NPI Overview

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandated that the Secretary of Health and Human Service s (HHS) adopt a standard unique health identifier for health care providers. On January 23, 2004 , the Secretary published a Final Rule that adopted the National Provider Identifier (NPI) as this identifier. All HIPAA covered healthcare providers, whether they are individuals or organizations, must obtain an NPI for use to identify themselves in HIPAA standard transactions. Once enumerated, a provider's NPI will not change. The NPI remains with the provider regardless of job or location changes. HIPAA covered entities such as provider completing electronic transactions, healthcare clearinghouses, and large health plans, must use only the NPI to identify covered healthcare providers in standard transactions by May 23, 2007 . Small health plans must use the NPI as their identifier by May 23, 2008 .

ENS has a plan of action and is dedicated to assisting our clients with their NPI implementation. The ENS NPI Solution provides both X12 and non-X12 clients the ability to submit their NPI on Claims and Real-Time transactions.

Click here to read more about the ENS NPI Solution for Claims.

Click here to read more about the ENS NPI Solution for Real-Time Transactions.

In addition to the NPI initiative, the current version of Form CMS-1500 (12-90) is being revised to accommodate the reporting of the NPI. The revised version will be Form CMS-1500 (08-05). The revised CMS-1500 Form will be effective October 1, 2006 , but will not be mandated for use until February 1, 2007 . There will be a dual acceptability period for both the existing and the revised forms.

ENS has developed a strategy to assist our clients that submit electronic claims via software/hardware systems that depend on the existing 1500 Claim Form in its current image. ENS will support submission of the revised CMS-1500 Form as well as the existing 1500 Claim Form. Regardless of form type, ENS will support submission of the NPI.

Click here to read more about the ENS Revised CMS-1500 Strategy.

ENS NPI Solution for Claims

X12 Claim Submissions – Professional and Institutional

ENS has created check digit logic using the Luhn Check Digit and will edit every NPI received for validity. If the NPI that is received is not a valid NPI, the claim will reject.

For X12 Claim submissions, ENS will support the submission of the NPI and Legacy Identifiers. Based on Payer readiness, ENS will forward the NPI and/or Legacy Identifiers on to the Payer. We do not anticipate requiring provider testing for NPI submission, but testing may be required by the Payer.

Click here for further information regarding Payer Readiness for NPI submission to Payer.

It is critical that submitters utilize the following guidelines when submitting the NPI and Legacy Identifiers:

• The NPI must appear in the NM109 and the corresponding ‘XX' qualifier in the NM108 element in the associated Loop .
• The provider Legacy ID and the provider Tax ID/SSN must be contained in the REF segments in the applicable Loop .
• After May 23, 2007 , although the legacy identifiers will not be allowed to be submitted, claims will still require the Tax ID/SSN in the REF segments in the applicable Loop .

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ASC X12N 837 v4010A1 Professional
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Batch Level

Claim Level

Line Level

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ASC X12N 837 v4010A1 Institutional
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NSF Claim Submissions – Professional

All clients submitting the NSF format will need to upgrade to version 3.01. The NSF format provides a location for a Billing Provider NPI, a Rendering Provider NPI and a Referring Provider NPI. Please note that for some Governmental Payers, the location allocated for NPI submission is currently utilized for governmental legacy identifiers. NSF submitters should consider not submitting the NPI until May 23, 2007 . ENS has created check digit logic using the Luhn Check Digit and will edit every NPI received for validity. If the NPI that is received is not a valid NPI, the claim will reject. The NSF format also provides allocation for Legacy Identifiers.

NSF Claim Submissions – Institutional

All clients submitting the NSF format will need to upgrade to version 6.0. The NSF format provides a location for a Billing Provider NPI as well as a Legacy Identifier. Please note that for some Governmental Payers, the location allocated for NPI submission is currently utilized for governmental legacy identifiers. NSF submitters should consider not submitting the NPI until May 23, 2007 . ENS has created check digit logic using the Luhn Check Digit and will edit every NPI received for validity. If the NPI that is received is not a valid NPI, the claim will reject.

