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Fox Systems Inc. National Provider Identifier (NPI) Presentation to Arizona Chapter of HIMSS. Agenda. Introduction to Fox Systems Inc. Current Status of NPI Enumeration What is the NPI, and What is it Not? Need for Compliance NPI Compliance Timelines Benefits of NPI

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fox systems inc
Fox Systems Inc.

National Provider Identifier (NPI) Presentation to

Arizona Chapter of HIMSS

  • Introduction to Fox Systems Inc.
  • Current Status of NPI Enumeration
  • What is the NPI, and What is it Not?
  • Need for Compliance
  • NPI Compliance Timelines
  • Benefits of NPI
  • Who Can and Cannot Get an NPI?
  • Provider Subparts
  • Applying for an NPI
  • Applying for an NPI
  • Provider Subparts
  • Provider Taxonomy
  • NPI Impact
  • Compliance Strategies and Issues
  • Next Steps
  • How FOX can Help your Organization
fox systems inc4
Fox Systems Inc.
  • Founded in 1987, FOX is a women-owned, business headquartered in Scottsdale, AZ which specializes in healthcare management and system consulting and solution services
  • FOX has provided system, management and HIPAA consulting and integration services to CMS and to more than 30 state Medicaid, public health, and behavioral health programs as well as other payers, providers, and MCOs
fox systems inc5
Fox Systems Inc.
  • Our customers are large and diverse, and include CMS, public and private sector payers, providers, managed care organizations, and Native tribes including.
    • DHHS Office for Civil Rights
    • CMSO - Medicaid
    • SAMHSA
    • Veterans Administration
    • Blue Cross and Blue Shield plans
    • Delta Dental Plans
    • Medicaid state agencies
    • Medicaid contractors
    • Hospitals, clinics, and other providers
    • Managed care organizations
fox systems inc6
Fox Systems Inc.
  • We have strong systems, business process, and operations expertise in all areas of healthcare operations including the following:
    • Claims processing
    • Beneficiary eligibility
    • Provider enrollment/certification/credentialing
    • Benefit plan management
    • Pharmacy benefits management
    • Managed care
    • Case management/disease management
    • Utilization review
    • Fraud and abuse detection
    • Data warehouse/decision support
    • Client registries
fox systems inc7
Fox Systems Inc.
  • Examples of large, complex healthcare clients served by FOX include:
    • State of Arizona – developed 1st Medicaid managed care system (PMMIS)
    • State of Florida Medicaid Program – Medicaid contractor and system procurement and QA
    • County of Los Angeles enterprise-wide HIPAA Security assessment
    • County of Los Angeles Department of Health Services – HIPAA TCS and Security assessment and gap analysis
    • LA Care Health Plan - implementation of HIPAA translator, system integration, and system maintenance
    • State of Oregon Medicaid – implementation of HIPAA translator, system integration and maintenance
    • TennCare Program – Medicaid contractor and system procurement and QA
    • County HIPAA assessments in Hillsborough (FL), Broward (FL), Henrico (VA), Montgomery (MD) and San Diego (CA)
fox systems inc8
Fox Systems Inc.
  • FOX has been providing services to CMS (formerly HCFA) since the early 1990s. Previous CMS projects included:
    • Development of Medicaid national fraud and abuse Best Practices Guides (SURS Best Practices)
    • Development of the national Early, Periodic Screening, Diagnosis and Treatment (EPSDT) system design for Medicaid
    • Performed Y2K risk assessment and remediation monitoring for Medicaid systems nationally
    • Performed HIPAA impact analysis for Medicaid systems nationally including development of the Medicaid HIPAA Compliance Concept Model (MHCCM) and supporting software
    • Provided support to DHHS Office for Civil Rights in responding to emailed HIPAA questions (AskHIPAA FAQs) from providers and other HIPAA entities
fox systems inc9
Fox Systems Inc.
