Sunday, March 1, 2015

EHR Incentive Program: How to Report Once in 2014 for Medicare Quality Reporting Programs



Providers participating in the 2014 Physician Quality Reporting System (PQRS) program may be eligible to report their quality data one time only to earn credit for multiple Medicare quality reporting programs. Individual eligible professionals and group practices will be able to report once on a single set of clinical quality measures (CQMs) and satisfy some of the various requirements of several of the following programs, depending on eligibility:

•    PQRS
•    Value-Based Payment Modifier (VM)
•    Medicare Electronic Health Record (EHR) Incentive Program
•    Medicare Shared Savings Program Accountable Care Organization (ACO)
•    Pioneer ACO
•    Comprehensive Primary Care Initiative (CPCI)

CMS aligned some of the reporting requirements for these programs starting in 2014 to reduce the burden of data collection. Those eligible professionals who choose to report once will reap several benefits:
•    Earn the 2014 PQRS incentive and avoid the 2016 PQRS payment adjustment.
•    Satisfy the CQM requirements of the Medicare EHR Incentive Program.
•    Satisfy requirements for the 2016 VM, ACO, and/or CPCI, if eligible.
Note: aligned reporting options are only available to eligible professionals beyond their first year of participation in the Medicare EHR Incentive Program.

How to Report Once
Individual eligible professionals and group practices must submit a full year (January 1 through December 31, 2014) of data to receive credit for the various programs. The following resources will help explain how providers can report their quality data one time for 2014 participation in applicable quality programs:

•    Reporting Once Interactive Tool: Provides reporting guidance based on how the eligible professional plans to participate in PQRS in 2014.
•    eHealth University Reporting Once Module: Explains how to report quality measures one time during the 2014 program year and satisfy quality reporting requirements PQRS, the Medicare EHR Incentive Program, the VM, and ACOs.
•    2014 CQM Electronic Reporting Guide: Provides an overview of 2014 CQMs and options for reporting them to CMS.
2014 QRDA III SEVT Testing Available
The Submission Engine Validation Tool (SEVT) for 2014 Quality Reporting Document Architecture (QRDA) III submission is available on the QualityNet Portal. CMS recommends QRDA submitters and certified EHR technology vendors use this tool for 2014 submission testing.

Sunday, February 8, 2015

CMS-1500 (02/12) data element requirements - all field update


The following information discusses the conditions and requirements of the item fields within the CMS-1500 (02/12) paper claim form.

The National Uniform Claim Committee (NUCC) has created a presentation that reviews the changes to the revised form in detail. Click here  to view the NUCC presentation on the CMS-1500 (02/12) paper claim form.

Status Key:
R = Completion of this item is required by Medicare for every claim
C = Completion of this item is conditionally required based on certain circumstances
NR = Completion of this item is not required by Medicare Claims missing, or containing incomplete, or invalid information for any required or conditionally required item will be returned as unprocessable.

Note: Providers can utilize the First Coast Service Options Inc. (First Coast) PC-ACE Pro32™ software to submit claims electronically. PC-ACE Pro32™ software has built-in edits to avoid submitting claims without required information being included. Some item numbers contain links to

