Avoid claim denials. Attest your NPI today! See page 3 Texas Medicaid Bulletin no. 217 May 2008 This is a combined, special bulletin for all Medicaid, Children with Special Health Care Needs (CSHCN) Services Program, and Family Planning providers. This bulletin is intended to notify providers of program changes related to the NPI full implementation beginning May 24, 2008. About this Bulletin On April 2, 2007, the Centers for Medicare & Medicaid Services (CMS) announced that it would allow contingency plans for entities that would not meet the May 23, 2007, deadline for NPI full compliance but have demonstrated a good faith effort to meet the compliance date. As a result, the Health and Human Services Commission (HHSC) extended the NPI contingency period until May 23, 2008. INSIDE All Providers About this Bulletin 1 NPI Implementation Checklist 2 Goodbye, TDHconnect 2 Complete Provider Attestation Today 3 NPI Dissemination 3 Claims Submission Reminders 4 Effective May 24, 2008, NPI full compliance will be implemented, and the contingency period will end. Reassignment of Primary Care Provider Panels 4 Medicare Crossover Claims 4 Third-Party Billers and Software Vendors 5 Authorization Requests 5 Using Benefit Codes 5 On May 24, 2008, CMS will lift its enforcementleniency policy and will begin penalizing non-compliant entities. HHSC and the Texas Medicaid & Healthcare Partnership (TMHP) have completed all processes required to implement NPI full compliance. The intent of this special bulletin is to provide reminders about TMHP s NPI implementation to ensure a smooth transition for providers and clients. Automated Inquiry System (AIS) 5 Taxonomy Codes for Group Billers 6 ER&S and Remittance and Status (R&S) Reports 6 Electronic Funds Transfer (EFT) and Paper Checks 6 NPI Information and Help 6 Copyright Acknowledgments Use of the American Medical Association s (AMA) copyrighted Current Procedural Terminology (CPT) is allowed in this publication with the following disclosure: Current Procedural Terminology (CPT) is copyright 2007 American Medical Association. All rights reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable Federal Acquisition Regula tion System/Department of Defense Regulation System (FARS/DFARS) restrictions apply to gov ernment use. The American Dental Association requires the following copyright notice in all publications containing Current Dental Terminology (CDT) codes: CDT4/2007 [including procedure codes, definitions (descriptions), and other data] is copyrighted by the American Dental Association. (c) 2006 American Dental Association. All Rights Reserved. Applicable Federal Acquisition Regulation System/Department of Defense Acquisition Regulation System (FARS/DFARS) restrictions apply.
NPI Implementation Checklist Providers that have not completed the following steps will experience claim rejections, claim denials, and payment delays. Yes No Use the spaces at right to check off the items below that have been completed. Attest NPIs for all active Texas Provider Identifiers (TPIs). Disenroll any TPIs that are no longer used for billing. Verify that any vendors and third-party billers currently used have completed testing with TMHP. Verify that any vendors and third-party billers currently used can accept different taxonomy codes, benefit codes, and physical addresses. Discontinue using TDHconnect and complete setup for TexMedConnect. Obtain NPIs from other providers to ensure referrals are correctly billed. Obtain NPIs from facilities to ensure that the facility location block is correctly filled. Goodbye, TDHconnect Effective May 24, 2008, TDHconnect will be discontinued. Transactions submitted using TDHconnect do not support the NPI. Providers will be required to complete electronic transactions through either TexMedConnect (TMHP s online replacement for TDHconnect) or third-party billers that submit files on the provider s behalf. All transactions submitted through TDHconnect will be rejected. Medicare Claims through TDHconnect Medicare claims currently submitted to Medicare through TDHconnect will no longer be accepted. Providers must now submit these claims directly to Medicare. TexMedConnect does not support claim submission directly to Medicare. TexMedConnect Effective May 24, 2008, providers will be required to complete electronic transactions through either TexMedConnect or third-party billers that submit NPI-compliant files on the provider s behalf. The following electronic transactions are available through TexMedConnect: Claim submission and appeal Claim status inquiry Eligibility verification Electronic Remittance and Status (ER&S) reports TMHP conducts free workshops about using TexMedConnect. All providers are encouraged to attend these free workshops. Workshop training materials for TexMedConnect are available on the TMHP website at www.tmhp.com. Texas Medicaid Bulletin, No. 217 2 National Provider Identifier Special Bulletin
