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Getting, Sharing and Using the NPI: A National Landscape Presented by Walter G. Suarez, MD, MPH President and CEO Institute for HIPAA/HIT Education and Research. HIPAA/HINT Task Force NPI Conference Trenton, NJ - September 28, 2006. Basic NPI Concepts: Overview.

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hipaa hint task force npi conference trenton nj september 28 2006

Getting, Sharing and Using the NPI:A National Landscape Presented byWalter G. Suarez, MD, MPH President and CEOInstitute for HIPAA/HIT Education and Research

HIPAA/HINT Task Force NPI ConferenceTrenton, NJ - September 28, 2006

basic npi concepts overview
Basic NPI Concepts: Overview
  • NPI is a HIPAA–mandated Standard.
    • 10-digit, intelligence-free
  • HIPAA requires covered entities to submit/accept the new NPI in connection with all applicable HIPAA electronic transactions:
    • 1) Health care claims; 2) Claim payment/remittance advice; 3) Coordination of benefits; 4) Eligibility; 5) Referrals; 6) Claim status; 7) Enrollment; and 8) Premium Payment (NPI not used)
  • HIPAA does not require the use of NPI on paper transactions or other electronic transactions
  • HIPAA does not prohibit the use of the NPI for other legal purposes (e.g., paper transactions, public health, provider credentialing and enrollment)
basic npi concepts types of npi
Basic NPI Concepts:Types of NPI
  • Type 1 NPI
    • Issued to health care providers who are individuals (physicians, nurses, dentists, chiropractors, pharmacists, therapists, etc); Assigned for life, unless circumstances justify deactivation; One NPI per individual
  • Type 2 NPI
    • Issued to provider organizations (hospitals, group practices, nursing homes, home health agencies, pharmacies, laboratories, ambulance companies, Durable Medical Equipment suppliers)
    • An organization can obtain an NPI for the organization and NPIs for one or more components (known as “Subparts”)
    • Considered permanent, unless circumstances justify deactivation; In case of dissolution, the NPI would be deactivated and may be reactivated if legal entity is reactivated
    • The NPI of organization is not linked to that of its subparts or the individual providers that are part of it
basic npi concepts eligible required not eligible providers
Basic NPI Concepts:Eligible, Required, Not Eligible Providers
  • Eligible:
    • All individuals and organizations that meet the HIPAA definition of a “health care provider” (45 CFR § 160.103)
    • Does not have to be a “covered” provider (both covered and non-covered providers eligible to receive an NPI)
  • Required:
    • Meet the HIPAA definition of a “health care provider” AND Meet the definition of a “covered entity” under HIPAA (example: hospital that conducts administrative transactions electronically)
  • Not Eligible:
    • DO NOT meet the definition of a “health care provider”, even though individual/entity delivers services to patients/clients and is reimbursed for them (example: translation/interpreting services, non-emergency transportation, billing providers, clearinghouse)
basic npi concepts who needs an npi
Basic NPI Concepts:Who Needs an NPI
  • All covered health care providers that need to be identified in a health care transactions
    • For example, operating physician, attending physician, rendering provider, referring provider
  • Not all eligible health care providers need an NPI, even if they work for a covered health care organization
    • For example, in a covered hospital, not all nurses need an NPI, because they don’t need to be identified in a health care transaction
what is required from covered health care providers
What is Required from Covered Health Care Providers
  • Assess the need to obtain an NPI
  • Obtain NPIs
  • Use assigned NPI in all HIPAA transactions
  • Disclose NPI, when requested, to other individuals or entities that need it
  • Communicate to NPPES changes of information in required data elements submitted in application within 30 days of the change
  • Require business associates (such as billing agents) to use NPIs in HIPAA transactions
  • Comply with all these requirements for each subpart for which the entity has obtained an NPI
what is required from health plans and clearinghouses
What is Required from Health Plans and Clearinghouses
  • Use the NPI of any health care provider (including subparts) as the ONLY identifier in all the standard transactions where the NPI is required;
  • NOT require health care providers that have been assigned NPIs to obtain additional NPIs for any purpose
    • Health plans can decide which providers (and which subparts) they enroll in their provider networks
basic npi concepts additional important considerations
Basic NPI Concepts:Additional Important Considerations
  • Nothing prohibits the use of the NPI for other purpose outside of HIPAA, so long is a legal use
  • Nothing prohibits health plans from requiring covered providers to use the new NPI prior to the deadline
  • Nothing prohibits health plans from requiring non-covered health care providers in their networks to obtain and use an NPI (so long they are eligible to apply for one)
  • Nothing prohibits health plans or states from requiring the use of the NPI in paper transactions (UB92/UB04, CMS-1500 form, etc.)