 Item Number    Item Description and Guidance    Requirement Status
1    Type of insurance    R
1a  Patient’s Medicare Health Insurance Claim (HIC) number    R
2  Enter the patient’s last name, first name, and middle initial (if any), as shown on patient’s Medicare card.    R
3    Enter the patient’s eight digit birth date (MM/DD/CCYY) and sex.    R
4    Insured’s name
(Complete item only if there is insurance primary to Medicare. Complete this item only when items 6, 7, and 11a-c are completed.)    C
5    Patient’s mailing address, city, state, and phone number    R
6    Check appropriate box for patient’s relationship to insured.
(Complete item only if there is insurance primary to Medicare. Complete this item only when items 4, 7, and 11a-c are completed.)    C
7    Insured’s address and telephone number.
Note: When address is the same as patient’s, enter the word SAME.
(Complete item only if there is insurance primary to Medicare. Complete this item only when items 4, 6, and 11a-c are completed.)    C
8    Leave blank -- Medicare Part B Providers are not required to complete.    NR
9-9d    Medigap information (Leave Items 9b and 9c blank)    C
10a-c    Employment/accident indicators    R
10d    Medicaid ID  C
11    Primary insurance policy number
Note: Enter the word NONE if Medicare is primary    R
11a-c    Insured’s birth date, employer, plan name (Item 11b -- provide this information to the right of the vertical line.)    C
11d    Another health benefit plan
Leave blank -- Medicare Part B Providers are not required to complete.    NR
12    Patient’s signature and date    R
13    Patient signature -- Medigap authorization
Note: Must be completed if information contained in 9-9d.    C
14    Date of current illness, injury, or pregnancy
Note: Although space for a qualifier is included, Medicare does not use this information; do not enter a qualifier in item 14.    C
15    Leave blank -- Medicare Part B Providers are not required to complete.    NR
16    If patient is employed, enter dates patient will be unable to work in current occupation.    C
17    Enter the name and qualifier of the referring, ordering or supervising physician if the item or service was ordered, supervised or referred by a physician.
• The qualifiers appropriate for identifying an ordering, referring, or supervising role are as follows:
• DN -- referring provider
• DK -- ordering provider
• DQ -- supervising provider
• Enter the qualifier to the left of the dotted vertical line on item 17.
Note: Claims submitted with a national provider identifier (NPI) and without one of the qualifiers notated above or an invalid qualifier will be returned as an unprocessable claim (RUC).
See Claim completion FAQs on the First Coast provider website for additional details for reporting referring/ordering providers.
See also the Ordering/referring provider FAQs for additional guidance.    C
Required if services are ordered, referred or supervised
17a   DO NOT complete    NR
17b   If the service is referred or ordered, enter the national provider identifier (NPI) of the referring/ordering individual provider only.
(Click here to verify the provider's NPI is eligible to order or refer services.)    C
Required if services are ordered, referred or supervised
18    Hospitalization dates    C
19    Additional claim information
See CMS IOM Pub 100-04, Chapter 26, Section 10.4  for guidance on completion of Item 19    C
20    Outside lab
See Claim completion FAQs on the First Coast provider website for additional details for reporting purchased services.    C
21
Report up to twelve primary diagnosis codes
• For dates of service prior to October 1, 2014 -- report ICD-9-CM codes. Enter the ICD indicator 9 as a single digit between the vertical, dotted lines.
• For dates of service on and after October 1, 2014 -- report ICD-10-CM codes. Enter the ICD indicator 0 as a single digit between the vertical, dotted lines.
• If submitting a claim with a span of dates for a service, use the “from” date to determine which ICD code set to use.    R
22    Leave blank -- Medicare Part B Providers are not required to complete.    NR
23    Prior authorization number     C
24A    Date(s) of service (DOS)    R
24B
Place of service (POS)
See CMS IOM Pub 100-04, Chapter 26, Section 10.5  for codes and definitions.    R
24C    Leave blank -- Medicare Part B Providers are not required to complete.    NR
24D    Procedure code/applicable modifiers   R
24E-Diagnosis pointer
Note: the reference will be a letter from A-L. This information appears opposite the diagnosis codes in Item 21. Relate lines A- L to lines of service in 24E by the letter of the line.     R
24F    Charge (in dollars) for service    R
24G    Days/Units    R
24H    Leave blank -- Medicare Part B Providers are not required to complete.    NR
24I - Leave blank -- Medicare Part B Providers are not required to complete.    NR
24J-Enter the NPI of the rendering provider in the lower non-shaded portion.
Do not report anything in the upper shaded portion of item 24J.    C
25    Federal tax identification number (TIN)    C
26    Patient’s account number    C
27    Assignment
See CMS IOM Pub 100-04, Chapter 1, Section 30.3.1  for list of provider and claim types for which assignment must always be accepted.    R
28    Total Charges    R
29    Enter amount collected from patient, if any.
Note: Please review When not to show patient paid amounts on claims article before collecting payments from patients.
C
30    Leave blank -- Medicare Part B Providers are not required to complete.    NR
31    Provider signature and date
Note: "Signature on File" and/or a computer generated signature are acceptable. See section 10.4 Item 32  for details R
32-For services payable under the Medicare Physician Fee Schedule (MPFS) and anesthesia services:
Name, address and ZIP of location where services were rendered for all locations.
Note: As of January 1, 2011, all locations (including patient's home) must be reported.    R
32a-If reporting anti-markup services (formerly purchased diagnostic services), enter the NPI of the provider who performed the service.
Note: DO NOT report for providers outside of local jurisdiction. Instead, you are required to report the NPI of the provider who purchased the service.    C
32b-DO NOT complete    NR
33-Billing provider’s name, address, ZIP and telephone number    R
33a-Enter the NPI of the billing provider or group.    R
33b -DO NOT complete    NR

