Obtaining Additional NPIs To Resolve Claim Issues -Groups/Organizations Only

This instruction is only relevant to groups and organizations who are in the process of obtaining additional NPIs in response to:

• Development letters sent by Highmark Medicare Services indicating they have one NPI corresponding to more than one Medicare legacy identifier (PIN), or
   
• Claim processing issues related to invalid NPI/legacy PIN combinations

If you have experienced either situation identified above, follow these steps to take corrective action:

• Review the CMS "Medicare Subpart Expectations Paper" to determine if you are eligible to obtain a separate NPI to correspond with each of your Medicare PINs.   This document is available at http://www.cms.hhs.gov/NationalProvIdentStand/Downloads/Medsubparts01252006.pdf.  If you are eligible to obtain additional NPIs and wish to do so, please visit https://nppes.cms.hhs.gov/NPPES/Welcome.do and click on the NPI link to apply.
   
• Confirm whether the provider/supplier has been loaded into the national Provider Enrollment database, PECOS, by calling the Customer Contact Center at 1-866-488-0548 (Part B), 1-800-560-6170 (PA Part A), or 1-866-488-0545 (MD Part A).
   
• If the provider is not in PECOS, additional NPIs will only be crosswalked to existing legacy PINs if the data provided to NPPES matches Medicare legacy PIN data (e.g., provider legacy PIN, legal business name, Tax ID, practice address and zip code, type of NPI).   If you need to verify information contained within your legacy PIN file prior to submitting an NPPES application, contact Provider Enrollment Services at 1-866-488-0549.
   
• If the provider/supplier is in PECOS, additional NPIs can only be crosswalked to legacy PINs through an update to PECOS.  In lieu of submitting an 855 application, providers may complete and submit a spreadsheet to HMS to add these NPIs to the crosswalk file.  This spreadsheet must contain the information below.  NOTE:  The spreadsheet may not be used to add or modify any data on file for that legacy PIN, except the NPI.  If we identify new or modified information on the spreadsheet, an 855 application will be required.
   
• Current Medicare Legacy Identifier (legacy PIN, OSCAR);
• Legal Business Name (LBN);
• Tax Identification Number;
• Doing Business Name (DBA);
• Practice Address;
• Corresponding NPI;
• Phone Number.

Example

Please include a cover letter, describing your specific situation (i.e. claim rejections, development letters) and send the spreadsheet to:

Highmark Medicare Services
Provider Enrollment Services
P.O. Box 890157
Camp Hill, PA  17089-0157

Individual Physicians/Practitioners and Groups/Organizations - Choosing a Preferred PIN (PTAN) for your NPI 

If you continue to receive development letters from us indicating you have one NPI that corresponds to more than one Medicare legacy identifier (PIN/PTAN), and you are a group or an organization that is not eligible for additional NPIs, or you are an individual supplier who is, by law, not entitled to more than one NPI, there may be an answer.    

Effective the beginning of April, 2008, we now have the capability to ‘flag’ one of the PINs/PTANs linked to your NPI as “preferred” in our claims processing system.  What this means is, if you choose a preferred PIN/PTAN for your NPI, our claims system will process your claim(s) using the preferred selection when a unique match is not otherwise attainable via the routine NPI to PIN/PTAN crosswalking process.  This eliminates the requirement for us to develop to you for every claim where the system is unable to crosswalk the submitted NPI to one of your PINs/PTANs.

Please understand this option will not be a viable solution for every provider/supplier who has one NPI linked to multiple PINs/PTANs; there are some limitations.  We will have to review your provider file before a final determination can be made.  Some additional items to keep in mind:

• We will need signed consent prior to flagging a preferred PIN/PTAN and in some cases, we may need to request a complete CMS-855 enrollment application
• Only one preferred PIN can be chosen for an NPI
• The preferred PIN/PTAN selection process is valid only when crosswalking occurs for primary providers on a claim; it will not extend to secondary providers 

If you are interested in determining whether or not selecting a preferred PIN/PTAN could resolve your claim development issues, you can call our Provider Enrollment customer service line at 1-866-488-0549.  Also, we may be contacting you directly to offer this option in follow-up to responses we receive to development letters.  In either case, if you are interested in selecting a preferred PIN/PTAN, we will let you know what we need from you to facilitate the flagging process

Change of Information Request May Lead to Revocation

Highmark Medicare Services, in accordance with Section 7.1.1 of Chapter 10 in the Program Integrity Manual, will request a complete CMS-855 application, if a provider/supplier requests any change to the information on their file, and they are not in the Provider Enrollment Chain and Ownership System (PECOS).  The provider/supplier has 60 calendar days from the date of our request to furnish the entire CMS-855 application.