  • Currently, FOX is assisting CMS in:
    • The development of the new Medicaid Information Technology Architecture (MITA) for future Medicaid systems
    • The development of new system certification criteria (qualifying for enhanced FFP) for Medicaid systems nationally including HIPAA and NPI compliance
fox systems inc10
Fox Systems Inc.
  • Fox Systems was selected by CMS to be the NPI Enumerator through May 23, 2010 and has the responsibility for:
    • Performing the functions required to carry out the basic operations of assigning National Provider Identifiers (NPIs) to health care providers
    • Using the National Plan and Provider Enumeration System (NPPES), developed and maintained by CGI-AMS, as the basic tool
    • Performing activities including:
      • Providing paper applications
      • Data entry of applications
      • Notifying providers about new NPIs issued
      • Resolution of pended applications
      • Mailing and correspondence
      • Call center-based customer service
fox systems inc11
Fox Systems Inc.
  • As NPI Enumerator, FOX is also tasked to work with provider organizations and other qualified entities that wish to submit files through Electronic File Interchange (EFI)
    • Validate the organization’s identity and establish accounts
    • Work with organizations to determine if their providers have NPIs
    • Reset web users’ passwords and user IDs
    • Maintain a call center for providers
  • EFI was originally scheduled for implementation during the Summer of 2005 but has been delayed
fox systems inc12
Fox Systems Inc.
  • As Enumerator, FOX is not responsible for:
    • NPI provider outreach and training (CMS)
    • Operating or maintaining the NPPES or the NPI Website (other CMS contractor)
    • Determining the establishment of subparts (provider responsibility)
    • Determining provider taxonomies (provider responsibility)
    • Answering policy questions (CMS)
current enumeration status
Current Enumeration Status
  • Over 113,000 providers enumerated through August 2005
  • Estimated 3-4 million providers will eventually be enumerated (rough guess because depends on provider designation of subparts)
what is the npi
What is the NPI?
  • The NPI is one of the required HIPAA identifiers to be used in “standard” electronic health care transactions.
  • It is a unique and permanent healthcare provider identifier consisting of 10 numeric positions, preceded with “80840,” per the National Committee for Information Technology Standards .284 standard
  • An NPI is inactivated only upon death or dissolution of the health care provider.
what is the npi15
What is the NPI?
  • NPI will replace existing legacy provider numbers used for billing, servicing, referring, etc. including:
    • UPIN
    • Medicaid Provider Number
    • Medicare Provider Number
    • Blue Cross and Blue Shield Numbers
    • Other internal proprietary healthplan provider numbers
need for compliance
Need for Compliance
  • Required whenever the HIPAA Implementation Guides require a provider identifier in a transaction, i.e., needed in order to continue to conduct Electronic Data Interchange involving:
    • Claims and encounters
    • Claim status and inquiry
    • Payments
    • COB
    • Remittances
    • Eligibility inquiries
    • Prior authorizations and referrals
  • Evolving new HIPAA transactions (e.g.., X12 855 provider enrollment) and updates of current transactions will also require use of the NPI.
  • Failure to abide by the rules set forth in the HIPAA NPI Final Rule will lead to various sanctions.
what the npi is not
What the NPI is NOT
  • An NPI will not:
    • Guarantee reimbursement by health plans
    • Enroll providers in health plans
    • Make providers covered entities
    • Require providers to conduct electronic transactions
  • While it is required for HIPAA EDI, it is not required for internal use within a healthcare organization as long as it is able to be mapped to internally used legacy identifiers but relationships must be “one to one”, “one to many”, or “many to one”. Not “many to many”.
npi compliance timelines
NPI Compliance Timelines
  • January 23, 2004 – Final Rule published
  • May 23, 2005 – Health care providers (HCPs) can begin applying for NPIs
  • Compliance dates:
    • May 23, 2007 – all covered entities including payers except for small health plans
    • May 23, 2008 – small health plans
benefits of npi
Benefits of NPI
  • Simplify healthcare transaction processing including claims and COB, patient eligibility and enrollment functions, provider enrollment, etc., and eventually reduce healthcare administrative costs
  • Improve the quality of care
  • Improve UM, UR and fraud and abuse detection
who can get an npi
Who Can Get an NPI?