Complete Provider Attestation Today Providers that have not attested their NPI and related data will experience rejection and denial of electronic and paper claims, forms, and other transactions. Providers must attest their NPIs and related data to TMHP by May 23, 2008. Related data includes a taxonomy code and a physical address with a ZIP+4 Code. During attestation some providers may also be assigned a benefit code to identify specific state programs as part of their NPI-related data. NPIs can be attested on the TMHP website at www.tmhp.com. Providers that have not attested their NPI and related data or that do not use their attested NPI and related data will experience rejection or denial of paper and electronic claims, forms, and other transactions beginning May 24, 2008. TMHP created a web page on the TMHP website that enables providers to report their NPIs and attest to NPI data for each of their current TPIs. TMHP strongly encourages providers to complete attestation as soon as possible. The attestation process is easy to complete. Refer to the January 2007 NPI Special Bulletin, No. 202, (also available on the TMHP website) for step-by-step instructions. All providers that can be enrolled in state funded programs but cannot obtain an NPI, may be assigned an API to use for HIPAA covered transactions. Any provider who has been assigned an API by state-funded programs and later obtains an NPI will no longer be able to use the API and will be required to use the NPI. Attestation and Taxonomy Codes Taxonomy codes are assigned based on the provider type and specialty. When enrolling, group providers must assign a taxonomy code for the group TPI and each enrolled performing provider. The group TPI will have a taxonomy code that describes either a multi-specialty or single-specialty group. Each performing provider must choose a taxonomy code that describes the services rendered by that provider. CSHCN Services Program Attestation TMHP completed NPI attestation on behalf of the CSHCN Services Program. The NPI attestation was completed using the CSHCN Services Program TPI and the NPI, taxonomy code, and physical address provided during the NPI attestation with Texas Medicaid. Benefit codes were also assigned to CSHCN Services Program providers and must be included on transactions to TMHP. Refer to page 5 for more information about benefit codes. NPI Dissemination Effective April 25, 2008, TMHP began verifying the NPIs provided during attestation against the National Plan and Provider Enumeration System (NPPES) to ensure that all attested NPIs are active. TMHP will send a notification letter to all providers with NPIs listed as inactive by NPPES. Providers will be allowed a 60-day grace period to contact NPPES and resolve their NPI status. If the inactive NPI has not been reinstated within the 60-day grace period, TMHP will disenroll all TPIs associated with the inactive NPI. TMHP will also close all Primary Care Case Management (PCCM) panel reports for the disenrolled TPIs. Clients enrolled in these panel reports will be notified to choose a different primary care provider. See Reassignment of Primary Care Provider Panels on page 4 of this bulletin. National Provider Identifier Special Bulletin 3 Texas Medicaid Bulletin, No. 217
Claims Submission Reminders Beginning May 24, 2008, all electronic transactions submitted to TMHP must have an NPI with corresponding related data. Electronic transactions received with TPIs will be rejected. Claim and Transaction Batch Files Electronic claim and transaction batch files containing multiple claims and transactions that do not contain an NPI or contain a TPI will not be rejected at the batch file level. Electronic claim and transaction batch files will be accepted, and only the specific claim or transaction missing an NPI will be rejected. Paper Claims All providers must continue to submit their TPI and NPI for the billing and performing providers on all paper claims. All other provider fields on the claim forms require an NPI only. If an NPI and TPI are not included in the billing and performing provider fields, or if an NPI is not included on all other provider identifier fields, the claim will be denied. Revised instruction tables for the CMS-1500 claim form, UB-04 CMS-1450 claim form, 2006 ADA Dental Claim Form, and 2017 Family Planning claim form are available in the May/June 2008 Texas Medicaid Bulletin, No. 215. Appeals All electronic