National Provider Identifier Implementation

This information pertains to BadgerCare Plus, Wisconsin Medicaid, and SeniorCare and for the purpose of this BadgerCare Plus Update are referred to as BadgerCare Plus.

To facilitate continuity of business for health care providers during the transition to National Provider Identifier (NPI) implementation, Wisconsin Medicaid and BadgerCare Plus will accept an NPI and/or a Medicaid provider number on Health Insurance Portability and Accountability Act of 1996 (HIPAA) standard electronic transactions received on and after May 19, 2008. Only HIPAA standard electronic transactions submitted by health care providers will accept NPIs and/or Medicaid provider numbers. Other business functions will continue to require Medicaid provider numbers until ForwardHealth interChange implementation in October 2008.

For more information about ForwardHealth interChange, refer to the March 2008 Update (2008-24), titled “Introducing ForwardHealth interChange, a New Web-Based Information System for State Health Care Programs.”

Standard electronic transactions that will accept NPI and related data, processing modifications, billing changes, and business functions that will continue to require eight-digit Medicaid provider numbers are detailed in this Update.

Reporting National Provider Identifier

All health care providers who have not reported their NPI to BadgerCare Plus are required to do so immediately if they intend to indicate NPI on allowable electronic transactions beginning May 19, 2008. Providers should not indicate their NPI on transactions without first reporting NPI to BadgerCare Plus as it will result in claim denials or delays in processing transactions and payments. Providers may report their NPI immediately online using the Web-based application, “Report Your NPI Online,” on the Wisconsin Medicaid Web site at dhs.wisconsin.gov/medicaid/ via the NPI link or via another submission method as detailed in the March 2008 Update (2008-19), titled “Health Care Providers Are Required to Report Their National Provider Identifier to Wisconsin Medicaid Immediately.”

Refer to Attachment 1 of this Update for a screen shot of the Web-based application.

The NPI reported will be cross-referenced to the corresponding Medicaid provider number currently on file with BadgerCare Plus to process transactions.

National Provider Identifier Confirmation Letter Data

When a provider initially reports his or her NPI to BadgerCare Plus, an NPI confirmation letter acknowledging receipt is sent. The NPI confirmation letter lists the provider's reported NPI, designated taxonomy code, and ZIP code data from the provider information on file with BadgerCare Plus at the time the NPI was reported. Providers are cautioned that any changes to certification or address information after reporting NPI to BadgerCare Plus may alter their appropriate taxonomy code or ZIP code data that was originally listed on the confirmation letter.

Providers are responsible for keeping their information current with BadgerCare Plus and for submitting the correct data on their transactions. Attachment 4 of this Update is a table of required taxonomy codes for BadgerCare Plus. Providers should refer to this list for any changes to provider type and specialty that may affect the designated taxonomy code or if they do not have access to their original NPI confirmation letter.

Provider Exceptions

As previously published, analysis of federal law has identified personal care only providers, specialized medical vehicle providers, blood banks, and Community Care Organizations as providers of non-healthcare services which makes them exempt from the NPI requirement. These are the only providers required to continue indicating their Medicaid provider number on standard electronic transactions. Transactions submitted by these providers with an NPI will be denied.

Business Functions Continuing to Utilize Medicaid Provider Numbers

Certain business functions will not be affected by NPI implementation and will continue to require and send Medicaid provider numbers until ForwardHealth interChange implementation in October 2008.

Paper Claims

All paper claim forms will require Medicaid provider numbers. Paper claims submitted with NPI and related data only will be denied, including paper Medicare crossover claims.

Paper Remittance and Status Reports

All paper Remittance and Status Reports (R/S) will reflect Medicaid provider numbers only and not an NPI.

Prior Authorization Requests

Paper prior authorization (PA) request forms will require Medicaid provider numbers. Paper PAs submitted with NPI and related data only will be returned, which may affect the processing date. The following PA functions will continue to require Medicaid provider numbers:

• Specialized Transmission Approval Technology- Prior Authorization (STAT-PA).
• Web PA.

Provider Certification and Maintenance

BadgerCare Plus will continue to issue Medicaid provider numbers for certification. Additionally, providers are required to continue indicating their Medicaid provider number on all documents to update certification information with BadgerCare Plus.

Other Business

The following business functions will continue to utilize Medicaid provider numbers:

• Automated Voice Response System.
• Level of Care Request forms (nursing home providers only).
• Omnibus Budget Reconciliation Act (OBRA) nurse forms (nursing home providers only).
• Provider Services inquiries.

Refer to Attachment 2 for business functions that will continue to utilize Medicaid provider numbers.

Required Data for National Provider Identifier

Many health care providers obtained one NPI corresponding to one Medicaid provider number, whereas others have one NPI corresponding to multiple Medicaid provider numbers. To determine the correct provider file to be used when processing standard electronic transactions with an NPI, other data will be required to be submitted by providers on standard electronic transactions. Therefore, health care providers who indicate only their NPI on standard electronic transactions will be required to indicate the NPI that was reported to BadgerCare Plus and also the following data:

• Taxonomy code that is required by BadgerCare Plus, as further detailed in this Update.
• ZIP+4 code that corresponds to the physical address on file with BadgerCare Plus.