WINHECET™ Submitters

ENS will be launching a campaign to transition existing WINHECET™ clients to the ENS Health-e Claim™ product. In order to facilitate this transition, ENS will provide the following services:

• ENS will work with each client utilizing a claim format conversion tool to convert the existing claim format map from WINHECET™ to a Health-e Claim™ map. Special care will be taken to insure that all coordinates have been appropriately mapped.
• ENS will work with each client to convert the provider data currently loaded within the WINHECET™ structure to Health-e Claim™.
• An on-line tutorial will be made available to assist with training clients on “How to Use Health-e Claim™”.

In addition, clients will have the ability to print claims in the provider's office from Health-e Claim™ using the existing CMS-1500 Form or the revised CMS-1500 Form. ENS will be launching this campaign January 1, 2007 .

ENS has done some research and has information regarding internet connectivity options for clients who currently do not have internet connectivity in their office. Please contact the ENS Sales Team and request this information.

Revised CMS-1500 Strategy

Health-e Claim™ Submissions - Professional

The ENS Clearinghouse service provides translation from standard formats to non-standard formats and non-standard formats to standard formats. Clients will have the ability to define what format of the CMS-1500 Form they will be sending as ENS will be able to accommodate both the existing CMS-1500 print image submitters as well as the revised CMS-1500 print image. In addition, further enhancements to the existing Health-e Claim™ product will provide the ability to print claims in the provider's office from a print image of the existing CMS-1500 Form and the revised CMS-1500 Form. ENS has created check digit logic using the Luhn Check Digit and will edit every NPI received for validity.

Existing CMS-1500 Print Image Submitters

To assist clients that may not be able to submit NPI in their claims, we are enhancing the existing Health-e Claim™ product to support the entry and storage within the Manage Provider Information of one NPI for the Billing Provider, one NPI for Rendering Provider and one NPI for the Facility. Clients will have the ability to enter this information via web-entry. If the NPI that is entered is not a valid NPI, the screen will require the correct NPI to be entered prior to storing this information. ENS will facilitate the submission of these NPI entries on claims received via Print Image in the existing CMS-1500 format.

Revised CMS-1500 Print Image Submitters

Although the Manage Provider Information will store the NPI, if a revised CMS-1500 Print Image is received with a different NPI, the NPI on the Print Image will override the NPI stored within Manage Provider Information. This will assist those submitters with sub-parts within their organization. If the NPI that is received is not a valid NPI, the screen validation will require the correct NPI to be entered prior to submission of the claim. The client will have the ability to fix the error within View Claim Errors. In the event the Print Image is received and the NPI is not populated on the Print Image and the NPI is stored within Manage Provider Information, ENS will facilitate the submission of the NPI entries based on the NPI stored within Manage Provider Information.

Direct Data Entry (DDE)

ENS will be enhancing the Direct Data Entry (DDE) screen to the revised CMS-1500 Form view. Clients will have the ability to enter NPI and Legacy Identifiers via web-entry. The system will automatically pull the NPI from the information stored in the Manage Provider Information, but clients will have the ability override the NPI on the screen in the event a more complex enumeration has been instituted due to sub-parts within their organization. If the NPI that is entered is not a valid NPI, the screen validation will require the correct NPI to be entered prior to submission of the claim.

Payer Readiness for Claims

A transition period has been published by the Centers for Medicare and Medicaid Service s (CMS). Claims submitted from October 2, 2006 , through May 22, 2007 , may contain both the NPI and Legacy Identifiers also referred to as the CMS Dual Submission Strategy. ENS will implement the CMS Dual Submission Strategy within the following timelines to Governmental Payers:

• Medicare – September 1 through May 22, 2007
• Medicaid – November 1 through May 22, 2007
• Blue Shield – January 1, 2006 through May 22, 2007

*Please note that CMS has indicated that the NPI may be submitted, but must be submitted with an existing legacy Medicare number. If a claim is submitted with only an NPI, the provider may not be paid for the claim. During these timeframes, although ENS will implement the CMS Dual Submission Strategy, those claims with legacy identifiers only will continue to be processed through to the Payer.

For Commercial Payers between December 1, 2006 , through May 22, 2007 , ENS will allow for the submission of both the NPI and Legacy Identifiers; however, the NPI will only be forwarded to those Commercial Payers who have indicated their readiness to receive the NPI. It is not necessary to wait until a payer has indicated that they are ready to accept NPI data. ENS will suppress the NPI on submissions to Commercial Payers who have not indicated that they are ready to receive the NPI. Notations regarding the readiness of the Commercial Payers will be made on the ENS Claims Payer List. ENS will accept claims that do not contain an NPI unless otherwise instructed by the Payer.