Monday, January 12, 2015

Face-to-Face Encounters and Certification for Home Health Care and Physician Documentation Requirements (G0180 and G0179)


Physician play a key role in documenting eligibility and medical necessity for home health care for Medicare beneficiaries. If you certify the need for home health care for any of your patients, we encourage you to review this article carefully. As a physician, you are responsible for providing appropriate, accurate supporting documentation of your face-to-face (FTF) encounters with your patients regarding home health care and certification of need. Medicare provides payment for physician initial and re-certification of Medicare-covered home health services under a home health plan of care (G0180 and G0179).

Background: Qualifying Criteria for the Medicare Home Health Benefit
To qualify for the Medicare home health benefit, under section 1814(a)(2)(C) and 1835(a)(2)(A) of the Social Security Act, Medicare beneficiaries must meet all of the following requirements:
•    Be confined to the home;
•    Under the care of a physician;
•    Receiving services under a plan of care established and periodically reviewed by a physician;
•    Be in need of skilled nursing care on an intermittent basis or physical therapy or speech-language pathology; or
•    Have a continuing need for occupational therapy.
The Centers for Medicare & Medicaid Services (CMS) further defines “intermittent,” for purposes of this benefit, as “skilled nursing or home health aide services furnished any number of days per week as long as they are furnished (combined) less than 8 hours each day and 28 or fewer hours each week (or, subject to review on a case-by-case basis as to the need for care, less than 8 hours each day and fewer than 35 hours per week).” CMS also defines home confinement; we strongly encourage you to review the definition of home confinement in its entirety in the CMS Medicare Benefit Policy Manual (the web address to access this manual is provided at the end of this letter).

Major Documentation Errors
Analysis of the recent errors identified by the Comprehensive Error Rate Testing (CERT) Review Contractor shows a nationwide, significant, and continuing increase in denials related to documentation for the FTF.  The most common error is insufficient documentation of clinical findings by the physician/non-physician practitioner (NPP) to show:
•    The encounter was related to the primary reason for home care
•    How the patient’s condition supports the patient’s homebound status; or
•    How the patient’s condition supports the need for skilled services
Acceptable FTF documentation does not have to be lengthy or overly detailed.  However, the FTF documentation must show the reason skilled service is necessary for the treatment of the patient’s illness or injury, based on the physician’s clinical findings during the face-to-face encounter, and specific statements regarding why the patient is homebound.
Following are examples of FTF documentation that, used alone, are considered insufficient documentation.

Homebound StatusNeed for Skilled Services
“Functional decline”“Family is asking for help”
“Dementia” or “confusion”“Continues to have problems”
“Difficult to travel to doctor’s office”List of tasks for nurse to do
“Unable to leave home”/ “Unable to drive“Patient unable to do wound care”
“Weak”“Diabetes”
“Status post total hip”


Examples of appropriate documentation include:
•    “Wound care to left great toe. No s/s of infection, but patient remains at risk due to diabetic status.  Skilled nurse visits to perform wound care and assess wound status.  Patient on bed to chair activities only.”
•    “Lung sounds coarse throughout. Patient finished antibiotic therapy today for pneumonia, and to see pulmonologist tomorrow for follow up due to COPD and emphysema.  Short of breath with talking and ambulation of 1-2 feet.  Nurse to assess respiratory status for s/s of recurring infection/ changes in respiratory status.”
•    “CHF, CLL, weakness, 3+ edema in R & L legs; needs cardiac assessment, monitoring of signs & symptoms of disease, and patient education; homebound due to shortness of breath with minimal exertion, e.g., walking 5 feet.”
•    “Status post right total hip replacement. Needs physical therapy to restore ability to walk without assistance. Homebound temporarily due to requiring a walker, inability to negotiate uneven surfaces and stairs, inability to walk greater than 5 - 10 feet before needing to rest. ”
In all cases, your documentation must be specific to that patient’s condition at the time of your encounter with him or her.

