Once again about NPI

Just posting the excerpt from the net on NPI...

What is NPI?
NPI is the acronym for the National Provider Identifier. It is one provision of the Administrative Simplification portion of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

What is the purpose of NPI?
The NPI is a single identification number that will be assigned by the federal government to health care providers. The NPI will be used to identify physicians, hospitals and other medical professionals in all electronic HIPAA transactions. It is intended to improve the efficiency of the health care system and help to reduce fraud and abuse.

What are HIPAA transactions?
American National Standards Institute (ANSI) is a committee that defines standards for many American industries. Thus far, HIPAA has mandated that nine ANSI transactions must be used for specific electronic health care transactions. These transactions include: 837 Claim, 835 Remittance Advice, 834 Enrollment, 270 Eligibility Inquiry, 271 Eligibility Response, 276 Claim Status Inquiry, 277 Claims Status Response, 278 Referral, and 820 Premium Payment. It is expected that additional transactions will be mandated in the future.

Who must comply with NPI requirements and when?
The NPI must be used in all HIPAA transactions by all covered entities health plans, health care clearinghouses, and health care providers by May 23, 2007 (small health plans have until May 23, 2008).

What will the NPI look like?
The NPI will be a ten digit numeric field that will include one check digit in the tenth position to ensure accuracy. This format will permit 200 billion unique identifiers to be issued without re-using the same values. The NPI will contain NO imbedded intelligence. In other words, you will not be able to determine a provider’s state, region, specialty, or any other information directly from their NPI.

How will the NPI be generated?
The NPI will be generated by a new system called the National Plan and Provider Enumeration System (NPPES) and issued by the U.S. Department of Health and Human Services (HHS) through the Centers for Medicare and Medicaid Services (CMS).

How will a provider be issued a NPI?
Providers are able to apply to CMS for a NPI starting May 23, 2005 and must have a NPI by May 23, 2007, when exchanging electronic transactions (small health plans have until May 23, 2008). Applications are available on the CMS web site at http://www.cms.hhs.gov/NationalProvIdentStand/03_apply.asp. Providers will need to supply adequate information to ensure that they can be identified uniquely by the National Plan and Provider Enumeration System (NPPES). Should any of that information change in the future, CMS must be notified within 30 days.

What if a doctor changes practices, moves, or changes specialties?
Even if a provider moves, changes specialty, or changes practices, the provider will retain the same NPI, but must notify CMS and supply the new information. The NPI is intended to identify the provider throughout his or her career. Organization NPIs also are intended to be permanent except in rare situations such as when a health care provider does not wish to continue an association with a previously used NPI, or when a health care provider's NPI has been used fraudulently by another.

How will Empire be able to associate a provider with his or her NPI?
The NPIs will be maintained in a database in the National Plan and Provider Enumeration System (NPPES). CMS will provide a method of extracting data from the NPPES database. Empire is developing a strategy for acquiring NPI data from the database and will use it to identify providers submitting HIPAA transactions. In most cases, it will probably mean modifying current processes to include the NPIs.

Is a NPI required on paper transactions?
The NPI is required in electronic exchanges of HIPAA transactions. Existing identification numbers can continue to be used in paper and non-HIPAA electronic transactions after the mandatory compliance date. However, the NPI mandate does allow payers to require the use of the NPI on all transactions, including paper, to improve processing efficiency.

Will NPIs only be issued for hospitals and physicians?
No. In addition to hospitals and physicians, NPIs will be issued to institutional and other health care providers such as:
skilled nursing facilities,

home health agencies,

comprehensive outpatient rehabilitation facilities,

assorted clinics and centers,

clinical laboratories,

various licensed/certified health care practitioners, and

suppliers of durable medical equipment.
They also will be issued to any appropriately licensed or certified health care practitioners or organizations, including pharmacies, nursing homes and many types of therapists, technicians, aides, and any other individual or organization that furnishes health care services or supplies. In other words, a NPI applies to any health care individual or organization that bills and is paid for health care services or supplies. If organizations, such as hospitals, are made up of components, or separate physical locations that qualify as separate health care facilities, they also will be issued their own NPI. These types of arrangements are referred to as “sub-parts” in the NPI Final Rule.

What is Empire doing to prepare for NPI?
Empire’s NPI program has established project teams throughout its organization. These teams are dedicated to researching the issues, assessing systems, reviewing business processes, and educating the Empire organization about implementation procedures while helping to ensure an understanding of the expected end-result.