ENS NPI Solution for Real-Time Transactions

ENS has created check digit logic using the Luhn Check Digit and will edit every NPI received for validity. If the NPI that is received is not a valid NPI, the Real-Time Transaction will reject.

X12 270/271 Eligibility

For X12 270/271 transactions, ENS will support the submission and receipt of the NPI and Legacy Identifiers. ENS will forward the NPI and/or Legacy Identifiers on to the Payer as received based on Payer readiness. Notations regarding the readiness of the Payers will be made on the ENS Eligibility Payer List and the ENS Real-Time Eligibility Companion Guide. ENS will process 270 requests that do not contain an NPI unless otherwise instructed by the Payer.

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ASC X12.281/282 270/271 v4010A1 Healthcare Eligibility/Benefit Inquiry and Response
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Non-X12 Eligibility Transactions
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Within the ENS suite of services in Health-e Network™, ENS provides clients the ability to enter Eligibility criteria as mandated within the HIPAA transaction into a User Interface and receive Eligibility information. As of 1/1/07 , ENS will be available to be contacted by Payers to add an NPI field to the User Interface to allow the users to enter the NPI on the screen to be sent to the Payer. We will keep the existing Provider Identifier on the screen to be submitted as a Secondary Identifier.

X12 276/277 Claim Status

ENS will support the submission and receipt of the NPI or Legacy Identifiers for the X12 276/277 X12 transactions. The 276/277 Implementation Guide allows for one identifier. ENS will forward the NPI or Legacy Identifiers on to the Payer as received. Notations regarding the readiness of the Payers will be made on the ENS Claim Status Payer List and the ENS Real-Time Claim Status Companion Guide.

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ASC X12.316/317 276/277 v4010A1 Healthcare Claim Status Request and Response
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Non-X12 Claim Status Transactions
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ENS also provides clients the ability to trade Claim Status transactions with Payers via a User Interface. As of 1/1/07 , ENS will be available to be contacted by Payers to add an NPI field to the User Interface to allow the users to enter the NPI on the screen to be sent to the Payer. We will keep the existing Provider Identifier on the screen. The NPI and existing Provider Identifier will be mutually exclusive allowing one identifier or the other.

X12 and Non-X12 278 Referrals/Authorizations

For the ENS 278 Payer connections, ENS will work with each Payer individually on their NPI readiness with the 278 transaction. Notations regarding the readiness of the Payers will be made on the ENS Referrals/Authorization Payer List and an NPI field will be added to the User Interface for our non-X12 clients.

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ASC X12.336 278 v4010A1 Healthcare Service s Review Request for Review and Response
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ENS NPI Solution for 835 Transactions

ENS has defined two areas necessitating action of which we have structured our primary strategy that will assist in transitioning to the NPI for 835 transactions to include; Enrollment and Communication.

Enrollment –

• ENS’ strategic improvement to the current ERA Online Enrollment process will be to expand the existing provider database by adding a feature to the ERA Online Enrollment process to enroll new and re-enroll existing providers through this method with their NPIs.  Providers will be able to enroll multiple NPIs for each of their subparts, if necessary.  ENS will then be able to accurately cross-reference the existing provider information for conversion purposes.

• ERA Re-Enrollment for existing ENS clients to the payer will be handled on a per payer request.  Notifications will be posted accordingly.

Communication - 

• Users will be responsible for informing ENS when a new NPI has been issued by completing the Enrollment of the NPI through the ERA Online Enrollment process.  Through the ERA online Enrollment process there will be a feature that can be selected to only enroll NPIs for the 835 electronic transactions.

• The ENS ERA website for viewing and downloading ERAs will be enhanced with an additional field that will display the provider NPI along with the existing field which identifies the TIN.

• ENS will continue to communicate any and all NPI changes that may surface as we move forward to streamline the NPI process.

** Please note:

The submitter’s claim identifier number (837 - CLM01) is currently required to be returned in the CLP01 element in the 835.  This is not affected by the NPI regulations or related changes.  The 835 ERA Implementation Guide states the following regarding the CLP01:  “This data element is the primary key for posting the remittance information into the provider’s database.” 