Who May Document the FTF Encounter?

The FTF encounter must be performed by the certifying physician, a physician who cared for the patient in an acute or post-acute facility during a recent acute or post-acute stay and has privileges at the facility, or a qualified nonphysician practitioner (NPP) working in conjunction with the certifying physician.  An NPP in an acute or post-acute facility is able to perform the FTF encounter in collaboration with or under the supervision of the physician who has privileges and cared for the patient in the acute or post-acute facility.  That NPP can then report the FTF encounter to the certifying physician.
Medicare guidelines also contain specific documentation requirements:

The certifying physician must document that the FTF visit took place, regardless of who performed the encounter.
If the FTF encounter was not performed by the certifying physician, the NPP or physician who cared for the patient and performed the FTF must provide the face-to-face record of the FTF encounter to the certifying physician.  NPPs performing the FTF encounter in an acute/post-acute facility must inform the physician they are collaborating with, or under the supervision of, so that the physician can inform the certifying physician of the clinical findings of the FTF.
The certifying physician cannot merely co-sign the encounter documentation if performed by an NPP.  He or she must complete/sign the form or a staff member from his or her office may complete the form from the physician’s encounter notes, which the certifying physician would then sign.
The FTF encounter documentation must be clearly titled, dated, and signed by the certifying physician before the home health agency submits a claim to Medicare and must include:
The date of the FTF encounter, and
Clinical findings to support that the encounter is related to the primary reason for home care, the patient is homebound, and in need of Medicare covered home health services.
Finally, because the FTF encounter is a requirement for payment, when the FTF encounter requirements as outlined above are not met, the home health agency’s entire claim is denied.  For cases in which the beneficiary’s condition otherwise warrants Medicare coverage of skilled home health services, but FTF encounter documentation is insufficient, the beneficiary’s ability to receive this skilled care may be jeopardized.

Home health agencies may ask you to provide supporting documentation from your medical records to ensure that Medicare will cover home health services. You are permitted, and strongly encouraged, to provide this documentation, the disclosure of which is permitted under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). No specific authorization is required from your patients in order to do this. Also, please note that you may not charge the home health agency for providing this information. We ask you to work in partnership with these agencies so they can provide appropriate and medically necessary care for your homebound patients.

Monday, December 15, 2014

What are 837 I format and cms 1450 claim

The 837I (Institutional) is the standard format used by institutional providers to transmit health care claims electronically. The Form CMS-1450, also known as the UB-04, is the standard claim form to bill Medicare Fee-For-Service (FFS) Contractors when a paper claimis allowed. In addition to billing Medicare, the 837I and Form CMS-1450 may be suitable for billing various
government and some private insurers.

Data elements in the Centers for Medicare & Medicaid Services (CMS) uniform electronic billing specifications are consistent with the hard copy data set to the extent that one processing system can handle both. CMS designates the form as the Form CMS-1450 and the form is referred to throughout this fact sheet as the CMS-1450.

Institutional providers include hospitals, Skilled Nursing Facilities (SNFs), End Stage Renal Disease (ESRD) providers, Home Health Agencies (HHAs), hospices, outpatient rehabilitation clinics, Comprehensive Outpatient Rehabilitation Facilities (CORFs), Community Mental Health Centers (CMHCs), Critical Access Hospitals (CAHs), Federally Qualified Health Centers (FQHCs), histocompatibility laboratories, Indian Health Service (IHS) facilities, organ procurement organizations, Religious Non-Medical Health Care Institutions (RNHCIs), and Rural Health Clinics (RHCs).