If the provider/supplier fails to submit a complete application within the 60-day period, we are required by CMS to take steps to revoke the provider’s/supplier’s billing privileges.  If your Medicare billing privileges are revoked, your Medicare provider agreement (approval to participate in the Medicare program) will be terminated by act of regulation (42CFR 424.535(b)).

You may submit a Corrective Action Plan (CAP) within 30 days after the postmark date of the revocation.  Submission of a CAP shall contain, at a minimum, verifiable evidence of the provider’s/supplier’s compliance at the time the revocation was issued.  If a CAP is approved, billing privilege will be reissued retroactive to the date of the revocation.  If a CAP is not approved, your next course of action is to request a Reconsideration/Appeal.

To avoid revocation, please submit all information requested by Highmark Medicare Services, in order to furnish the entire CMS-855 application, within 60 calendar days from the date of the request.  If you would like to speak with an Enrollment Representative, please call (866) 488-0549 between the hours of 8:30 a.m. and 4:15 p.m. Monday through Thursday and 8:30 a.m. through 1:30 p.m. on Friday.

The following newly mandated guidelines have contributed to delays in processing CMS-855 applications.  This article includes a description of some of those changes, and some helpful information to ensure submission of complete and accurate applications.

1. The new (06/2006) version of CMS-855 enrollment applications must be used.  Although these forms have been improved, because of the changes, we are experiencing an increase in returns and development due to inaccurate or missing information.  Over 60% of the forms we receive are missing required information or attachments used for verification, or have information within the application, but not in the proper field(s).  This causes delays in processing.
   
   • CMS requires us to immediately return an application if any of the following conditions exist:
     
     • There is no signature on the CMS-855 application
       
     • The 11/2001 version of a CMS-855 application was submitted
       
     • The application contains a copied or stamped signature
       
     • The signature on the application is not dated
       
     • The CMS-855I application is signed by someone other than the individual practitioner applying for enrollment
       
     • The applicant fails to submit all forms needed to process a reassignment package within 15 calendar days of receipt
       
     • The applicant sends its CMS-855 application to the wrong contractor (e.g. the application was sent to Carrier X instead of Carrier Y)
       
     • The applicant completes the application in pencil
       
     • The applicant submits the wrong application (e.g., a CMS-855B is submitted to a fiscal intermediary)
       
     • A web-generated application does not appear to have been downloaded from CMS’ web site
       
     • The application was not mailed (i.e., it was faxed or e-mailed)
       
     • A CMS-855 application is submitted more than 30 days prior to the effective date listed within the application (this does not apply to certified providers, ambulatory surgical centers, or portable x-ray suppliers.)
       
     • A provider/supplier submits a new CMS-855 application prior to the expiration of the time period in which the provider/supplier is entitled to appeal the denial of a previously submitted application
       
     • The applicant submits a CMS-855 application for the sole purpose of enrolling in Medicaid
       
     • A CMS-855 is not needed for the transaction in question   (e.g. an enrolled physician is reassigning benefits and submits both a CMS-855I   and a CMS-855R; since only the CMS-855R is needed, the CMS-855I will be returned)
       
     • A CMS-588 is sent as a stand-alone change of information request (i.e., it is not accompanied by a CMS-855) but was (1) unsigned, (2) undated, or (3) contained a copied, stamped, or faxed signature
       
     • A CMS-855R is submitted, and the group practice is already enrolled; however, the authorized official is not on file – we will return the CMS-855R and request the group submit a CMS-855B change request to add the authorized official
       
