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NPI Needed by April 16
April 5, 2007

The Department of Public Welfare (DPW) has stressed that providers must obtain National Provider Identifiers (NPI) and register them with the Medical Assistance (MA) Program by April 16 in order to be validated by the May 23 deadline established by the Centers for Medicare and Medicaid Services (CMS) for NPI implementation. Beginning May 23, DPW will accept only NPI numbers for providers that submit HIPAA electronic 837 claims. Legacy numbers, instead of NPIs, will continue to be used for certain atypical provider types, such as many home and community habilitation service providers. A complete list of atypical provider types and specialties is available on the DPW web site (www.dpw.state.pa.us/Resources/Documents/Pdf/AtypicalProvTypesAndSpecialties.pdf). A Provider Quick Tip on atypical providers yields additional clarification and is available at (www.dpw.state.pa.us/omap/promise/PDF/PROMISeQuickTip32.pdf).

Office of Medical Assistance Programs (OMAP) Bulletin 99-06-14, Instructions For Registering Your National Provider Identifier (NPI) Number to the Department of Public Welfare (DPW), details how to obtain the NPI and register with DPW (www.dpw.state.pa.us/General/Bulletins/003673169.aspx?BulletinDetailId=1536). DPW will use the provider’s NPI number, taxonomy code, and nine-digit zip code to crosswalk to the existing MA number and service location. The MA number will be used for internal processing within OMAP;, then the outgoing communication will use the NPI information. The bulletin includes guidelines for obtaining and registering NPIs. Guidelines include, but are not limited to, the following:

  • Organizations may obtain multiple (subpart) NPI numbers. The appropriate NPI or subpart NPI number must be registered under each active service location to which it applies.
  • Provider group practices should secure an NPI for each service location from which they perform HIPAA compliant billing. Billing service locations should be consolidated on the PROMISe system.
  • Each service location can have only one NPI assigned to it.
  • DPW recommends that organizations obtain an NPI number for each licensed or certified site.
  • Organizations having multiple NPI numbers must have a corresponding MA enrolled service location to connect to each unique NPI number.
  • All applicable taxonomy codes should be selected for the service locations that will be used to submit claims. A taxonomy code crosswalk is available on the DPW web site at (www.dpw.state.pa.us/Resources/Documents/Pdf/PaDpwPT-PSToTaxonomyCrosswalk.pdf).

Taxonomy codes should be selected based upon the specialty code that is currently on file for the MA enrolled provider. If the provider cannot identify the appropriate taxonomy code, then he the provider should contact the enrollment area through the PROMISe mailbox (PROMISe@state.pa.us) or the Provider Hotline (800-537-8862) for clarification.

Information on subparting is available through the NPI section of the DPW web site (www.dpw.state.pa.us/Business/NPIinfo), e.g., a Provider Quick Tip on subparts. Also, Fox Systems, Inc., the national NPI enumerator, developed a decision tree document to provide assistance in making decisions about subparts (www.sharpworkgroup.com/presentations/DecisonTree_07_25_06_final.pdf). Updated provider handbooks, companion guides, and billing guides are available online the DPW web site (www.dpw.state.pa.us/Business/BillingInfo/003675041.htm and www.dpw.state.pa.us/omap/provinf/companionguides.asp). A new Provider Quick Tip explains the extended deadline for use of the CMS-1500 (08/05) claim form (www.dpw.state.pa.us/omap/promise/PDF/PROMISeQuickTip33.pdf). This version of the form that includes NPI information will be required beginning May 23. Claims presented on the old version after May 23 will be returned to the provider. Additional NPI resources, including Provider Quick Tips on various topics and questions and answers, are also available ion the NPI section of the DPW web site.

CMS has issued contingency guidance in anticipation that all affected parties will not have obtained and verified their NPIs by the May 23 deadline (www.cms.hhs.gov/NationalProvIdentStand/Downloads/NPI_Contingency.pdf). The guidance allows CMS to review entities’ good faith efforts to comply with NPI requirements during the year following the implementation deadline in making determinations about non-compliance. Through May 23, 2008, CMS will not impose penalties on covered entities that use contingency plans to ensure continuing payments if the entities have made “reasonable and diligent efforts” to become compliant. In determining whether a good faith effort was made, CMS will assess continuing actions and demonstrable progress. Entities are encouraged to document their good faith efforts to comply in order to rebut any complaint that might be filed. Complaints will drive enforcement efforts.

PCPA has addressed concerns to OMAP regarding delays in validation of NPI information. OMAP statistics continue to indicate a very low registration rate for behavioral health service providers. However, many PCPA members have indicated that they had submitted the information and were waiting for validation. At this time providers should anticipate verification within 30 days. The registration information will be returned to the provider if it is incomplete. Once verified and the information is inputted into PROMISe, providers will be issued a Provider Change Letter through the PROMISe system. OMAP has indicated for some time its concern that there would be an onslaught of registration requests nearer to the deadline. Providers who have not yet done so are asked to obtain an NPI(s) and register with DPW as soon as possible.

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