ANSI ASC X12N 837I


The American National Standards Institute (ANSI) Accredited Standards Committee (ASC) X12N 837I (Institutional) Version 5010A2 is the current electronic claim version. To learn more, visit the ASC X12 website on the Internet.

ANSI = American National Standards Institute
ASC = Accredited Standards Committee
X12N = Insurance section of ASC X12 for the health insurance industry’s administrative transactions
837 = Standard format for transmitting health care claims electronically
I = Institutional version of the 837 electronic format
Version 5010A2 = Current version of the Health Insurance Portability and Accountability Act (HIPAA) electronic transaction standards for institutional providers.
The National Uniform Billing Committee (NUBC) makes their UB-04 manual available through their website. This manual contains the updated specifications for the data elements and codes included on the CMS-1450 and used in the 837I transaction standard. Medicare FFS Contractors may include a crosswalk between the ASC X12N 837I and the CMS-1450 on their websites

When Does Medicare Accept a Hard Copy Claim Form?

Initial claims for payment under Medicare must be submitted electronically unless an institutional provider qualifies for a waiver or exception from the Administrative Simplification Compliance Act (ASCA) requirement for electronic submission of claims.

Before submitting a hard copy claim, providers should self-assess to determine if they meet one
or more of the ASCA exceptions. For example, institutional providers that have fewer than 25 Full-Time Equivalent (FTE) employees and bill a Medicare FFS Contractor are considered to be small and might therefore qualify to be exempt from Medicare electronic billing requirements. If an institutional provider meets an exception, there is no need to submit a waiver request.

There are other situations when the ASCA electronic billing requirement could be waived for some or all claims, such as if disability of all members of an institutional provider’s staff prevents use of a computer for electronic submission of claims. Institutional providers must obtain Medicare pre-approval to submit paper claims in these situations by submitting a waiver request to their Medicare FFS Contractor.

Timely Filing


The timely filing period for both paper and electronic Medicare claims is 12 months, or one calendar year, after the date of service.

Claims are denied if they arrive after the deadline date. When a claim is denied for having been filed after the timely filing period, such a denial does not constitute an initial determination. As such, the determination that a claim was not filed timely is not subject to appeal.

In general, the start date for determining the 12-month timely filing period is the date of service or ‘From’ date on the claim. Medicare uses the line item ‘Through’ date to determine the date of service for claims filing timeliness for claims that include span dates of service (i.e., a ‘From’ and ‘Through’ date span on the claim).
Medicare regulations allow exceptions to the 12-month time limit for filing claims.

Where to Submit FFS Claims


Claims for services must be submitted to the appropriate Medicare FFS Contractor. Contact the Medicare FFS Contractor by referencing the
Provider Compliance Group Interactive Map on the CMS website. Medicare beneficiaries cannot be charged for completing or filing a claim. Providers may be subject to penalty for violations.

If a beneficiary is enrolled in a Medicare Advantage (MA) Plan, claims should not be submitted to the Medicare FFS Contractor; the beneficiary’s MA Plan is responsible for claims processing. CMS provides a list of MA claims processing contacts on the CMS website.

Medicare Secondary Payer (MSP)

MSP provisions apply to situations when Medicare is not the beneficiary’s primary health insurance coverage and ensure that Medicare does not pay for services and items that certain other health insurance or coverage is primarily responsible for paying. For more information, reference the “Medicare Secondary Payer for Provider, Physician, and Other Supplier Billing Staff” fact sheet available through the MLN “Catalog of Products” on the CMS website. The Medicare Secondary Payer web page offers information on MSP laws and the various methods employed by CMS to gather data on other insurance that may be primary to Medicare.



Tuesday, November 11, 2014

provider identifying qualifiers box 17

This MLN Matters® Article is intended for physicians and other providers submitting claims to Medicare contractors (carriers, A/B Medicare Administrative Contractors (A/B MACs), and Durable Medical Equipment Medicare Administrative Contractors
(DME/MACs)) for services provided to Medicare beneficiaries.

This change request (CR) 8509 revises the current CMS 1500 claim form instructions to
reflect the revised CMS 1500 claim form, version 02/12.