npi enumeration vis vis enrollment credentialing licensing and state laws
NPI Enumeration vis-à-vis Enrollment, Credentialing, Licensing and State Laws
  • NPI Enumeration is separate and independent from provider enrollment, credentialing and licensing
  • Health plans may begin to require health care provider to obtain an NPI before they enroll in their network
  • Hospitals may begin to require providers to obtain an NPI before they are credentialed
  • State professional licensing boards may begin to ask in the licensing application for an NPI (will probably not require an NPI as part of the licensing process per-se)
  • State laws may expand NPI requirements to non-covered health care providers and non-covered transactions (paper)
top ten components of npi planning a checklist
Top Ten Components of NPI Planning – A Checklist
  • Understand NPI Rule 
    • Review NPI Rules, FAQs from CMS
  • Identify Internal NPI Needs/Obtain NPIs 
    • Individual providers / Provider Organization/Subparts
    • Understand current Identifier usage
    • Understand payer enumeration expectations
    • Develop strategy to obtain NPIs (application method, decision to apply on behalf of employees)
top ten components of npi planning a checklist1
Top Ten Components of NPI Planning – A Checklist
  • Identify Internal Systems Affected by NPI 
    • Providers: Assess Practice Management System, Administrative/Financial System, Electronic Health Record
    • Payers: Provider Enrollment/Credentialing, Provider Network Management/Contracting, Eligibility System, Authorization/Medical Management, Claims Processing, Finance/Claim Payment System, Provider Services Outreach, Utilization Review, Performance Measurement, Employer/Employee Enrollment System
top ten components of npi planning a checklist2
Top Ten Components of NPI Planning – A Checklist
  • Identify External NPI Needs 
    • Providers: Assess need to obtain NPIs from externalproviders (referring, contracted, consultative, etc) needed to be identified in claim transactions
    • Payers/Clearinghouses: Assess provider networks identifying individual and organizational providersand subparts
  • Communication between Payers and Providers 
    • NPI expectations, NPI readiness, Transition plans
  • Communication with Billing and System Vendors 
    • Assess which vendors need to be contacted
    • Approach vendors with structured set of questions
top ten components of npi planning a checklist3
Top Ten Components of NPI Planning – A Checklist
  • Develop NPPES Dissemination/NPI Information Exchange Strategy (NPI Validation and Verification) 
    • NPPES Dissemination: Request NPI information from NPPES
    • NPI Information Exchange: NPIs communicated between trading partners
  • Develop Internal NPI-to-Legacy ID Crosswalks 
    • Identify sources of information to populate crosswalks
    • Identify interdependencies between NPIs and Legacy IDs(one to many, many to one NPI-to-Legacy relationships)
    • Identify interdependencies between Type 1 and Type 2 NPIs in your organization (Type 1-to-Type 2 NPI relationships; Type 2-to-Type 2 NPI relationships)
top ten components of npi planning a checklist4
Top Ten Components of NPI Planning – A Checklist
  • Establish NPI Transition Plan 
    • Four transition phases, including Dual Use Strategy
    • NPI in primary identifier; Legacy ID in secondary (REF) segments
    • Plan/test/implement new paper claim forms incorporating NPI
  • Complete transition of all business processes/ systems to NPI 
    • NPI to be the ONLY identifier used in transactions after 5/23/07
    • Develop contingency plans for payment continuity, pended/rejected transactions, continuation of dual-use
    • Consider impact of additional year for small health plans…
transition phases for electronic transactions
Transition Phases for Electronic Transactions
  • Phase I – NO NPI
    • Only proprietary (legacy) identifiers will be accepted
    • Transactions that include an NPI will be rejected (even if they include a legacy ID)
  • Phase II – NPI+Legacy
    • Transactions may include an NPI, AS LONG AS the corresponding legacy identifier IS ALSO included in the transaction; transactions with only the NPI will be rejected; transactions with only legacy ID will continue to be accepted (for providers that are late-adopters)
    • Transactions with only legacy ID can continue to be accepted
transition phases for electronic transactions1
Transition Phases for Electronic Transactions
  • Phase III – NPI only or NPI+Legacy
    • Transactions may begin to be sent with the NPI only (no legacy ID)
    • Transactions can continue to be sent with a both the NPI and the legacy ID
    • Transactions with only legacy ID can also continue to be accepted
  • Phase IV – NPI ONLY
    • Transactions MUST ONLY include the NPI as the identifier for providers
    • If transaction includes a legacy identifier (even if an NPI is also include) the transaction will be rejected
    • May 23, 2007 for everyone (except small health plans)
transition phases for paper claims cms 1500 form
Transition Phases for Paper Claims:CMS 1500 Form
  • National Uniform Claims Committee (NUCC) approved a new Health Insurance Claim Form (CMS 1500) to replace current one
    • Will specifically accommodate the reporting of the NPI
    • National Instructions Reference Manual also prepared and released