       
2. CMS requires us to pre-screen all applications for missing data elements.  While we strive to request information for all missing data elements during the prescreening process, at times we may need to ask for additional information during verification and credentialing of your application as well.  If you receive a request for additional information, include all the information requested in your reply and direct it to the attention of the specialist who sent the request letter; this expedites handling and speeds up processing of your application.  When development is required, whether during the pre-screening or credentialing phase, we have found applicants most often overlook the following (not listed in any particular order): 
   
   
   • The certification information in Section 2 of the CMS-855I and CMS-855B applications is not completed – the checkbox must either indicate certification information is not applicable to the applicant, or the certification number, State where issued, effective date and expiration date information must be provided
     
   • If the applicant is reassigning all Medicare benefits, or is a physician assistant, we must have your Medicare identification number and National Provider Identifier (NPI) in Section 1A of the CMS-855I application
     
   • Section 1 of the CMS-855R must contain the effective date when the individual practitioner began seeing patients on behalf of the group
     
   • A newly signed and dated certification statement is required when returning information subsequent to a request for additional or missing information – we cannot accept the original certification statement; even if it is re-signed and re-dated
     
   • If an individual practitioner is reassigning benefits to a group(s) by submission of a CMS-855R, and is also concurrently enrolling via submission of a CMS-855I, the individual must list all groups to which he/she is reassigning benefits in Section 4B of the CMS-855I
     
   • At least one owner and one managing employee must be reported in Section 6 of the CMS-855B application – this individual can be the same person
     
     
3. The National Provider Identifier (NPI) number is now a required element on each CMS-855 application.  Providers must also supply a copy of the notice (e-mail or letter - generated from the National Plan and Provider Enumeration System [NPPES]) sent to them from the NPI Enumerator so we can verify the NPI.  We are instructed to request the NPI notification as an attachment with each 855.  If the information on the NPI notification does not match the information on other official sources, we will request that you correct this information on the NPPES file.  We will not be able to finalize processing your CMS-855 until issues of this nature are resolved.  (Example:  The NPI notification lists the name as Tom Jones’ Medical Practice, while the IRS tax document lists the name as Dr. Thomas Jones’ Medical Practice, PC)
   
4. The CMS-588 form (Authorization for Electronic Funds Transfer) is now required in conjunction with all CMS-855 applications, whether the application is submitted for a new enrollee or to effectuate a change of information for an already enrolled provider (if the provider currently receives paper checks).  Tips:  
   
   
   • Have the bank fill out the routing number to avoid errors
     
   • To validate the bank account, you must submit a copy of a voided check, personalized deposit slip (starter checks cannot be used for this purpose) or confirmation of the bank account on bank letterhead signed by a bank official/officer - the letter must include the name of the account, electronic routing transit number, account number and type of account
     
   • Don’t forget to annotate Highmark Medicare Services in the “contractor” field on the CMS-588 form 
     
     
5. CMS requires us to request a full CMS-855 application if we receive a change of information request for an enrolled provider/supplier (including changes to EFT) when we do not yet have a record established for the provider/supplier in the national provider database, the Provider Enrollment, Chain and Ownership System (PECOS).  Tip – it is likely we’ll request a full application if you have not updated your file since approximately mid-2003.  We will also request full CMS-855 application if you are reactivating your file. 
   
   
6. As we have communicated in previous Medicare Report articles, and also outlined in the instructions within the CMS-855 applications, any change of information must be reported within 90 days of the effective date of the change.  The only exception is for changes of ownership or control, which must be reported within 30 calendar days of the effective date.  In accordance with 42 CFR 424.82 and 42 CFR 424.535, if a provider/supplier fails to timely report a change of information/ownership/control, we may deactivate the provider/supplier’s billing privileges.  In order to reactivate privileges, as mentioned above, the provider/supplier must submit a complete CMS-855 application.
   
   
7. Release of Information rules have been clarified by CMS.    We can only release enrollment information to the authorized/delegated official on file and our response must be in writing. 
   
   
   Tip:  We can talk about an application still in process with the contact person listed on that form.
   
   
8. We cannot mark or alter the CMS-855 applications in any way, so we may not accept information over the phone.   We also cannot highlight a blank form to instruct providers.