- 1. Minnesota HIPAA Collaborative Provider Enumeration
Strategies Patrice KuppeAllina Hospitals and Clinics
2. Provider Enumeration Strategies
- Strategies for People and Organizations
3. Provider Enumeration Strategies
- Two Types of Enumeration Considerations
4. Provider Enumeration Strategies / People
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- (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
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- What types of providers show up on your claims? Employed?
Contracted? Non-Employed? (Referring, Ordering)
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- How many do you have of each?
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- 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
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- Pro - Gives you better control over obtaining the NPI
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- Pro - Number is available for billing
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- 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
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- Print Application. Complete in with data you know. Highlight
anything missing*Taxonomy
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- 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
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- 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
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- Pro - Helps reinforce that the NPI is theirs
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- Con - May be more work to obtain NPI from provider than if you
do it for them
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- Create notification telling them NPI is required
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- Require NPI and NPI notification letter issued by NPPES
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- Create monitoring process to perform follow-up for those that
are missing
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- Create incentives as we get closer to the deadline
9.
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- 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
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- Pick a date as deadline approaches to run reports on who is
still missing
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- 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
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- Notify provider to provide NPI
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- Provider should work with their employer to obtain NPI
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- 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
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- Notify provider to provide NPI
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- Provider should work with their employer to obtain the NPI
- Provider should supply NPI to you Start asking today
12.
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- 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
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- 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
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- An individual cannot be a subpart
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- 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
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- Does the department/group currently have a separate provider
number in order to adhere to Federal Regulation such as DME?
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- 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
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- 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 TimbuktuNPI 1 Payer C Payer B Payer A Medicare Fclty Nme 17.
Provider Enumeration Strategies / Organization
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- One NPI to one legacy ID = Lowest risk
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- Health plan has a one-one match - easy crosswalk
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- Many NPIs to one legacy ID = Medium risk
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- Many to one mapping eases burden on plan. If health plan
creates accurate crosswalk should be low risk
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- One NPI to many legacy IDs = Highest risk
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- 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
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- Consideration could be given to legal status, state licensure,
tax identities, and existing health plan requirements
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- 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
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- include Medicare special enrollment criteria, (e.g. exempt
psych unit)
- Second step assess the reasons behind organizational
enumeration
- Third step Decide your preferred method
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- Identify any impacted areas
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- 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.
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- 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
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- Each provider should then uniformly bill all payers using its
chosen level of granularity
Provider Enumeration Strategies / Organization 22. Provider
Enumeration Strategies / Organization
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- Identified payers who assigned unique payer specific group
numbers
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- Determined where the gaps occurred
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- Contacted payers where enumeration gaps were identified and
collaboratively worked with payers on changes
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- Reviewed our proposed subpart scheme with the payer to
determine if there were major issues arising from change in
enumeration
23.
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- Most enumeration differences could be accommodated by
information in the claim itself
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- 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
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- Electronic File Interchange (EFI)
25. Provider Enumeration Strategies / Applications
- Before you begin, make sure you have the following
information
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- State of Birth (if Country of Birth is U.S.)
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- Practice Location Address and Phone Number
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- Taxonomy (Provider Specialty)
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- State License Information**required for certain taxonomies
only
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- Contact Person Phone Number and e-mail
26.
- Taxonomy may be required on claims
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- 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
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- Dermatology- 207N00000X [more]
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- Clinical & Laboratory Dermatological Immunology- 207NI0002X
[more]
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- Dermatological Surgery- 207NS0135X [more]
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- Dermatopathology- 207ND0900X [more]
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- MOHS-Micrographic Surgery- 207ND0101X [more]
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- 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
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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
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- Cons: Slowest Method, Risk of NPPES keying wrong data
28. Provider Enumeration Strategies / Applications
- Web - https://nppes.cms.hhs.gov
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- Real-time check for missing information
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- The NPI for the individual or the organization applying on-line
will be issued via an e-mail or through regular mail
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- Use the applications navigation buttons, NEXT or PREVIOUS - Do
NOT use the browsers buttons, BACK and FORWARD
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- Print each page as you complete the application to keep a
record of your file
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- Save your username and password for future use
29.
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- Approved EFI filing organizations submit multiple applications
in one batch file instead of single paper or Web applications
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- The EFI filing organization must obtain authorization from each
provider and must certify the accuracy of the data
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- 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
athttps://nppes.cms.hhs.gov/NPPES/EFIHome.do
Provider Enumeration Strategies / Applications 30.
- How long will it take to get aNPI ?
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- CMS FAQ:Cant predict the amount of time it will take because
several factors come into play
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- volume of applications being processed at a given time
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- whether the application was submitted electronically or on
paper
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- 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
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- Mailed to the contact person identified by the health care
provider in the application (sometimes the contact person is also
the health care provider)
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- 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
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- E-mailed to those health care providers (individuals and
organizations) who apply for NPIs via the web-based process
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- 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)
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- This type of notification will not contain any specific
logos
Provider Enumeration Strategies / Notifications 32. Provider
Enumeration Strategies / Notifications
- NPI notification from EFI Organization
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- 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
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- May go to the contact person or to the health care provider;
this is determined by each EFIO
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- The NPI notification generated by the EFIOs will have various
formats, determined by each EFIO but consistent with CMS
requirements
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- Every NPI notification generated by an EFIO must contain the
health care providers name, address and NPI
33. Provider Enumeration Strategies / Notifications
- How to Obtain NPI notification - Needed for Medicare
Enrollment
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- The provider can callNPI Enumerator at 1-800-465-3203 to have
another NPI notification generated
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- If the health care provider was enumerated via EFI, the health
care provider must contact the EFI organization (EFIO) for a copy
of the EFIOs notification
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- The provider can log onto NPPES website
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- 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
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- 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
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- Then print a copy of the screenshot