  • National transition period: October 1, 2006 through March 31, 2007
    • Each health plan to define its own timeframe, within this transition period (e.g., Medicare’s timeframe: January 2-March 31 2007)
    • Health plan should communicate to providers their transition timeframe, instructions for submission
    • After March 31, 2007, old form will be phased-out
  • NUCC website: http://www.nucc.org
transition phases for paper claims ub 04
Transition Phases for Paper Claims:UB-04
  • National Uniform Billing Committee (NUBC) approved a new Institutional Billing Form (UB-04) to replace current UB-92
    • Will accommodate the reporting of the NPI
    • Other changes made to better conform with electronic standard
  • National transition period: March 1, 2007 through May 23, 2007
    • Health plans expected to adopt this timeframe (including Medicare)
    • After May 23, 2007, UB-92 will be phased-out
  • NUBC website: http://www.nubc.org
transition phases for paper claims new dental claim form
Transition Phases for Paper Claims:New Dental Claim Form
  • Dental Content Committee of American Dental Association (ADA) has approved revisions to the paper Dental Claim Form
    • Will accommodate reporting of NPI for “Billing Dentist/Dental Entity” and for “Treating Dentist”
  • Effective date of new form is January 1, 2007; Full transition period has not yet been set (announcement to be made via ADANews this Quarter, along with new version of CDT Manual)
    • New manual contains detailed instructions for revised form
  • ADA website: http://www.ada.org
identifying current provider ids
Identifying Current Provider IDs
  • What Provider IDs do you currently have/use?
identifying current provider ids1
Identifying Current Provider IDs
  • What Provider IDs do you currently have/use?
identifying current provider ids2
Identifying Current Provider IDs
  • What Provider IDs do you currently have/use?
  • Option 1 – Obtain NPI for Subpart
  • Option 2 – Use organization-level NPI and a Taxonomy Code
importance of taxonomy codes in the application for npis
Importance of Taxonomy Codes in the Application for NPIs
  • Taxonomy codes are external code sets created to identify the specialty of the provider (source: www.wpc-edi.com/codes/taxonomy)
  • NPI application requires the submission of at least one Taxonomy Code in the application (primary specialty)
  • Provider can submit more than one Taxonomy Code in their application (all Taxonomy Codes that apply to that provider)
  • Taxonomy codes are used in the NPI application process as an additional identifying factor of the applicant
  • Taxonomy codes are not used to determine eligibility of an applicant to an NPI, or to require additional documentation to support application
enumeration approaches under npi organizational
Enumeration Approaches under NPI – Organizational
  • Three Key Distinguishing Elements in NPI Application Process:
    • Tax ID (TIN, Employer Identification Number, EIN)
    • Entity/Subpart Address
    • Taxonomy Code
the role of taxonomy code in the npi application process
The Role of Taxonomy Code in the NPI Application Process
  • When applying separately for NPIs for two or more components with different taxonomy codes, entity will have different situations:
    • Case 1: Tax ID is same, Address is different, Taxonomy Code is different
      • Two separate locations owned by same entity, one is a pharmacy, one is a DME
      • Each might need an NPI if, for example, they are required to enrolled separately for Medicare purposes
the role of taxonomy code in the npi application process1
The Role of Taxonomy Code in the NPI Application Process
  • Case 2: Tax ID is same, Address is the same, Taxonomy Code is different
    • Example 1: One hospital, two or more different units inside the hospital (e.g., rehab unit, psych unit)
      • Hospital can obtain one NPI for hospital, one for each unit
      • Hospital can obtain one NPI for hospital and use the taxonomy code to identify unit
    • Example 2: An entity that has in the same location a pharmacy and a DME
      • Each type of business service will be able to obtain an NPI
      • Medicare will allow one NPI (DME will be required to have one), which could apply to the other business (using taxonomy code)
nppes dissemination notice where is it what will it include
NPPES Dissemination Notice:Where is it? What will it include?
  • Notice still under internal review at HHS; OMB must approve it; Expected now to be published in late October (as a Final Notice or a Preliminary Notice with 30-day Comment)
  • Expected to include:
    • WHO will be able to obtain NPI data from NPPES
    • WHAT will be the data elements available from NPPES
    • FOR WHAT PURPOSE will the data be available
    • HOW will the data be made available from NPPES
    • WHEN will the data be available
    • WHAT RESTRICTIONS will organizations have
    • CHARGESthat may apply
nppes dissemination vis vis npi information exchange
NPPES Dissemination vis-à-vis NPI Information Exchange
  • NPPES Dissemination
    • Release or disclosure of NPI and NPI-related information by and from NPPES to an individual or organization permitted to received such information
    • Will be determined by CMS NPI Dissemination Notice
    • Important to distinguish 2 processes related to NPI Dissemination:
      • Disclosure of NPI data by and from NPPES to an EFIO
