General Information

The federal Health Insurance Portability and Accountability Act of 1996 required the federal Department of Health and Human Services (HHS) to adopt national identification standards for health care providers who conduct standard electronic transactions. The Final Rule published by the HHS adopted the National Provider Identifier (NPI) as the standard identifier for health care providers to replace payer-specific identification numbers.

Per the definitions of the Final Rule, Wisconsin Medicaid has identified entities that are not considered health care providers and are therefore not eligible to obtain an NPI, except in certain instances. This information is detailed in the July 2007 Wisconsin Medicaid and BadgerCare Update (2007-53), titled “Wisconsin Medicaid Will Require National Provider Identifiers for All Health Care Providers.”

In the future, all health care providers will be required to indicate their NPI when conducting business with Wisconsin Medicaid. However, currently providers are required to continue indicating their eight-digit Medicaid provider number on all electronic and paper claims and other transactions (e.g., prior authorization requirements) submitted to Wisconsin Medicaid until further notice in a future Update. Refer to the May 2007 Update (2007-39), titled “Reminder: Wisconsin Medicaid Will Not Implement the National Provider Identifier on May 23, 2007 — Medicaid Provider Numbers Will Continue to Be Required”, for additional information. In preparation for full NPI implementation, Wisconsin Medicaid is now collecting NPIs from health care providers and issuing confirmation letters acknowledging receipt.

Obtaining a National Provider Identifier

Eligible health care providers who have not yet obtained an NPI may apply online at the National Plan and Provider Enumeration System Web site at https://nppes.cms.hhs.gov/NPPES/Welcome.do.

Reporting National Provider Identifiers

For NPI collection, providers are asked to designate the NPI they will use for conducting business with Wisconsin Medicaid. Most providers will have one NPI corresponding to one Medicaid provider number.

If an organization has identified subparts resulting in multiple NPIs and a subpart’s NPI will be used for conducting business with Wisconsin Medicaid, that subpart of the organization is required to be certified by Wisconsin Medicaid. If a subpart is not currently certified by Wisconsin Medicaid, a certification packet may be obtained from the Wisconsin Medicaid Web site or by calling Provider Services. Wisconsin Medicaid certification is required for a subpart only if the subpart’s NPI will be used in conducting business with Wisconsin Medicaid.

If an organization has identified subparts for the purpose of submitting claims to Medicare, and the NPIs will only appear on automatic crossover claims to Wisconsin Medicaid, the NPIs submitted to Medicare are considered to be secondary NPIs. Wisconsin Medicaid is collecting secondary NPIs to process Medicare automatic crossover claims.

Providers are encouraged to visit the Centers for Medicare and Medicaid Services Web site at www.cms.hhs.gov/ for additional NPI information.

Submitting National Provider Identifier Information

When submitting NPI information to Wisconsin Medicaid, providers should adhere to the following guidelines:

• If a provider has one Medicaid provider number and one NPI, both numbers should be submitted.
• If a provider has one Medicaid provider number and more than one NPI, the provider is required to designate the NPI that directly corresponds to the Wisconsin Medicaid provider number. Any other NPIs that correspond with the Medicaid provider number are considered to be secondary NPIs and are used to process automatic crossover claims only. Wisconsin Medicaid certification is required for NPIs used for conducting business with Wisconsin Medicaid.
• If a provider has more than one Medicaid provider number and only one NPI, the provider is required to separately submit the NPI for each Medicaid provider number.

National Provider Identifier Collection Process

Providers are encouraged to submit their NPI(s) to Wisconsin Medicaid by November 1, 2007, using one of the following methods:

• Web-based application: Providers may submit their NPI using the Web-based application via the link on the Medicaid Web site at dhs.wisconsin.gov/medicaid/.
• E-mail: Providers may submit their own spreadsheet electronically to the e-mail address at winpi@dhfs.state.wi.us. The spreadsheet must contain all of the required elements on the National Provider Identifier Collection form, HCF 13505 (07/07); this includes the eight-digit Medicaid provider number and corresponding NPI, a contact name, and a telephone number. Additionally, providers are required to indicate whether or not they are able to continue submitting their Medicaid provider number on electronic claim submissions.
• Mail: Providers may photocopy and complete the National Provider Identifier Collection form in the Attachment (fillable PDF, 117 KB) of this Update. Completed forms must be mailed to the following address:

Wisconsin Medicaid
Provider Maintenance
6406 Bridge Rd
Madison WI 53784-0006

National Provider Identifier Confirmation Letter

Wisconsin Medicaid will mail a confirmation letter acknowledging receipt of each Medicaid provider number submission to the address in the Wisconsin Medicaid provider file.

The confirmation letter lists the NPI designated for conducting business with Wisconsin Medicaid, any secondary NPIs (i.e., NPIs utilized for Medicare automatic crossover claims only), the taxonomy code associated with provider certification, and the provider’s ZIP code. The taxonomy code and ZIP code will be required to be used in conjunction with the reported NPI when conducting future business with Wisconsin Medicaid. Providers are encouraged to retain the confirmation letter for future reference.

Attachment — National Provider Identifier Collection (fillable PDF, 117 KB) | Word (fillable, 46 KB)