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Minnesota HIPAA Collaborative 	 Minnesota HIPAA Collaborative
Minnesota HIPAA Collaborative 	 Minnesota HIPAA Collaborative
Minnesota HIPAA Collaborative 	 Minnesota HIPAA Collaborative
Minnesota HIPAA Collaborative 	 Minnesota HIPAA Collaborative
Minnesota HIPAA Collaborative 	 Minnesota HIPAA Collaborative
Minnesota HIPAA Collaborative 	 Minnesota HIPAA Collaborative
Minnesota HIPAA Collaborative 	 Minnesota HIPAA Collaborative
Minnesota HIPAA Collaborative 	 Minnesota HIPAA Collaborative
Minnesota HIPAA Collaborative 	 Minnesota HIPAA Collaborative
Minnesota HIPAA Collaborative 	 Minnesota HIPAA Collaborative
Minnesota HIPAA Collaborative 	 Minnesota HIPAA Collaborative
Minnesota HIPAA Collaborative 	 Minnesota HIPAA Collaborative
Minnesota HIPAA Collaborative 	 Minnesota HIPAA Collaborative
Minnesota HIPAA Collaborative 	 Minnesota HIPAA Collaborative
Minnesota HIPAA Collaborative 	 Minnesota HIPAA Collaborative
Minnesota HIPAA Collaborative 	 Minnesota HIPAA Collaborative
Minnesota HIPAA Collaborative 	 Minnesota HIPAA Collaborative
Minnesota HIPAA Collaborative 	 Minnesota HIPAA Collaborative
Minnesota HIPAA Collaborative 	 Minnesota HIPAA Collaborative
Minnesota HIPAA Collaborative 	 Minnesota HIPAA Collaborative
Minnesota HIPAA Collaborative 	 Minnesota HIPAA Collaborative
Minnesota HIPAA Collaborative 	 Minnesota HIPAA Collaborative
Minnesota HIPAA Collaborative 	 Minnesota HIPAA Collaborative
Minnesota HIPAA Collaborative 	 Minnesota HIPAA Collaborative
Minnesota HIPAA Collaborative 	 Minnesota HIPAA Collaborative
Minnesota HIPAA Collaborative 	 Minnesota HIPAA Collaborative
Minnesota HIPAA Collaborative 	 Minnesota HIPAA Collaborative
Minnesota HIPAA Collaborative 	 Minnesota HIPAA Collaborative
Minnesota HIPAA Collaborative 	 Minnesota HIPAA Collaborative
Minnesota HIPAA Collaborative 	 Minnesota HIPAA Collaborative
Minnesota HIPAA Collaborative 	 Minnesota HIPAA Collaborative
Minnesota HIPAA Collaborative 	 Minnesota HIPAA Collaborative
Minnesota HIPAA Collaborative 	 Minnesota HIPAA Collaborative
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Minnesota HIPAA Collaborative Minnesota HIPAA Collaborative

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  • Transcript

    • 1. Minnesota HIPAA Collaborative Provider Enumeration Strategies Patrice Kuppe Allina Hospitals and Clinics
    • 2. Provider Enumeration Strategies
      • Strategies for People and Organizations
      • Tools for enumeration
        • Web
        • Paper
        • EFI
      • NPI Notifications
    • 3. Provider Enumeration Strategies
      • Two Types of Enumeration Considerations
        • Type 1 People
        • Type 2 Organizations
    • 4. Provider Enumeration Strategies / People
      • START NOW
        • Perform Assessment
        • Obtain NPIs
        • (Dissemination and Testing are covered in later presentations)
      • Proper preparation and business need assessment is critical to keep the revenue cycle intact
      • Require all new providers to obtain a NPI prior to hiring or granting privileges
    • 5. Provider Enumeration Strategies / People
      • Assessment
        • What types of providers show up on your claims? Employed? Contracted? Non-Employed? (Referring, Ordering)
        • How many do you have of each?
        • Do you have current contact information for these providers?
      • Create strategy on how you will obtain NPIs for each type
      • No information yet on industry-wide dissemination
    • 6. Provider Enumeration Strategies / People
      • Employed – You apply for the Provider
      • Get legal opinion before you apply
        • Pro - Gives you better control over obtaining the NPI
        • Pro - Number is available for billing
        • Con - Does not reinforce to the provider that this is their number to own for life
    • 7. Provider Enumeration Strategies / People
      • Employed – You apply for the Provider
      • Required written authorization from provider
        • Print Application. Complete in with data you know. Highlight anything missing *Taxonomy
        • Mail to provider. Enclose letter explaining if they sign, they are authorizing you to obtain the NPI for them. Explain this is their number, they own it for life
        • Apply for NPI on-line. Save original signed application. Send NPI notice and copy of original application to provider. Remind them they own NPI and are responsible for changes or updates
    • 8. Provider Enumeration Strategies / People
      • Employed – Provider obtains and reports their own NPI
        • Pro - Helps reinforce that the NPI is theirs
        • Con - May be more work to obtain NPI from provider than if you do it for them
        • Create notification telling them NPI is required
        • Require NPI and NPI notification letter – issued by NPPES
        • Create monitoring process to perform follow-up for those that are missing
        • Create incentives as we get closer to the deadline
    • 9.