  • Any “health care provider”
    • Both covered and noncovered (per HIPAA definition) entity providers
    • Individuals: Physicians, dentists, nurses, chiropractors, others
    • Organizations: Hospitals, ambulatory care facilities, laboratories, HMOs, group practices, others
  • Subparts of providers
who can get an npi21
Who Can Get an NPI?
  • Noncovered healthcare providers may also apply for NPIs:
    • Being assigned NPIs does not make providers covered entities
    • There is no requirement for noncovered providers to obtain or use NPIs
    • NPIs can be used on paper transactions
who cannot get an npi
Who Cannot Get an NPI?
  • Non-healthcare providers such as:
    • Social service providers under a Medicaid Waiver program
    • Housekeepers
    • Non-medical transportation.
  • This means that many providers (non-healthcare) on payer and other healthplan networks will not require an NPI
provider subparts
Provider Subparts
  • A provider is a distinct legal entity
  • Subpart is not another legal entity; it furnishes health care, e.g.. hospital unit, member of chain
  • A provider’s subparts does not necessarily correlate to a hybrid entity, a health care component, or an organized health care arrangement
  • An individual is not a provider subpart
provider subparts24
Provider Subparts
  • Covered provider is responsible for determining subpart’s need for NPI and applying for subpart NPI applications
  • Covered provider is responsible for all enumerated subparts’ compliance with NPI Rule
npi applications
NPI Applications
  • The Current NPI Enumeration Process
    • Provider completes application form to apply for NPI:
      • Can file electronically through Web or on paper to NPI Enumerator (FOX)
      • Application is processed by NPPES with:

-- Data editing

-- Data validation

-- Duplicate application detection

    • Provider receives notification of NPI
    • Provider responsible for notifying health plans and other trading partners
npi applications26
NPI Applications
  • Information collected on application for NPI used for assignment of NPI is matched against previously submitted NPI applications
  • Different information required for individuals and organizations
  • Limited to minimum information necessary for unique identification and communication
npi applications individuals
NPI Applications - Individuals
  • Required: name, gender, address/telephone, Taxonomy Code(s), date of birth, State/country of birth, contact person’s name/telephone
  • Situational: license number(s)/State(s) (required for certain Taxonomy Codes)
  • Optional: SSN/ITIN, name prefix/suffix, other name(s), credential(s), other identifiers
npi applications organizations
NPI Applications - Organizations
  • Required: name, address/telephone, Taxonomy Code, authorized official’s name/telephone, contact person’s name/telephone
  • Situational: EIN (required if provider has one), license number(s)/State(s)(required for certain Taxonomy Codes)
  • Optional: other name(s), other identifiers
npi data validation
NPI Data Validation
  • Key NPI Application Data is not validated by the NPPES:
    • That the submitted address belongs to the individual
    • Situationally required state license number(s) is valid and belongs to the applying provider
    • Optional legacy provider IDs for other health plans and regulatory agencies including:
      • Medicaid ID(s) and associated states
      • Medicare UPIN
      • BCBS #s
      • NCPDP #
      • DEA #
      • CLIA #
      • Etc.
provider taxonomy
Provider Taxonomy
  • Provider Taxonomy is a unique ten character, alphanumeric code which defines a provider’s scope of practice for use in HIPAA standard electronic transactions.
  • Developed and maintained by the National Uniform Claim Committee (NUCC).
  • The Provider Taxonomy code has three hierarchical “levels“:
    • Provider Type
    • Classification
    • Area of Specialization.
provider taxonomy31
Provider Taxonomy
  • Used by a provider (individual, group, or institution) to identify and self declare with the NPI Enumerator their specialty category(ies) as associated with a single NPI, i.e., providers may have one or more than one taxonomy associated to them.