Where can I learn more about NPI?
To learn more about NPI from CMS, visit http://www.cms.hhs.gov/NationalProvIdentStand/ in the coming months or access the CMS HIPAA Hotline at (866) 282-0659. In addition, we encourage you to log on to www.empireblue.com to find the most up-to-date information regarding HIPAA and Empire’s compliance status.

Has CMS issued any additional information on the application process for the NPI?
In early May of 2005, CMS issued a “Dear Provider Letter” that can be accessed at http://www.cms.hhs.gov/NationalProvIdentStand/. This letter briefly outlines the application process and the various ways the provider may obtain an NPI.

When will the providers be able to begin applying for an NPI?
According to CMS, providers may begin applying as early as May 23, 2005 as stated in the regulation. Providers may apply electronically through CMS’ web-based application system on May 23, 2005 located at the following URL: https://nppes.cms.hhs.gov/NPPES. For those providers who prefer to use the paper format, they will be able to start using the paper application process on July 1st, 2005. A copy of the application and the enumerator’s address will be available at the same web site at https://nppes.cms.hhs.gov/NPPES. Also, the provider may choose to submit their application through an organization, professional association, or employer. This process is yet to be finalized and is expected to be available sometime during the fall of 2005.


What if a provider has numerous health plan IDs, will each health plan require an additional NPI?
The NPI is the single provider identifier that will replace each of the different health plans’ numerous identifiers. This regulation requires each of the health plans to use the NPI as the sole identifier for each provider. The provider needs only to apply once for an NPI.

Where can I learn more about the NPI application process?
Up-to-date information regarding the NPI is available on the NPPES web site at https://nppes.cms.hhs.gov/NPPES. You may also contact the enumerator by telephone at 1-800-465-3203 or TTY 1-800-692-2326. In addition, an instructional web tool, called the NPI Viewlet, is now available for viewing at http://www.cms.hhs.gov/apps/npi/npiviewlet.asp.

http://www.empireblue.com/wps/portal/ehpprovider?content_path=provider/noapplication/f4/s4/t3/pw_ad079529.htm&label=NPI%20FAQs

What is level 1 to level 7 HIPAA is all about?

The levels of HIPAA test or validation are different type of validations and there is a myth that HIPAA level is directly proportional to the severity of the HIPAA test, but this is not true more than calling it as levels of HIPAA it could be called as different types of HIPAA and these levels are independent to each other.

But type 1 and type 2 are pre requisites for other types of testing

Let us see below what are the different types of HIPAA validation.



Type 1: EDI syntax integrity testing – Testing of the EDI file for valid segments,
segment order, element attributes, testing for numeric values in numeric data elements,
validation of X12 or NCPDP syntax, and compliance with X12 and NCPDP rules. This
will validate the basic syntactical integrity of the EDI submission.

Type 2: HIPAA syntactical requirement testing – Testing for HIPAA Implementation
Guide-specific syntax requirements, such as limits on repeat counts, used and not
used qualifiers, codes, elements and segments. Also included in this type is testing for
HIPAA required or intra-segment situational data elements, testing for non-medical
code sets as laid out in the Implementation Guide, and values and codes noted in the
Implementation Guide via an X12 code list or table.


Type 3: Balancing – Testing the transaction for balanced field totals, financial
balancing of claims or remittance advice, and balancing of summary fields, if
appropriate. An example of this includes items such as all claim line item amounts
equal the total claim amount. (See pages 19-22, Healthcare Claim Payment/Advice –
835 Implementation Guide for balancing requirements of the 835 transaction.)


Type 4: Situation testing – The testing of specific inter-segment situations described
in the HIPAA Implementation Guides, such that: If A occurs then B must be populated.
This is considered to include the validation of situational fields given values or situations
present elsewhere in the file. Example: if the claim is for an accident, the accident date
must be present.


Type 5: External code set testing – Testing for valid Implementation Guide-specific
code set values and other code sets adopted as HIPAA standards. This level of testing
will not only validate the code sets but also make sure the usage is appropriate for any
particular transaction and appropriate with the coding guidelines that apply to the
specific code set. Validates external code sets and tables such as CPT, ICD9, CDT,
NDC, status codes, adjustment reason codes, and their appropriate use for the
transaction.


Type 6: Product types or line of services: This testing type is required to ensure that
the segments/records of data that differ based on certain healthcare services are
properly created and processed into claims data formats. These specific requirements
are described in the Implementation Guides for the different product types or lines of
service. For example, ambulance, chiropractic, podiatry, home health, parenteral and
enteral nutrition, durable medical equipment, psychiatry, and other specialized services
have specific requirements in the Implementation Guide that must be tested before
putting the transaction in production. This type of testing only applies to a trading
partner candidate that conducts transactions for the specific line of business or product
type.