appeals submitted to TMHP will require an NPI and related data (as outlined above for electronic claims). For claims that were submitted before the end of the contingency period, providers have the option to submit the appeal request on paper as a TPI-only claim. Providers that choose to appeal the claim with NPI information will be required to continue submitting a TPI along with an NPI until the claim is finalized. TPI-Only Transactions on the TMHP Website TPI-only professional claims and eligibility requests submitted through the TMHP website will no longer be available beginning May 24, 2008. Reassignment of Primary Care Provider Panels On April 1, 2008, TMHP began reassigning the clients of any primary care providers that had not completed the attestation process. PCCM For providers with multiple TPIs and with at least one attested TPI, TMHP has transferred the clients from the unattested TPI to the attested TPI if the following criteria were met: The attested TPI suffix is credentialed with PCCM as the same type of provider as the unattested TPI suffix. The attested TPI suffix has the same physical address as the unattested TPI suffix. For providers without an attested TPI meeting the criteria above, TMHP is notifying their clients to choose a different primary care provider and the provider s panel report will be closed. TMHP encourages all primary care providers to verify their attestation status. Managed Care Beginning April 1, 2008, unattested primary care providers who are members of a managed care plan began having clients reassigned by their managed care plan or the enrollment broker. Medicare Crossover Claims Medicare does not require a taxonomy code for Part B claims; consequently, some claims submitted to TMHP from Medicare for payment of coinsurance and deductible may not include the taxonomy code needed for accurate processing. To ensure timely payment for claims that are sent to TMHP from Medicare, TMHP requests that providers submit all claims to Medicare with their primary taxonomy code. The provider should also verify that their physical address for Medicare matches the physical address for their TPI. For questions, call the TMHP Contact Center at 1-800-925-9126. Texas Medicaid Bulletin, No. 217 4 National Provider Identifier Special Bulletin
Third-Party Billers and Software Vendors Providers are responsible for ensuring that their third-party biller or software vendor is aware of and complies with NPI claims submission requirements. Third-party billers and software vendors were required to complete the mandatory Electronic Data Interchange (EDI) testing of NPI transactions by December 1, 2007. Third-party billers and software vendors that have not completed NPI testing at TMHP and want to do so must contact the TMHP EDI Help Desk at 1-888-863-3638. Providers can verify whether a vendor has completed testing by reviewing the NPI-compliant Submitter List, which is available on the EDI web page of the TMHP website. Providers should submit a small batch of electronic claims using only NPIs. If the claims are accepted for processing, the number of claims in each subsequent batch should be increased until all claims are submitted in the NPI-only format. Providers can refer their third-party billers and software vendors to the EDI Companion Guides that are available on the EDI webpage of the TMHP website at www.tmhp.com/c5/edi/default.aspx. Authorization Requests Effective May 24, 2008, online authorization requests submitted on the TMHP website will require an NPI. The ability to submit authorization requests on the TMHP website with TPIs will no longer be available. An updated Provider Electronic Authorization Submission Guide will be published on the TMHP website. Effective May 24, 2008, paper authorization requests must be submitted to TMHP with an NPI and a TPI. Authorization requests submitted without an NPI will be returned to the provider. For questions, call the TMHP Contact Center at 1-800-925-9126. Using Benefit Codes A benefit code is an additional data element that TMHP uses to identify state programs. Benefit codes may be used as part of the NPI to TPI crosswalk process and are assigned to providers during attestation. Providers must use their assigned benefit code when submitting NPI-only claims and authorizations. Two new benefit codes have been created to assist with the NPI crosswalk solution. The new benefit codes must be used by home health durable medical equipment (DME) providers. Benefit code DM2 must be used for claims filed to Texas Medicaid and DM3 must be used for the CSHCN Services Program. Providers participating in the following programs or services must use the associated benefit