  • When determining what taxonomy code or codes to associate with a provider, need to review the requirements of all the trading partners with which the code(s) are being used.
provider taxonomy32
Provider Taxonomy
  • The “Individual Category” of providers includes:
    • Physicians
    • Behavioral Health and Social Service Providers
    • Chiropractic Providers
    • Dental Providers
    • Dietary and Nutritional Service Providers
    • Emergency Medical Service Providers
    • Eye and Vision Service Providers
    • Nursing Service Providers
    • Nursing Service Related Providers
    • Other Service Providers
    • Pharmacy Service Providers
    • Physician Assistants and Advanced Practice Nursing Providers
    • Podiatric Medicine and Surgery Providers
provider taxonomy33
Provider Taxonomy
    • Respiratory, Rehabilitative and Restorative Providers
    • Speech, Language and Hearing Providers
    • Student, Health Care
    • Technologist, Technician, and Other Technical Service Providers
  • The Group (of Individuals) category includes:
    • Multi-Specialty
    • Single Specialty
provider taxonomy34
Provider Taxonomy
  • Organizational/Non-individual Providers include:
    • Agencies
    • Ambulatory Health Care Facilities
    • Hospital Units
    • Hospitals
    • Laboratories
    • Managed Care Organizations
    • Nursing and Custodial Care Facilities
    • Residential Treatment Facilities
    • Respite Care Facilities
    • Suppliers
    • Transportation Services
provider taxonomy35
Provider Taxonomy
  • Provider Type (1st level)
    • A major grouping of service(s) or occupation(s) of health care providers. Examples include:
      • Allopathic & Osteopathic Physicians
      • Dental Providers
      • Hospitals
      • Etc.
provider taxonomy36
Provider Taxonomy
  • Classification (2nd level)
    • A more specific service or occupation related to the Provider Type, often based upon the General Specialty Certificates as issued by the appropriate national boards, e.g.., within Allopathic & Osteopathic Physicians, Classifications would include:
      • Allergy and Immunology
      • Anesthesiology
      • Dermatology
      • General Practice
      • Internal Medicine
      • Obstetrics and Gynecology
      • Etc
provider taxonomy37
Provider Taxonomy
  • Classification (2nd level)
    • Within Provider Type “Hospitals”, Classifications would include:
      • Christian Science Sanitarium
      • Chronic Disease Hospital
      • General Acute Care Hospital
      • Military Hospital
      • Psych Hospital
      • Rehab Hospital
provider taxonomy38
Provider Taxonomy
  • Area of Specialization (3rd level)
    • A more specialized area of the Classification in which a provider chooses to practice or make services available. For example, the Area of Specialization for provider type Allopathic & Osteopathic Physicians is based upon the Subspecialty Certificates as issued by the appropriate national boards, e.g., for OB-GYN.
      • Gynecologic oncology
      • Maternal and Fetal medicine
      • Obstetrics
      • Reproductive endocrinology
provider taxonomy39
Provider Taxonomy
  • Area of Specialization (3rd level)
    • For the Classification General Acute Hospital, Areas of Specialization include:
      • Children
      • Critical Access
      • Rural
      • Women
npi impacts
NPI Impacts
  • NPI affects all healthcare organizations but health plan and clearinghouse impacts are much greater than provider impacts
  • Health plan impacts include 2 major risks:
    • Risk of not obtaining NPI timely and accurate data from provider is significant
    • Legacy claims, provider and other systems will not support use of NPI
npi impacts41
NPI Impacts
  • Under the current process, health plans are at great risk that their providers:
    • will not apply for NPIs on a timely basis
    • will apply for Subpart NPIs and taxonomy codes which are in conflict with health plans’ internal credentialing and scope of service data
    • will not disseminate assigned NPIs to health plans either:
      • on a timely basis, or
      • accurately
npi impacts42
NPI Impacts
  • Until CMS’ Electronic File Interchange (EFI) for batch enumeration is implemented, only individual providers can apply for an NPI
  • When EFI is implemented, only select, designated organizations will be able to submit in behalf of their providers
  • In the absence of strong health plan support, providers will have transition issues which require:
    • Development of health plan policies and procedures concerning NPI application
    • Education of providers concerning how to apply
  • In the absence of such measures, there could be major disruption of provider cash flow, disruption of services to clients, and negative publicity
npi impacts43
NPI Impacts
  • Impact on Health Plan Systems
    • Need to assess and remediate legacy health plan automated systems for NPI compliance
    • Existing health plan claims, credentialing and other legacy systems are not NPI-compliant and may result in non-payment, incorrect, late, fraudulent or otherwise inappropriate payments to their network
npi impacts44
NPI Impacts
  • Impact on Health Plan Systems
    • Legacy and health plan-assigned provider identifiers will not be permitted in standard transactions, and the NPI is “non-intelligent”, hence matching NPIs against legacy provider credentialing and enrollment data will be difficult
npi impacts45
NPI Impacts
  • Changes required to Health Plan Systems could include:
    • Accommodating NPI field size and format
    • Remediating all code based on intelligence in legacy numbers
    • Creating cross-references between legacy provider numbers and NPI’s
    • Supporting both NPI and non-NPI (for providers not eligible for NPI) provider IDs
    • Converting claims history for reporting and other processes based on provider IDs
npi impacts46
NPI Impacts
  • Systems will need to map NPI and any Subpart NPIs to legacy IDs
  • Systems will need to map taxonomy codes to legacy system methods of defining allowable and reimbursable scope of service, e.g., Category of Service
npi impacts47
NPI Impacts
  • Changes to Health Plan Processes:
    • Credentialing and provider enrollment
      • Ensure NPI subtypes and taxonomies are consistent with health plan processes including contracting
      • Add one-time, re-enrollment process to ensure collection of initial NPIs
      • Add ongoing process for collection of new NPIs and NPI record updates
      • Reconcile NPI data against provider enrollment and credentialing databases
    • Provider contracting and reimbursement
      • Ensure contracts and reimbursement aligned to appropriate NPI-compatible provider logical designation, e.g., taxonomy maps to COS
npi impacts48
NPI Impacts
  • Changes to Health Plan Processes:
    • Health plans will need to capture NPI for enrolled providers – either manually or through automated interface, e.g., EFI. Also impacts provider enrollment workflow.
    • It will be difficult for health plans to link NPIs of their providers and subparts with known provider affiliations because no links between covered organization healthcare providers and their subparts are captured within the NPPES. There is nothing on the NPI application update form that denotes an applicant as a subpart.
npi impacts49
NPI Impacts
  • Compliance Issues
    • Extensive provider education required
      • Obtaining an NPI, Subpart NPI, and taxonomy codes
      • Working with health plan and system vendor for changes
      • Possible new transaction requirements
      • Testing / implementing with multiple payers
      • Migration guidance
    • Paper vs. electronic transactions
      • Covered vs. Noncovered providers
      • Require NPI on both?
      • How to handle non-healthcare providers?
npi impacts50
NPI Impacts
  • Compliance Issues
    • How does implementation strategy align with other health plans and CMS?
    • Transition planning
      • How best to transition providers in an orderly manner by May 23, 2007
    • Contingency planning
npi impacts51
NPI Impacts
  • Implementation strategy also needs to consider:
      • Forthcoming ICD-10
      • Claim Attachments
      • X12 version release requirements
      • Opportunities to reduce costs and complexities in system changes, process changes, and provider communications should be pursued.
npi impacts52
NPI Impacts
  • Impact on Clearinghouses
    • Similar to effects on health plans
    • More complex—many providers and many health plans
    • Must accommodate identifiers of noncovered providers who do not obtain NPIs
npi impacts53
NPI Impacts
  • Provider Impacts
    • May begin applying for NPIs on May 23, 2005
    • Must begin using the NPI in standard transactions by May 23, 2007
    • Must notify NPI Enumerator within 30 days of any changes to application information.
