider Identifier (NPI) Presented By:

2. Agenda Overview of NPI Impacts of NPI The VK/CARIS Approach to NPI Compliance

3. HIPAA Regulations

4. NPI, What is It? The NPI… Replaces the use of proprietary and legacy provider numbers used to identify a provider to a health plan in standard transactions Is assigned for life and is replaced only under extreme circumstances Remains active for providers sanctioned or barred from one or more health plans Cannot be used as a substitute for the TIN or DEA number The NPI number is a 10 digit number with the last digit as a check digit. The NPI will not hold embedded information Proprietary numbers like BCBS, UPIN, Medicare, Medicaid or other payers Think about the impacts the 10 digit number will have on your systems and processes, today we are using 9 digit tax ID and social security numbers. The NPI number is a 10 digit number with the last digit as a check digit. The NPI will not hold embedded information Proprietary numbers like BCBS, UPIN, Medicare, Medicaid or other payers Think about the impacts the 10 digit number will have on your systems and processes, today we are using 9 digit tax ID and social security numbers.

5. Benefits of NPI Establishes nationally accepted unique identifier for each provider Validating provider numbers as part of re-credentialing medical staff may be simplified or eliminated Re-assigning provider numbers within the health plan could completely vanish Provider’s internal administrative costs for maintaining plan specific identifiers is significantly reduced Simplified Coordination of Benefits (COB) with careful consideration to subpart enumeration strategy Fraud and abuse surrounding multiple provider identifiers will be reduced

6. Who’s Eligible to Obtain an NPI? “All health care providers regardless of whether they conduct transactions electronically or on paper or conduct any covered transactions will be eligible to apply for the national provider identifiers.” Definition of health care provider: “a provider of medical or health services and any other person or organization who furnishes, bills, or is paid for health care in the normal course of business.” Examples may be registered nurses, radiology, and respiratory therapists. On May 23, 2005 all health care providers that meet the definition of health care provider will be eligible to enroll for their NPI. Compliance for use and receipt of the NPI number will be May 27, 2007 for all providers and health plans. Small health plans will be May 27, 2008. Encourage all providers to file earlyOn May 23, 2005 all health care providers that meet the definition of health care provider will be eligible to enroll for their NPI. Compliance for use and receipt of the NPI number will be May 27, 2007 for all providers and health plans. Small health plans will be May 27, 2008. Encourage all providers to file early

7. Who’s Required to Obtain an NPI? Providers that meet the definition of a health care provider; and Transmit electronic transactions as defined by HIPAA; or Use a business associate to transmit health information in electronic form on their behalf, in connection with a standard transaction. This fits the definition of a covered health care provider in the other parts of the rule. Must meet the definition of a health care provider AND submit transactions electronically. Consider all relationships: Larger entities submitting claims on behalf of smaller entities.This fits the definition of a covered health care provider in the other parts of the rule. Must meet the definition of a health care provider AND submit transactions electronically. Consider all relationships: Larger entities submitting claims on behalf of smaller entities.

8. Non-Eligible Entities The final rule stipulates some entities as non-eligible to receive an NPI such as: Taxi services that deliver patients to health care providers Billing services and re-pricers that bill for health care providers Atypical providers such as: Pastoral/spiritual care provider Family members Au pairs Others who provide care or administer medications but are not health care providers The following providers may be NPI eligible due to other types of care they provide, or if they bill for their services to health plans and currently have assigned legacy numbers: Complimentary and Alternative Medicine Providers Holistic, fitness, some weight-loss, naturopathic and other entities

9. NPI Categories for Enumeration Type 1 – Entity Type Code - assigned to health care providers who are individual human beings: Physicians Nurses Pharmacists Dentists Chiropractors Physical Therapists

10. What is a subpart? Definition: Any component of the covered organization, health care provider needing an NPI in order to be identified in HIPAA standard transactions. Subpart designation may be based on: Whether subparts conduct standard transactions Existing federal regulations require the subpart to have unique identifiers to be reimbursed by federal health plans Certain other reasons Examples of hospital components that may be considered a subpart (subject to criteria) are: Outpatient Departments Surgical Centers Psychiatric Units Laboratories Subparts requiring an NPI obtain an organization or type code 2 entity NPI Covered entity – must be submitting transactions electronically Remember a health care provider is a provider of medical or health services and any other person or organization who furnishes, bills, or is paid for health care in the normal course of business.Covered entity – must be submitting transactions electronically Remember a health care provider is a provider of medical or health services and any other person or organization who furnishes, bills, or is paid for health care in the normal course of business.