      • Disclosure of NPI data by and from NPPES to a non-EFIO
nppes dissemination vis vis npi information exchange1
NPPES Dissemination vis-à-vis NPI Information Exchange
  • NPI Information Exchange
    • Ability of an individual or organization to disclose or distribute NPIs and NPI-related information to another individual or organizations
    • Examples:
      • Individual providers disclosing or distributing their own NPI or NPI-related information to others
      • Provider organizations disclosing or distributing their own NPI information OR the NPI informaiton of individual providers employed by or part of the organization
nppes dissemination vis vis npi information exchange2
NPPES Dissemination vis-à-vis NPI Information Exchange
  • NPI Information Exchange (cont.)
    • Examples (cont.):
      • EFI Organizations disclosing or distributing NPI information of individuals or organizations they received from NPPES as part of an EFI submission
        • NOTE: The uses and disclosures of NPI information received from NPPES by an EFIO is subject to the EFIO Certification Statement
      • Other organizations disclosing or distributing the NPI information of health care providers outside their organization, whether NPI information was obtained from NPPES, the providers themselves, or other third party
npi validation
NPI Validation
  • Process by which a recipient of an NPI will evaluate the intrinsic validity and reliability of the number received
  • Three Steps:
    • Total number of characters (digits) = 10
    • String starts with a 1-4 (1-2 initially)
    • Perform a Check-Digit routine
npi verification
NPI Verification
  • NPI Verification - External
    • Process to evaluate and confirm that an NPI belongs to the individual, organization, or organization component it is supposed to identify
  • NPI-Legacy ID Mapping Verification
    • Process to confirm that the internal link between an NPI and the legacy ID(s) is verified
why do we need npi information exchange
Why Do We Need NPI Information Exchange?
  • No NPPES Dissemination available yet
  • Currently, the main method to obtain NPI information from providers
  • Needed to begin populating crosswalks, creating internal NPI-to-Legacy ID mapping
  • Allows payers to learn about appropriate subpart identification by providers
  • Identifies relationships between individual providers and provider organizations
types of npi information exchange needs
Types of NPI Information Exchange Needs
  • Provider-to-Provider
    • NPI of referring provider
    • NPI of ordering provider
    • Hospitals billing for physicians with admitting privileges
    • Services provided by providers in SNFs
    • Pharmacy needing prescribing provider’s NPI
  • Provider-to-Payer/Clearinghouse
    • One of the major building blocks for NPI implementation
    • Critical during transition to communicate NPI to payers
    • Needed to appropriately identify and map organization subparts and individual providers with multiple legacy IDs
types of npi information exchange needs1
Types of NPI Information Exchange Needs
  • Provider-to-Payer/Clearinghouse (cont.)
    • In many instances, the first time a provider communicates an NPI to a payer will be during submission of an electronic claim
    • Payers should establish different methods for providers to communicate NPIs, and inform providers of those methods
    • Providers should communicate their NPIs to payers as soon as they receive them utilizing one of these methods
  • Other exchanges
    • Payer/Clearinghouse-to-Payer/Clearinghouse
    • Payer to Employer
    • Exchanges for purposes beyond HIPAA (clinical data exchanges, Public Health, QA, other)
methods for conducting npi information exchanges
Methods for Conducting NPI Information Exchanges
  • Industry recommended standard methods for NPI information exchange published by the Workgroup for Electronic Data Interchange (WEDI)
    • “NPI Information Exchange: Strategies and Approaches” Report available at http://www.wedi.org/snip/index.shtml
    • Follow “SNIP Work Products” link
  • Report covers various exchange methods, including:
    • Paper Form, Phone, IVR
    • Web interfaces
    • Electronic bulk exchanges (Type 1 only; Type 1+Type 2)
      • Via Excel format
      • Via XML format
the c word contingency
The ‘C’ Word = Contingency
  • Little “c” – Internal Contingency Plans
    • Every health plan, provider, clearinghouse should consider their own internal contingency plans
      • Payment Continuity issues
      • Delays in business process changes
      • Delays in system upgrades, testing, implementation
the c word contingency1
The ‘C’ Word = Contingency
  • Big “C” – A National Contingency Plan
    • Most evidence today strongly points to the need for one
      • Lowest than expected NPIs issued
      • Reality that many providers will wait until last minute to apply/obtain NPI (“the last 300K getting NPIs May 22…”
      • Challenge to collect, validate, verify, map, store NPIs, test transactions, complete transition in time
      • Lack of NPPES Dissemination that limits ability to verify and populate NPI databases
      • Fear that transactions will be rejected/pended and providers will ‘drop to paper’
    • Some payers already considering NOT rejecting transactions with NPI+Legacy after compliance date
how did this happen
How Did This Happen?