    • Must disclose its NPI when requested
    • Require business associates to use NPIs appropriately
npi impacts54
NPI Impacts
  • Provider Impacts
    • EIN (issued by IRS) may be used, for tax purposes, per the X12 Implementation Guides (Pay-to, Billing Providers)
    • Billing will be simplified and COB payments will be faster
compliance strategies
Compliance Strategies
  • Network Provider Enumeration Issues
    • All strategies will need to take into consideration that:
      • The organizational provider determines how many NPIs it will need, therefore there will be inconsistencies in the number of NPIs organizational providers will have
      • The provider self-declares taxonomy, so there will be inconsistencies between the health plan and provider in respect to contracted and reported scope of services
      • The provider is responsible for self-reporting to trading partners
compliance strategies56
Compliance Strategies
  • Legacy System and Business Process Issues
    • Need to develop strategy on how to use the NPI without embedded logic.
      • Encapsulate
      • Remediate (impacts claim and line level)
      • Retirement of systems
      • Impacts to data warehouse information and reporting
    • Need to determine impacts to provider correspondence, forms, tracking systems, IVR, imaging processes
    • Need to evaluate provider enrollment processes for impacts
npi assessment methodologies
NPI Assessment Methodologies
  • Is embedded provider number intelligence used for:
      • Contracting?
      • Network Development?
      • Payment by location, provider type or specialty?
      • Category of Service?
      • Type of Service?
      • Provider Type
      • Reporting?
  • Does a provider have multiple numbers for reimbursement at the same and/or different locations?
  • Do legacy systems contain hard-coded provider numbers for any reason?
next steps
Next Steps
  • Become fully informed about the NPI and its implementation
  • Establish dedicated NPI working group with authority and funding within the organization
  • Identify processes/systems that are affected by provider identifiers
  • Identify alternatives for compliance
  • Select most appropriate alternative for you
  • Develop implementation plans (internal, external with trading partners and others)
  • Educate staff and providers
how fox can assist your organization
How FOX can Assist Your Organization
  • Conduct Assessment and Gap Analysis of:
    • Impacted business areas and processes
      • Provider network/enrollment
      • Contracting
      • Claims processing and COB/TPL
      • Authorizations/referrals
      • Utilization review/fraud and abuse detection
      • Compliance
how fox can assist your organization60
How FOX can Assist Your Organization
  • Conduct Assessment and Gap Analysis of:
    • Impacted systems
      • Provider enrollment/credentialing
      • Claims processing
      • Prior authorizations
      • Data warehouse/reporting
how fox can assist your organization61
How FOX can Assist Your Organization
  • FOX can perform an assessment of legacy systems using software tools which:
    • Automate up to 100% discovery of Business Logic & Processes (Activities) of any Cobol/CICS/VSAM/DB2 application in XML, plain English and Graphical Flowchart formats.
    • Extract Business Rules and present in plain English within MS Word documents, and also depict in flowchart format which are editable using the tool’s editor
    • Automate up to 100% discovery of Database Model of any Cobol/CICS/VSAM/DB2 application in SQL DDL, XML and AllFusion® ERwin® format
how fox can assist your organization62
How FOX can Assist Your Organization
  • These tools also:
    • Develop system inventory
    • Develop data model/data dictionary
    • Document architecture and technology
    • Document functionality and complexity
    • Develop baseline for remediation activities
how fox can assist your organization64
How FOX can Assist Your Organization
  • Legacy system NPI remediation is supported by automated reengineering/remediation toolsets which:
    • Reverse engineer business rules into code
    • Convert data and process models into schema and code
    • Convert legacy code and data structures into new language code and database tables
    • Convert legacy applications into Web-enabled, n-tier client/server architecture
how fox can assist your organization66
How FOX can Assist Your Organization
  • Other NPI-related services include:
    • Project Management Office (PMO) resources including PMP-certified project managers with HIPAA experience
    • Business Process Reengineering to implement changes needed to accommodate NPI included new policies and procedures
    • Training support including development of training guides and training of staff or trainers
how fox can assist your organization67
How FOX can Assist Your Organization
  • Provider training and outreach support with experience provider services personnel
  • Liaison services with CMS regarding NPI system interface requirements
  • System compliance alternatives analysis
  • Replacement system procurement and IV&V services