code when submitting claims and authorizations. Providers should refer to their attestation or enrollment information to verify benefit code assignments for their TPIs. Program Benefit Code Comprehensive Care Program (CCP) CSHCN Services Program Texas Health Steps (THSteps) Medical THSteps Dental Family Planning Agencies Hearing Aid Dispensers Maternity County Indigent Health Care Program Early Childhood Intervention (ECI) Providers Tuberculosis Clinics Texas Medicaid Home Health DME CSHCN Services Program Home Health DME For questions, call the TMHP Contact Center at 1-800-925-9126. Automated Inquiry System (AIS) CCP CSN EP1 DE1 FP3 HA1 MA1 CA1 ECI TB1 DM2 DM3 Effective May 24, 2008, AIS will require an NPI to proceed with automated inquiries. Providers having more than one TPI for a single NPI will also be prompted to enter their TPI. Unattested providers will not be able to use AIS. National Provider Identifier Special Bulletin 5 Texas Medicaid Bulletin, No. 217
NPI Information and Help A webpage dedicated to NPI is available on the TMHP website at www.tmhp.com/c13/npi Announcements/default.aspx. This page will be updated continually as more information about NPI is made available. The following websites may also be helpful: National Plan and Provider Enumeration System (NPPES): https://nppes.cms.hhs.gov NPPES assigns NPIs and assists health plans and providers with issues relating to unique identification. Centers for Medicare & Medicaid Services (CMS): www.cms.hhs.gov The CMS website includes educational materials on NPI and its implementation, as well as the application process. This resource provides answers to common NPI questions. National Uniform Claim Committee (NUCC): www.nucc.org The NUCC website contains information about standardized data sets for transmitting claim and encounter information. National Uniform Billing Committee (NUBC): www.nubc.org The NUBC website helps define the data content associated with each of the electronic transactions mentioned in the Health Insurance Portability and Accountability Act (HIPAA) of 1996. Washington Publishing Company (WPC) Taxonomy Code Sets: www.wpc-edi.com /taxonomy/more_information The Health Care Provider Taxonomy Code Sets allow a single provider (individual, group, or institution) to identify their specialty category. Providers may have one or more associated codes. Expanded Zip Code (Zip+4) Look-up: http://zip4.usps.com/zip4/welcome.jsp The ZIP+4 code is used by TMHP during the crosswalk process to identify the provider s specific TPI associated with the NPI submitted. Taxonomy Codes for Group Billers Group billing providers that submit NPI-only claims for professional and dental services are no longer required to submit the taxonomy code they provided during attestation. Electronic claims that do not contain the group billing provider taxonomy code will not be rejected. Group billing providers are encouraged to continue sending their taxonomy code to assist with the NPI crosswalk. Billing providers that are not associated with a group are required to continue submitting a taxonomy code on all electronic claims. TMHP will reject NPI-only claims for non-group billing providers (individuals and facilities) that are submitted without a taxonomy code. The revised professional (837P) and dental (837D) EDI Companion Guides are available on the EDI web page of the TMHP website. ER&S and Remittance and Status (R&S) Reports ER&S reports will contain the billing NPI and related data, including the benefit code when applicable. Providers billing for multiple TPIs will receive multiple ER&S reports with NPI and related data. Claims submitted with an unattested TPI that are not finalized by the end of the contingency period will be listed on a separate ER&S report. As a result, providers may receive one NPI-only ER&S report and one TPI-only ER&S report. Paper R&S reports will contain both the NPI and TPI. Electronic Funds Transfer (EFT) and Paper Checks EFT statements and paper checks will display the following information: Provider identifier: The provider s NPI will replace the TPI as the provider number. Benefit code: The provider s benefit code, if applicable, will be included. Payments for claims submitted before the end of the contingency period for unattested providers will be generated with the TPI. Texas Medicaid Bulletin, No. 217 6 National Provider Identifier Special Bulletin
Notes National Provider Identifier Special Bulletin 7 Texas Medicaid Bulletin, No. 217
IMPORTANT On May 24, 2008, your Medicaid claims may be rejected or denied and your Medicaid payments stopped! See inside for important information. PRSRT STD U.S. POSTAGE PAID TMHP ATTENTION: BUSINESS OFFICE