835 Health Care Payment, 4010A1 Implementation Guide

How to Apply

Healthcare providers can apply for NPI's in one of three ways:

• By utilizing the web-based process. https://nppes.cms.hhs.gov/NPPES/Welcome.do
• By filling out a paper NPI Application/Update form and mailing it to the Enumerator. This option has been available since July 1, 2005 . The form is available upon request through the NPI Enumerator. The contact information is:
• Phone: 1-800-465-3203 or TTY 1-800-692-2326
• E-mail: customerservice@npienumerator.com
• Mailing Address: NPI Enumerator
  P.O. Box 6059
  Fargo , ND 58108-6059

NPI in NSF for Group practices and Solo Proctice:

ENS has developed a strategy to assist our clients that submit electronic claims via software/hardware systems utilizing the National Standard Format.  ENS will support submission of the version 3.01 and will support submission of the NPI.  The NSF format provides a location for a Billing Provider NPI, a Rendering Provider NPI and a Referring Provider NPI.  Please note that for some Governmental Payers, the location allocated for NPI submission is currently utilized for governmental legacy identifiers.  ENS has created check digit logic using the Luhn Check Digit and will edit every NPI received for validity.  The NSF format also provides allocation for Legacy Identifiers.  Refer to the list below on locations for Legacy numbers and NPI numbers.

NPI in NSF for Group practices:

BA0.09 pos 48 is for the billing\group NPI for any payer. If practice was assigned a group NPI it will go here.

• If they are billing Medicare claims then the Medicare legacy group number needs to show under the CA0.28 pos 213.
• If they are billing any other payer then the legacy group number needs to show in the BA0.12 pos 75(Medicaid), BA0.13 pos 90 (Champus\Tricare), BA0.14 pos 105 (Blue Shield) or BA0.15 pos 120 (Commercial) depending on which payer it is.
• BA0.06 pos 32 is for the billing\group Tax ID for any payer. The Tax ID number is required for any payer to be present in this record.

FA0.23 pos 93 is for the rendering\individual NPI for any payer.

• The legacy individual number for any payer needs to show under the FB1.17 pos 202.
• FA0.58 pos 285 is for the rendering\performing provider Tax ID (or SSN). The Tax ID (or SSN) number is not required per standard specs in this location for ANSI translation purposes. Based on payer specifics you might be required to supply the Tax ID (or SSN) in this location. If the FA0.58 pos 285 is present then the FA0.57 pos 284 for the rendering\performing provider Tax ID Type code is also required. The code of T = TIN or S = SSN will identify the ID as a TIN or SSN.

NPI in NSF for Solo practices:

BA0.09 pos 48 is for the billing\group NPI for any payer. If practice does not have a group NPI then the solo provider NPI will go here.

• If they are billing Medicare claims then the Medicare legacy individual number needs to show under the CA0.28 pos 213.
• If they are billing any other payer then the legacy individual number needs to show in the BA0.12 pos 75(Medicaid), BA0.13 pos 90 (Champus\Tricare), BA0.14 pos 105 (Blue Shield) or BA0.15 pos 120 (Commercial) depending on which payer it is.
• BA0.06 pos 32 is for the provider Tax ID for any payer. The Tax ID number is required for any payer to be present in this record.

FA0.23 pos 93 is for the rendering\individual NPI for any payer.

• The legacy individual number for any payer needs to show under the FB1.17 pos 202.
• FA0.58 pos 285 is for the rendering\performing provider Tax ID. The Tax ID number is not required per standard specs in this location for ANSI translation purposes. Based on payer specifics you might be required to supply the Tax ID in this location. If the FA0.58 pos 285 is present then the FA0.57 pos 284 for the rendering\performing provider Tax ID Type code is also required. The code of T = TIN or S = SSN will identify the ID as a TIN or SSN.

Additional links regarding NPI information:

• The Who, What, When, Why and How of NPI. Information for Health Care Providers.
  http://www.cms.hhs.gov/MedicareProviderSupEnroll/downloads/
  EnrollmentSheet_WWWWH.pdf
• NPI Education Resources provided by CMS
  http://www.cms.hhs.gov/nationalprovidentstand/04_education.asp
• National Plan and Provider Enumeration System (NPPS)
  https://nppes.cms.hhs.gov/NPPES/Welcome.do
• Necessary Steps to Be Successful When Converting from WinHecet to Health-e Claims