The National Uniform Claim Committee (NUCC) recently revised the CMS 1500 claim form. On June 10, 2013, the White House Office of Management and Budget (OMB) approved the revised form, 02/12. The revised form has a number of changes. Those most notable for Medicare are new indicators to differentiate between ICD-9 and ICD-10 codes on a claim, and qualifiers to identify whether certain providers are being identified as having performed an ordering, referring, or supervising role in the furnishing of the service. In addition, the revised form uses letters, instead of numbers, as diagnosis code pointers, and expands the number of possible diagnosis codes on a claim to 12.The qualifiers that are appropriate for identifying an ordering, referring, or supervising role are as follows:

• DN - Referring Provider
• DK - Ordering Provider
DQ - Supervising Provider

Providers should enter the qualifier to the left of the dotted vertical line on item 17.

Friday, November 7, 2014

Electronic Billing Guide: Submitting Medical Documentation for Part A/B 5010 Electronic Claims


Submitting Medical Documentation For Part A/B 5010 Electronic Claims

Under the Health Insurance Portability and Accountability Act (HIPAA), claims for reimbursement by the Medicare Program must be submitted electronically, except where waived, even for claims with attachments. The process for accepting medical documentation and attaching it to the electronic claim has been improved due to our imaging system. The Claim Supplemental Information segment (PWK) is used whenever paper documentation has been sent for an electronic claim. When sending an electronic claim that contains an attachment, follow these rules to submit the attachment for your electronic claim:

Maintain the appropriate medical documentation on file for electronic (and paper) claims.
Complete the Medicare Part A Fax/Mail Cover Sheet * or the Medicare Part B Fax/Mail Cover Sheet * form. For accurate processing of your claim(s), please complete all requested information in capital letters and avoid contact with the edge of the boxes.

Important tips to keep in mind when faxing medical records for electronic claims:

•    Only send medical documentation when necessary for the adjudication of procedures/services that are unusual or require such documentation on a pre-payment basis.
•    The narrative field on the claim is to be utilized in situations where sufficient information for the documentation of a procedure/modifier can be provided without sending the medical records. When additional information cannot be contained in the narrative of the claim, additional documentation (medical records) may be submitted via mail or fax.
•    Only fax documentation for one patient per cover sheet. The cover sheet is for Part A or B electronic claims.
•    Clearly write the: Attachment Control Number, Internal Control Number (ICN/DCN), Patient Name, Health Insurance Claim (HIC) Number, Date of Service, Total Claim Billed Amount, National Provider Identification (NPI) Number, Contact Information, and State Where Services Were Provided on the cover sheet.  Failure to submit all items requested will result in documentation being returned and could delay claim processing.
•    The fax/mail cover sheets are not to be modified.
•    Only the first iteration of the PWK, at either the claim level and/or line level, will be considered for adjudication.
•    Submitters must send ALL relevant PWK data at the same time for the same claim.
•    After submitting the electronic claim, locate the ICN/DCN number on the 277CA claims acknowledgement report.  The ICN/DCN is located in the 2200D REF segment.
•    Fax the cover sheet and medical documentation to (877) 439-5479. You may fax documentation any time after claim submission, including the same day. Faxing is available 24 hours a day, 7 days a week. Faxes should be sent within seven calendar days of your electronic claim submission.
Novitas Solutions strongly recommends faxing your medical documentation. If you are not able to fax your documentation, mail the Medicare Part A Fax/Mail Cover Sheet * or the Medicare Part B Fax/Mail Cover Sheet * and all pertinent medical documentation within ten calendar days of your electronic claim submission.

In the Claim Supplemental Information Segment (PWK) of the electronic claim:
•    Select the appropriate Report Type Code for the medical documentation. For information on what codes are needed in the PWK segment.
•    Use the By Fax or By Mail option for the Attachment Transmission Code
•    Enter AC for the Identification Code Qualifier
•    Report the Attachment Control Number - This number may be assigned by your software or can be any number you chose including the patient account number or other identifying number.
Note: Only send medical documentation when necessary for the adjudication of procedures/services that are unusual or require such documentation on a pre-payment basis.
Technically Speaking, Claim Supplemental Information (PWK) is reported as follows:

Data Element    Segment
Attachment Report Type Code    2300 or 2400 - PWK01
Attachment Transmission Code    2300 or 2400 - PWK02
Identification Code Qualifier    2300 or 2400 - PWK05
Attachment Control Number    2300 or 2400 - PWK06

Friday, October 10, 2014

NPI AND PTAN Difference and Relationship - complete review

This article explains the difference between a National Provider Identifier (NPI) and a Provider Transaction Access Number (PTAN). There are no policy changes in this article.

