Minnesota HIPAA Collaborative Minnesota HIPAA Collaborative

Minnesota HIPAA Collaborative Provider Enumeration Strategies Patrice Kuppe Allina Hospitals and Clinics

Provider Enumeration Strategies

Strategies for People and Organizations

Tools for enumeration

Web

Paper

EFI

NPI Notifications

Provider Enumeration Strategies

Two Types of Enumeration Considerations

Type 1 People

Type 2 Organizations

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

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

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

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

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

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

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

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

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

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)

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?

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 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

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

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

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

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

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

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

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 / Applications

Three Methods for enumeration

Paper

Web

Electronic File Interchange (EFI)

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

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

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

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

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

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

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

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

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