      • Change Processes Now
        • Pick a date and inform all upfront business processes (hiring, scheduling, credentialing, etc) that from THIS date forward no one is allowed into your system without an NPI
        • Pick a date as deadline approaches to run reports on who is still missing
        • Enclose information in pay check notices
      Provider Enumeration Strategies / People
    • 10. Provider Enumeration Strategies / People
      • Contracted – They get their own NPI
      • Main employer should take on the burden
        • Notify provider to provide NPI
        • Provider should work with their employer to obtain NPI
        • Provider should supply NPI and notification letter to you
    • 11. Provider Enumeration Strategies / People
      • Referring, Ordering – They get their own NPI
      • Main employer should take on the burden
        • Notify provider to provide NPI
        • Provider should work with their employer to obtain the NPI
      • Provider should supply NPI to you – Start asking today
    • 12.
      • Organizations
        • Clinics, hospitals, nursing homes, durable medical equipment suppliers, clinical laboratories, pharmacies, and many other “institutional” type providers
      • Within an organization you may have a subpart
        • Subparts by definition are not legal entities; a provision of health care is presumed
      Provider Enumeration Strategies / Organization
    • 13.
      • The subpart designation applies only to a department or group within a larger organization
        • An individual cannot be a subpart
        • A clinical laboratory in a hospital may be considered a subpart but the pathologist within is not (although s/he may obtain an Individual or Type 1 Entity NPI)
      Provider Enumeration Strategies / Organization
    • 14.
      • Considerations on determining subparts
        • Does the department/group currently have a separate provider number in order to adhere to Federal Regulation such as DME?
        • If the department/group were a separate legal entity, would it be a health care provider required to obtain an NPI?
      Provider Enumeration Strategies / Organization
    • 15.
      • Assess current state of health plan legacy numbers
      • Document your current state
        • Look at claims
        • Look at enrollment files and/or billing tables
      • Are your organizations subparted differently by health plans?
      Provider Enumeration Strategies / Organization
    • 16. Provider Enumeration Strategies / Organization 231725700 37906 5T985BU DME12345 Paris DME NPI 3 231725700 75142 5T985BU CO1111 Paris Mental Health 231725700 37906 5T985BU CO1111 Paris NPI 2 344825800 75142 49825AN C01111 Timbuktu Mental Health 344825800 37905 49825AN CO1111 Timbuktu NPI 1 Payer C Payer B Payer A Medicare Fclty Nme  
    • 17. Provider Enumeration Strategies / Organization
      • Determine Risk
        • One NPI to one legacy ID = Lowest risk
          • Health plan has a one-one match - easy crosswalk
        • Many NPIs to one legacy ID = Medium risk
          • Many to one mapping eases burden on plan. If health plan creates accurate crosswalk should be low risk
        • One NPI to many legacy IDs = Highest risk
          • Health plan has to use other data in the claim to match the provider if they plan to maintain crosswalk to legacy IDs
    • 18.
      • Organizational Providers are required to determine if they need to identify subparts
        • Consideration could be given to legal status, state licensure, tax identities, and existing health plan requirements
        • Subparts that conduct their own HIPAA transactions must have their own NPI
      Provider Enumeration Strategies / Organization
    • 19.
      • NPPES does not associate the Organizational Provider NPIs to their subpart NPIs or any employee individual NPIs
      • Every NPI assigned is unique to that provider without regard to address, EIN, organization name(s), or any other data element that may be identical or shared between two or more providers
      Provider Enumeration Strategies / Organization
    • 20. Provider Enumeration Strategies / Organization
      • First step – Document how you are enrolled with all payers
        • include Medicare special enrollment criteria, (e.g. exempt psych unit)
      • Second step – assess the reasons behind organizational enumeration
        • Payer contract reason
        • Federal Regulation
      • Third step – Decide your preferred method
        • Identify any impacted areas
        • For subparts that have one NPI to many legacy IDs you should determine if there is other data on claim to help payer determine your organization
      • Goal is to use the same NPI scheme for all payers
    • 21.
      • Industry Recommendations
        • WEDI recommends to CMS and the industry that providers should determine their subparts as required by applicable Federal regulation and also determine any further subparts that the Final Rule permits / what meets the providers needs
        • Each provider should then uniformly bill all payers using its chosen level of granularity
        • MN HIPAA Collab agrees
      Provider Enumeration Strategies / Organization
    • 22. Provider Enumeration Strategies / Organization
      • Allina Enumeration
        • Identified payers who assigned unique payer specific “group” numbers
        • Determined where the “gaps” occurred
        • Contacted payers where enumeration gaps were identified and collaboratively worked with payers on changes
        • Reviewed our proposed subpart scheme with the payer to determine if there were major issues arising from change in enumeration
    • 23.
        • Most enumeration differences could be accommodated by information in the claim itself
          • Location - Zip Code
          • Unique CPT Codes
        • Created spreadsheet of all organizations and related legacy IDs including data required for NPPES
      • Applied for 125 organization NPIs in 30 days through NPPES.