Additionally, certain provider types will be required to indicate Contract Information Segment (CN1) data. Contract Information Segment is a data element on 837 Health Care Claim: Institutional (837I) and 837 Health Care Claim: Professional (837P) transactions. The CN1 is not required data for all providers — only for those providers who cannot be uniquely identified by NPI, taxonomy code, and ZIP+4 code data. The CN1 data requirement applies to the following provider types only:

• Hospitals (when billing 837I only for the services listed in Attachment 3).
• Case management.
• Community Support Program.
• Comprehensive Community Services.
• Crisis intervention providers.
• Day treatment providers.
• Prenatal Care Coordination.

Attachment 3 lists CN1 value codes.

Note:

Failure to indicate taxonomy code, ZIP+4 code, and CN1 data, if applicable, may result in claim denials or incorrect payments.

Taxonomy Code

Taxonomy codes are standard code sets used to provide information about the provider type and specialty. A taxonomy code is designated for provider types by BadgerCare Plus. The designated taxonomy code may not be the one providers originally submitted to the National Plan and Provider Enumeration System (NPPES) when obtaining their NPI. It is important for providers to indicate the taxonomy code required by BadgerCare Plus.

Note:

The taxonomy code required by BadgerCare Plus does not change provider certification or reimbursement terms.

ZIP+4 Code

The ZIP+4 code is the ZIP code of a provider’s physical address on file with BadgerCare Plus. Providers should ensure that their physical address is kept current with BadgerCare Plus so the appropriate ZIP+4 code is utilized. Providers may verify the ZIP+4 code for their address on the United States Postal Service Web site at www.usps.com/. The ZIP+4 code must be used on standard electronic transaction.

Electronic Claim Modifications

On and after May 19, 2008, standard electronic transactions, including National Council for Prescription Drug Programs Telecommunications Standard Format Version 5.1 (NCPDP 5.1), will accept an NPI and/or a Medicaid provider number.

Refer to Attachment 2 for a table of standard electronic transactions with acceptable identifiers and required data.

837 Health Care Claims: Institutional

On 837I transactions directly submitted to BadgerCare Plus, an NPI and/or a Medicaid provider number will be accepted for the billing provider and for other providers, including referring, attending, and admitting providers. The following conditions must be met for a health care provider to successfully submit an NPI on 837I transactions:

• The billing provider's NPI is on file with BadgerCare Plus.
• The required taxonomy code, current ZIP+4 code, and CN1 value code, if applicable, are indicated.

837 Health Care Claims: Professional

On 837P transactions directly submitted to BadgerCare Plus, an NPI and/or a Medicaid provider number will be accepted for billing, rendering, and referring providers. The following conditions must be met for a health care provider to successfully submit an NPI on 837P transactions:

• The billing provider's NPI is on file with BadgerCare Plus.
• The rendering provider's NPI is on file with BadgerCare Plus.
• The required taxonomy code, current ZIP+4 code, and CN1 value code, if applicable, are indicated.

837 Health Care Claims: Dental

On 837 Health Care Claim: Dental (837D) transactions directly submitted to BadgerCare Plus, an NPI and/or a Medicaid provider number will be accepted for billing and rendering providers. The following conditions must be met for a dental provider to successfully submit an NPI on 837D transactions:

• The billing provider's NPI is on file with BadgerCare Plus.
• The rendering provider's NPI is on file with BadgerCare Plus.
• The required taxonomy code and current ZIP+4 code are indicated.

Crossover Claims Received Automatically from Medicare

On 837I and 837P transactions submitted to Medicare that automatically crossover to Wisconsin Medicaid and BadgerCare Plus, health care providers indicating an NPI are required to adhere to the following guidelines as they apply:

• Providers with one NPI corresponding to one Medicaid provider number will be required to indicate the NPI that was reported to BadgerCare Plus in the Billing Provider Secondary Identification element on the claim.
• Providers with more than one NPI corresponding to a single Medicaid provider number are required to indicate the NPI listed as the secondary NPI on their confirmation letter in the Billing Provider Secondary Identification element on the claim.

Providers are encouraged to indicate their Medicaid provider number on Medicare claims that automatically crossover to Wisconsin Medicaid and BadgerCare Plus. Providers who submit electronic claims to Medicare are required to report their NPI to Wisconsin Medicaid and BadgerCare Plus to ensure successful processing of the crossover claims

Crossover Claims Submitted by Providers Electronically

On provider-submitted crossover 837I and 837P transactions, the Medicaid provider number and/or NPI with related data will be accepted.

