Revision on Transition Period to NPI

CR 4023 was revised on November 29, 2005, to clarify that the end date of the transition period for the revised CMS-1500 form is February 1, 2007.

Effective January 03, 2006, Medicare will begin accepting the NPI on the 837 and 276 4010A1 transactions with certain restrictions. With the scheduled implementation of the National Provider Identifier (NPI) in 2007, CMS has begun the process of making the necessary system changes to accommodate the NPI. The implementation will be completed in 3 stages. The first stage will be in effect beginning January 03, 2006 and pertains to Electronic Data Interchange.

In this first stage, the NPI will be accepted on the inbound 837 4010A1 file but will not be used for Medicare processing. The Medicare legacy provider number must continue to be submitted in addition to the NPI for Medicare processing. When an NPI is received on an inbound 837 file, it will be mapped to the outbound COB/COBC file issued in response to the inbound claim. Additionally, the NPI will be accepted on the 276 Claim Status Inquiry and returned on the 277 Claim Status Response transactions.

The implementation of stage 1 will allow for the acceptance of the NPI by removing existing pre-pass edits which currently reject claims submitted with the “XX” qualifier in the NM108 segment. In tandem, new pre-pass edits have been created to validate the value of the NPI and to ensure the provider’s corresponding Medicare legacy number or UPIN number continues to be submitted on the inbound 837 4010A1 file. New pre-pass edits have also been created for the 276 transaction to ensure the validity of the NPI on any claim status inquiry transaction.

In stage 2 (the subject of CR 4023) October 02, 2006 – May 22, 2007: CMS systems will accept an existing legacy Medicare billing number and/or an NPI on claims. If there is any issue with the provider’s NPI and no Medicare legacy identifier is submitted, the provider may not be paid for the claim. Therefore, Medicare strongly recommends that providers, clearinghouses, and billing services continue to submit the Medicare legacy identifier as a secondary identifier. Medicare will be capable of sending the NPI as primary provider identifier and legacy identifier as a secondary identifier in outbound claim, claim status response, remittance advice (electronic but not paper), and eligibility response electronic transactions.

May 23, 2007 – Forward: CMS systems will only accept NPI numbers. Coordination of benefit transactions sent to small health plans will continue to carry legacy identifiers, if requested by such a plan, through May 22, 2007.