      Provider Enumeration Strategies / Organization
    • 24. Provider Enumeration Strategies / Applications
      • Three Methods for enumeration
        • Paper
        • Web
        • Electronic File Interchange (EFI)
    • 25. Provider Enumeration Strategies / Applications
      • Before you begin, make sure you have the following information
        • Provider Name
        • SSN
        • Provider Date of Birth
        • Country of Birth
        • State of Birth (if Country of Birth is U.S.)
        • Mailing Address
        • Practice Location Address and Phone Number
        • Taxonomy (Provider Specialty)
        • State License Information**required for certain taxonomies only
        • Contact Person Name
        • Contact Person Phone Number and e-mail
        • Legacy IDs
    • 26.
      • Taxonomy may be required on claims
        • 09/21/06 Medicare recently announced it will be required on institutional claims – See CMS FAQ : http://questions.cms.hhs.gov/cgi-bin/cmshhs.cfg/php/enduser/std_adp.php?p_faqid=7896 *
      • Determine how granular you want to be in descriptors
          • Dermatology -  207N00000X [more]
            • Clinical & Laboratory Dermatological Immunology -  207NI0002X [more]
            • Dermatological Surgery -  207NS0135X [more]
            • Dermatopathology -  207ND0900X [more]
            • MOHS-Micrographic Surgery -  207ND0101X [more]
            • Pediatric Dermatology -  207NP0225X [more]
      • *NOTE: CMS interpretations are subject to change. Verify their web for most current information
      Provider Enumeration Strategies / Applications
    • 27. Provider Enumeration Strategies / Applications
      • Paper
      • http://www.cms.hhs.gov/NationalProvIdentStand/Downloads/NPIapplication.pdf
      • Soon you will only be able to call NPPES to ask for the paper form 1-800-465-3203
        • Cons: Slowest Method, Risk of NPPES keying wrong data
    • 28. Provider Enumeration Strategies / Applications
      • Web - https://nppes.cms.hhs.gov
      • WEB advantages
        • Real-time check for missing information
        • The NPI for the individual or the organization applying on-line will be issued via an e-mail or through regular mail
      • Web Application Hints
        • Use the application’s navigation buttons, NEXT or PREVIOUS - Do NOT use the browser’s buttons, BACK and FORWARD
        • Print each page as you complete the application to keep a record of your file
        • Save your username and password for future use
    • 29.
      • EFI bulk enumeration
        • Approved EFI filing organizations submit multiple applications in one batch file instead of single paper or Web applications
        • The EFI filing organization must obtain authorization from each provider and must certify the accuracy of the data
        • After the NPIs are issued, the EFI filing organization will be responsible for distributing the NPIs to providers. Information on EFI bulk enumeration is available at https://nppes.cms.hhs.gov/NPPES/EFIHome.do
      Provider Enumeration Strategies / Applications
    • 30.
      • How long will it take to get a NPI ?  
        • CMS FAQ: Can’t predict the amount of time it will take because several factors come into play
          • volume of applications being processed at a given time
          • whether the application was submitted electronically or on paper
          • whether the application was complete and passed all edits
      • CMS expects that a health care provider who submits a properly completed electronic application could have its NPI in 10 days
      Provider Enumeration Strategies / Applications
    • 31.
      • NPI notification letter from NPPES
        • Mailed to the contact person identified by the health care provider in the application (sometimes the contact person is also the health care provider)
        • Contains both the Fox logo (Fox is the NPI Enumerator) and the Centers for Medicare and Medicare Services (CMS) logo
      • NPI notification e-mail from NPPES
        • E-mailed to those health care providers (individuals and organizations) who apply for NPIs via the web-based process
        • The e-mail notification is addressed and e-mailed to the contact person identified by the health care provider in the application (sometimes the contact person is also the health care provider)
        • This type of notification will not contain any specific logos
      Provider Enumeration Strategies / Notifications
    • 32. Provider Enumeration Strategies / Notifications
      • NPI notification from EFI Organization
        • Generated by EFIOs and is addressed and mailed or e-mailed to those health care providers (individuals and organizations) who have been enumerated via the EFI process
        • May go to the contact person or to the health care provider; this is determined by each EFIO
        • The NPI notification generated by the EFIOs will have various formats, determined by each EFIO but consistent with CMS requirements
        • Every NPI notification generated by an EFIO must contain the health care provider’s name, address and NPI
    • 33. Provider Enumeration Strategies / Notifications
      • How to Obtain NPI notification - Needed for Medicare Enrollment
        • The provider can call NPI Enumerator at 1-800-465-3203 to have another NPI notification generated
        • If the health care provider was enumerated via EFI, the health care provider must contact the EFI organization (EFIO) for a copy of the EFIO’s notification
        • The provider can log onto NPPES website
          • Print a copy of the NPPES screenshot. The NPPES screenshot includes the name of the health care provider, the NPI, the Entity Type and the NPI Status
          • Health care providers who applied for an NPI via paper or EFI can select the ‘Create Login to View or Update your NPI Data’ link
            • Create a web login
            • Then print a copy of the screenshot

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