All providers and suppliers who provide services and bill Medicare for services provided to Medicare beneficiaries must have an NPI. Upon application to a Medicare Administrative Contractor (MAC), the provider or supplier will also be issued a
Provider Transaction Access Number (PTAN). While only the NPI can be submitted on claims, the PTAN is a critical number directly linked to the provider or supplier’s NPI.


Providers and suppliers receiving requests to revalidate their enrollment information have asked the Centers for Medicare & Medicaid Services (CMS) to clarify the differences between the NPI and the PTAN.

National Provider Identifier (NPI)

The NPI is a national standard under the Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification provisions.

• The NPI is a unique identification number for covered health care providers.
• The NPI is issued by the National Plan and Provider Enumeration System (NPPES).
• Covered health care providers and all health plans and health care clearinghouses must use the NPI in the administrative and financial transactions (for example, insurance claims) adopted under HIPAA.

• The NPI is a 10-position, intelligence-free numeric identifier (10-digit number). The NPI does not carry information about healthcare providers, such as the state in which they live or their medical specialty. This reduces the chances of insurance fraud.

• Covered providers and suppliers must share their NPI with other suppliers and providers, health plans, clearinghouses, and any entity that may need it for billing purposes.

Since May 23, 2008, Medicare has required that the NPI be used in place of all legacy provider identifiers, including the Unique Physician Identification Number (UPIN), as the unique identifier for all providers, and suppliers in HIPAA standard transactions.

You should note that individual health care providers (including physicians who are sole proprietors) may obtain only one NPI for themselves (Entity Type 1 Individual). Incorporated individuals should obtain one NPI for themselves (Entity Type 1
Individual) if they are health care providers and an additional NPI(s) for their corporation(s) (Entity Type 2 Organization). Organizations that render health care or furnish health care supplies may obtain NPIs (Entity Type 2 Organization) for their organizations and their subparts (if applicable).

For more information about the NPI, visit the NPPES website at https://nppes.cms.hhs.gov/NPPES/Welcome.do on the CMS website.

Provider Transaction Access Number (PTAN)

A PTAN is a Medicare-only number issued to providers by MACs upon enrollment to Medicare. When a MAC approves enrollment and issues an approval letter, the letter will contain the PTAN assigned to the provider.

** The approval letter will note that NPI must be used to bill the Medicare program and that PTAN will be used to autheniticate the provider when using MAC self help tools such as IVR , internet portal , online application etc.

** The PTAN's use should generally be limited to the provider's contacts with their MAC


Where can I find my PTAN?

You can find your PTAN by doing any one of the following:

1. View the letter sent by your MAC when your enrollment in Medicare was approved.

2. Log into Internet-based PECOS. Click on the “My Enrollments” button and then “View Enrollments”. Locate the applicable enrollment and click on the “View Medicare ID Report” link which will list all of the provider or supplier’s active
PTANs in one report.

3 The provider (or, in the case of an organizational provider, an authorized or delegated official) shall send a signed written request on company letterhead to your MAC; include your legal name/legal business name, national provider identifier
(NPI), telephone and fax numbers.


Relationship of the NPI to the PTAN

The NPI and the PTAN are related to each other for Medicare purposes. A provider must have one NPI and will have one, or more, PTAN(s) related to it in the Medicare system, representing the provider’s enrollment. If the provider has relationships with one or more medical groups or practices or with multiple Medicare contractors, separate PTANS are generally assigned.

Together, the NPI and PTAN identify the provider, or supplier in the Medicare program. CMS maintains both the NPI and PTAN in the Provider Enrollment Chain & Ownership System (PECOS), the master provider and supplier enrollment system.


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