Type 7: Implementation Guide-Specific Trading Partners: The Implementation
Guides contain some HIPAA requirements that are specific to Medicare, Medicaid, and
Indian Health. Compliance or testing with these payer specific requirements is not
required from all trading partners. If the trading partner candidate intends to exchange
transactions with one of these Implementation Guide special payers, this type of testing
is required. When a certification service certifies a trading partner for compliance, the
certification service must indicate whether these payer specific requirements were met
during the certification process. Other payers and trading partners may have their own
specific business requirements; but, unless they are listed in the HIPAA Implementation
Guides, they are not HIPAA requirements. These non-HIPAA trading partner specific
requirements must be tested as part of the business-to-business testing. For further
information on business-to-business testing and for further information on testing
trading partner rules that are not contained in the Implementation Guides.

Coordination of benefits or COB

What is coordination of benefits or COB?

The order in which two or more insurance companies will pay benefits for the same claim. This will avoid duplicate payment of the claim by more than one insurance.

How to handle coordination of benefits in CH ?

Handling COB in the clearinghouse where the data flow model is from Provider-Payer A-Provider (CH behalf of provider) -Payer B is clearly explained to the segment level, pls follow the excerpt from 837 IG

Coordination of Benefits Data Models - Detail
The 837 transaction handles two models of coordinating benefits. Both models
are discussed in Section 1.4.2.2, Coordination of Benefits Data Models. See Section
4, EDI Transmission Examples for Different Business Uses, for examples of
these models. The implementation guide contains notes on each COB-related
data element specifying when it is used. See the Federal Register for HIPAA
rules involving COB.
Model 1 - Provider-to-Payer-to-Provider
Step 1. In model 1, the provider originates the transaction and sends the claim information
to Payer A, the primary payer. See figure 1, Provider-to-Payer-to-
Provider COB Model. The Subscriber loop (Loop ID-2000B) contains information
about the person who holds the policy with Payer A. Loop ID-2320 contains information
about Payer B and the subscriber who holds the policy with Payer B. In
this model, the primary payer adjudicates the claim and sends an electronic remittance
advice (RA) transaction (835) back to the provider. The 835 contains the
claim adjustment reason codes that applies to that specific claim. The claim adjustment
reason codes detail what was adjusted and why.
Step 2. Upon receipt of the 835, the provider sends a second health care claim
transaction (837) to Payer B, the secondary payer. The Subscriber loop (Loop
ID-2000B) now contains information about the subscriber who holds the policy


from Payer B. The information about the subscriber for Payer A is now placed in
Loop ID-2320. Any total amounts paid at the claim level go in the AMT segment
in Loop ID-2300. Any claim level adjustments codes are retrieved from the 835
from Payer A and put in the CAS (Claims Adjustment) segment in Loop ID-2300.
Claim level amounts are placed in the AMT at the Loop ID 2320 level. Line Level
adjustment reason codes are retrieved similarly from the 835 and go in the CAS
segment in the 2430 loop. Payer B adjudicates the claim and sends the provider
an electronic remittance advice.
Step 3. If there are additional payers (not shown in figure 1, Provider-to-
Payer-to-Provider COB Model), step 2 is repeated with the Subscriber loop
(Loop ID-2000B) having information about the subscriber who holds the policy
from Payer C, the tertiary payer. COB information specific to Payer B is included
by running the Loop ID-2320 again and specifying the payer as secondary, and, if
necessary, by running Loop ID-2430 again for any line level adjudications.

And the next method given in the IG can be ignored as of now as it is about crossover of the payer.

Lets see which are the segments to be considered in 835 for COB, following is the excerpt from 835 IG

CROSSOVER CARRIER NAME
Loop: 2100 - CLAIM PAYMENT INFORMATION
Usage: SITUATIONAL
Repeat: 1
1724 Notes: 1. Use this NM1 segment to provide information about the crossover
carrier. Provide any reference numbers in NM109. The crossover
carrier is defined as any payer to which the claim is transferred for
further payment after being finalized by the current payer.
1636 Example: NM1*TT*2*ACME INSURANCE*****XV*123456789~



in the above example ACME ins is the next payer to which the claim has to be sent according to COB order.

And page 114-118 of 835 IG will give you all necessary description and detail about COB.

any more clarification pls revert.