National Council for Prescription Drug Programs Version 5.1

On and after May 19, 2008, the billing provider’s Medicaid provider number or NPI for the billing provider will be accepted on NCPDP 5.1 transactions. BadgerCare Plus supports the Workgroup for Electronic Data Interchange’s (WEDI) recommendation published in the WEDI National Provider Identifier White Papers that pharmacies obtain a unique NPI per licensed store and/or certification. If there is not a unique NPI for each certification, then claims will default to the first active certified pharmacy on file with BadgerCare Plus. In these instances, the provider will be responsible to post claims with the appropriate identifier.

Note:

Indicating an NPI for the billing provider on the NCPDP 5.1 transaction requires the billing provider’s NPI be on file with BadgerCare Plus for successful processing.

Prescriber ID Modification

On and after May 19, 2008, either a Drug Enforcement Agency (DEA) number or an NPI will be accepted in the Prescriber ID field of NCPDP Version 5.1 transactions.

Provider Electronic Solutions Software

In May 2008, Provider Electronic Solutions (PES) software will be modified to accommodate NPI. An R/S message will inform providers to download the PES NPI upgrade. Once the upgrade is applied, PES claims submission software will accept an NPI or Medicaid provider number. Billing providers indicating NPI will also be required to include a taxonomy code, ZIP+4 code, and CN1 data, if applicable, on PES transactions.

Remittance Advice

835 Health Care Claim Payment/Advice Transactions for 837 Transactions

On and after May 19, 2008, provider data indicated on 837 transactions will determine how claims are reported on the 835 response as follows:

• If an NPI and related data only are indicated on all 837 transactions submitted within the same processing cycle by the same billing provider, and the NPI is on file with BadgerCare Plus, the NPI will be reported in the 1000B loop of the 835 response.
• If a Medicaid provider number only is indicated on all 837 transactions submitted within the same processing cycle by the same billing provider, the Medicaid provider number will be reported in the 1000B loop of the 835 response.
• If a Medicaid provider number only is indicated on some 837 transactions and an NPI with related data only are indicated on other 837 transactions submitted within the same processing cycle by the same billing provider, the identifier indicated on the first processed claim will be reported in the 1000B loop on the 835 response; the NPI if first processed or the Medicaid provider number if first processed.
• If both the Medicaid provider number and NPI with related data are dually indicated on 837 transactions within the same processing cycle by the same billing provider, the NPI will be reported in the 1000B loop of the 835 response.

835 Health Care Claim Payment/Advice Transactions for National Council for Prescription Drug Programs Version 5.1 Transactions

On and after May 19, 2008, provider data indicated on NCPDP 5.1 transactions will determine how the transaction is reported on the 835 response as follows:

• If an NPI is indicated on all NCPDP 5.1 transactions submitted within the same processing cycle by the same billing provider, and the NPI is on file with BadgerCare Plus, the NPI will be reported in the 1000A loop of the 835 response.
• If a Medicaid provider number is indicated on all NCPDP 5.1 transactions submitted within the same processing cycle by the same billing provider, the Medicaid provider number will be reported in the 1000B loop of the 835 response.
• If a Medicaid provider number is indicated on some NCPDP 5.1 transactions and an NPI is indicated on other NCPDP 5.1 transactions submitted within the same processing cycle by the same billing provider, the identifier indicated on the first processed claim will be reported in the 1000B loop on the 835 response; the NPI if first processed or the Medicaid provider number if first processed.

Remittance and Status Reports

Paper R/S Reports will continue to reflect only Medicaid provider numbers at this time, including those for electronic claims that indicate an NPI only. The NPI will be cross-referenced to the Medicaid provider number on file and the Medicaid provider number will be the identifier reported on the R/S Report for these claims.

Note:

Indicating an NPI on standard electronic transactions requires the NPI be on file with BadgerCare Plus in order to be successfully cross-referenced to the Medicaid provider number.

270/271 Health Care Eligibility/Benefit Inquiry and Information Response

The 270/271 Health Care Eligibility/Benefit Inquiry and Information Response (270/271) will accept and send either the Medicaid provider number or the NPI. The identifier on the 270 will be verified to ensure that it is associated with a valid certification on file and the 271 response will report the same identifier indicated on the incoming 270.

Note:

Indicating an NPI on 270 transactions requires the provider's NPI be on file with BadgerCare Plus for successful processing.

Companion Documents

In April 2008, revised companion documents incorporating NPI and related data will be available on the Wisconsin Medicaid Web site at dhs.wisconsin.gov/medicaid/. Providers should work with their trading partners, clearinghouses, billing services, and other vendors that may be affected by companion document changes to ensure they are prepared for NPI modifications to standard electronic transactions.

Commercial Health Insurance

BadgerCare Plus continues to be the payer of last resort. Providers are required to bill commercial health insurance and follow standard billing procedures. Claim denials from other payers relating to NPI and related data should be resolved with that payer and not submitted to BadgerCare Plus. Payments made by BadgerCare Plus in these situations may be recouped.

Attachment 1 — Reporting a National Provider Identifier Online
Attachment 2 — National Provider Identifier Reference Guide
Attachment 3 — Contract Information Segment Value Codes
Attachment 4 — BadgerCare Plus Required Taxonomy Codes