2005 2006 May 23 2007

HIPAA NPI Plan

  • Providers obtain NPI
  • Provider uses NPI
  • Providers uses NPI as ONLY identifier
  • Payers/CH get ready to receive NPI
  • Payers/CH accept NPI+Legacy IDs
  • Payers/CH accept Txs with ONLY NPI
  • Transition
  • Compliance
how did this happen1
How Did This Happen?

2005 2006 05/23/07

Alternative (Ideal?)

  • Providers obtain NPI
  • Provider uses NPI
  • Providers uses NPI as ONLY identifier
  • Payers/CH get ready to receive NPI
  • Payers/CH accept NPI+Legacy IDs
  • Payers/CH accept Txs with ONLY NPI
  • Transition
  • Compliance
wedi npi hearing recommendation extend dual use period only
WEDI NPI Hearing Recommendation:Extend Dual Use Period ONLY

2006 May 2007 Nov 2007

  • Providers obtain NPI
  • Payers ready to receive
  • Clearinghouses ready
  • Transition
  • Legacy only Txs
  • NPI+Legacy Txs
  • NPI only Txs

Dual Use

Extended

wedi npi hearing recommendation extend dual use period only1
WEDI NPI Hearing Recommendation:Extend Dual Use Period ONLY

Conditions for Extended Dual Use:

  • Provider would still be required to obtain their NPIs by May 23, 2007
  • Providers would still be required to begin using NPIs by May 23, 2007
  • Providers would be permitted to continue to submit legacy IDs ALONG WITH THEIR NPIs until November 1, 2007
  • Providers would be prohibited from sending Legacy ID Only Transactions after May 23, 2007
  • Payers and CHs would still be required to be ready to accept NPIs by May 23, 2007
  • Payers and CHs would be permitted to continue accepting and sending NPI+Legacy ID Transactions until November 1, 2007
  • Legacy IDs would be phased-out November 1, 2007
npi resources
NPI Resources
  • CMS Main NPI Website:
    • http://www.cms.hhs.gov/NationalProvIdentStand/
  • WEDI SNIP NPI White Papers
    • http://www.wedi.org/snip/public/articles/index%7E3.shtml
  • WEDI NPI Outreach Initiative
    • http://www.wedi.org/npioi/
slide50
Thank You!

Walter G. Suarez, MD, MPH

President and CEO

Institute for HIPAA/HIT Education and Research

Alexandria, VA

Phone: (952) 221-3841

Email: walter.suarez@sga.us.com