Reassociation of Dollar (payment) with data (Remittance)

The association of Dollar (Payment) with Data (Remittance) is called as reassociation and it is the Buzz word in the Medical Banking industry..Ok, let me give some idea about 'Medical Banking'

It is the convergence of the traditional Treasury Management activity with that of the Healthcare clearinghouse,mainly the Treasury mgmt activities Viz Lockbox processing,Electronic payment processing or can be simply pointed to Collections.

This is very clearly mentioned in the 835 implementation guide as follows

The 835 is capable of sending health care claim payment remittance data with or without the dollars represented by the data. It is important to facilitate reassociation when the remittance data is sent separately from the monetary amounts. Reassociation requires that both remittance and monetary data contain information that allows a system to match the items received. The provider should have a method to ensure that payment and remittance advice are reconciled in the patient accounting/accounts receivable system.
Two key pieces of information facilitate reassociation — the trace number in the Reassociation Key Segment, TRN02, and the Company ID Number, TRN03. The trace number in conjunction with the company ID number provides a unique number that identifies the transaction.
The two ways of sending payment for health care remittance data are check or Automated Clearing House (ACH). In the case of a payment received by check, the check number is the trace number in TRN02, and the company ID number is in TRN03. When the check is processed, the check number and account information is captured. A table could be required to cross reference the account information from the check to the company ID number received in TRN03. This information should be gathered when the transaction is implemented with the payer. When sending a separate ACH payment, the CCD+ ACH format is used. Using this method, the Reassociation Key Segment in its entirety is contained in the ACH Addenda Record.

Provider Identification

Lot of confusions and Ideas float in identifying a Healthcare provider.. Let it be from a remittance or any other sources, as standardization of Provider Id number is still on papers in US. So, directly coming to the point.. Lets first under stand what are the different types of provider Identification numbers used in the Healthcare Industry in this post.. and in the next post lets discuss how we can identify a Provider by reading or cracking a X12 835 / Remittance..
Lets see the different types of Identification number for providers in the Industry

1. Provider Tax Id or Federal Taxpayer’s Identification Number

2. HCFA NPI or Health Care Financing Administration National Provider Identifier now CMS NPI

3. State License Number

4. Blue Cross Provider Number

5. Blue Shield Provider Number

6. Medicare Provider Number

7. Medicaid Provider Number

8. Dentist License Number

9. Anesthesia License Number

10. Provider UPIN Number

11. CHAMPUS Identification Number

12. National Association of Boards of Pharmacy Number

13. Provider Commercial Number

14. Provider Plan Network Identification Number

15. Payee Identification

17. Unique Physician Identification Number (UPIN).

18. Facility ID Number

19. SSN

Out of these 19 different types of provider identification numbers Blue Cross Provider Number, Blue Shield Provider Number, Medicare Provider Number, Dentist License Number, Anesthesia License Number, CHAMPUS Identification Number, Provider Commercial Number, Provider Plan Network Identification Number are not commonly used..

Lets discuss about the other types of Numbers one by one.

Provider Tax Id or Federal Taxpayer’s Identification Number

Federal Tax Identification Number, is a unique nine-digit number assigned by the Internal Revenue Service (IRS) to business entities operating in the United States for the purposes of identification

HCFA NPI or Health Care Financing Administration National Provider Identifier now CMS NPI

A National Provider Identifier or NPI is a unique 10-digit identification number issued to health care providers in the United States by the Centers for Medicare and Medicaid Services (CMS).
Provider UPIN Number A unique physician identification number, or UPIN, is used by Medicare to identify doctors across the United States. UPINs are six-place alpha numeric identifiers assigned to all physicians. And this will be replaced by NPI in future, previously scheduled to discontinue on second quarter of 2007.

State License Number

An Identification number given in the state of practice it varies state to state.

National Association of Boards of Pharmacy Number

This is a professional association representing the state boards of pharmacy and it provides a unique number to the pharmacists for identification these numbers are used for billing
Facility ID Number These numbers are assigned by the plan after enrolling a particular facility of a provider in its list ,this helps in locating the right facility of a Provider

Social Security number (SSN)

In the United States, a Social Security number (SSN) is a 9-digit number issued to citizens, permanent residents, and temporary (working) residents under section 205(c)(2) of the Social Security Act, codified as 42 U.S.C. § 405(c)(2). The number is issued to an individual by the Social Security Administration, an agency of the U.S. Federal Government. Its primary purpose is to track individuals for taxation purposes this number is also used to identify a provider.

In this post we saw the types of provider identification numbers ,in the next post we will see how to do a Provider Identification and validation with these numbers available in the remittance /835