11. When are Subparts Permitted to Obtain NPI Numbers? An NPI may be obtained by entities that do not meet the definition of a covered entity but otherwise qualify for assignment of an NPI because they meet the definition of a health care provider.

12. When are Subparts Required to Obtain NPI Numbers? An NPI must be obtained for, or by the subpart if, the subpart would be considered a covered health care provider if they were a separate legal entity. Remember there is a lot of confusion regarding subparts and not a lot of clarification from CMS on the enumeration process.Remember there is a lot of confusion regarding subparts and not a lot of clarification from CMS on the enumeration process.

13. NPI Responsibilities of a Provider Individual Providers An Individual is assigned a single NPI “Incorporated” individual = an organization Organization and individual eligible for NPIs The single NPI identifies the individual no matter where he/she renders the services Individuals cannot be considered “subparts” Organization Providers Determine for themselves the necessity to designate subparts, in accordance with NPI Final Rule; Control over assignment of NPIs within their organizations, in accordance with the NPI Final Rule

14. NPI Responsibilities of a Health Plan Health plans will continue their provider enrollment processes Health plans cannot require an enumerated health care provider to obtain an additional NPI Health plans are not prohibited from requiring their enrolled providers to obtain/use NPIs (if the provider is eligible) Health plans will not be able to require the use of a plan specific number in the standard transactions (UPIN, Medicare, Medicaid, BCBS)

15. What NPI Will “NOT” Do Be assigned to a non-health care provider Enroll a provider/subpart in a health plan Guarantee reimbursement by a health plan Convey covered entity status Assure licensure or credentials Require the enumerated health care provider/subpart to conduct standard transactions

16. Impacts to Vendors Dual process strategy for paper and electronic claims Identification and conversion of current provider identifiers Handling proprietary and NPI numbers during transition period for payers that are not ready Impacts in being the intermediary between health plans and providers Contract loading and payment impacts; tying the correct contract to the appropriate provider based on the NPI System conversions for acquisitioned companies that may not be compliant with Standard Transactions to date Compliance is imperative prior to the compliance date to allow the appropriate time for testing with payers and providers Handling claims for providers not required to submit or obtain an NPI

17. Impacts to Providers Entity and subpart enumeration strategy will impact cash flow Information systems will need to support the NPI and secondary identifiers (taxonomy) Business associates and trading partner impacts for implementing and supporting NPI Collection of NPI data from other providers Dissemination of NPI numbers to health plans, other providers, and vendors

18. Impacts to Health Plans Multiple provider numbers are given to the same provider Different contract levels for same provider Multiple systems and departments utilize provider numbers for various reasons Contracting strategies may be affected based on NPI solution determined Many interactions with external vendors occur utilizing provider numbers Collection of all NPI’s for physicians in and out of the health plan’s network will be challenging

19. Impacts to Health Plans, con’t. Matching NPI’s with current provider numbers will be cumbersome Medical management software will need to be able to handle the Referral Certification and Authorization (278) transaction containing the NPI Dual strategies will need to be maintained for providers submitting on paper versus electronic and for providers not required to have an NPI Other internal numbering schemes may be consistent with the NPI algorithm and may cause misidentification after NPI implementation Legacy provider numbers can no longer be required for providers to send

20. Enforcement Current contingency plan for Transaction Code Sets will be discontinued as of October 1, 2005 As of October 1, 2005 Medicare will reject non-compliant claims on the front end CMS anticipates a hard line to be taken with NPI compliance date

21. The Virchow Krause/CARIS Innovation Approach The VK and CARIS approach combines the technical assessment and expertise of VK with the healthcare and HIPAA expertise of CARIS to provide our clients with a complete NPI approach.

22. VK/CARIS Approach to NPI Compliance

23. Phase I – Determine Impact & Scope

25. Phase II – Define Solution Strategy & Plan

26. NPI Trail Example

27. Phase III – Implement Solution

28. Project Management

29. References for NPI General HIPAA Information: www.cms.gov Enrollment form: https://nppes.cms.hhs.gov HIPAA COW: www.hipaacow.org www.wedi.org./snip

30. Contact Information Carrie Romandine Christine Duprey Address: CARIS Innovation, Inc. 752 N. Memorial Drive Green Bay, WI 54303 Phone: 1.920.494.2782 (office) 1.920.639.6614 (Carrie’s mobile) 1.920.639.6615 (Chris’ mobile) E-mail: [email protected] [email protected] Jim Paddock Address: Virchow Krause, LLC 115 S. 84th Street, Suite 400 Milwaukee, WI 53214 Phone: 1.414.777.5441 (office) 1.414.810.9750 (mobile) E-mail: [email protected]

31. Questions

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