SPECIAL BULLETIN. NPI Implementation Overview. Period Announced! Contingency NPI. for Long Term Care (LTC) Providers INSIDE

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1 NATIONAL PROVIDER IDENTIFIER (NPI) SPECIAL BULLETIN for Long Term Care (LTC) Providers NPI Contingency Period Announced! See page 2 LONG TERM CARE SPECIAL BULLETIN NO. 205 JUNE 2007 This special bulletin is intended to notify Long Term Care providers of program changes related to the National Provider Identifier (NPI) implementation and the recently announced Contingency Period beginning May 21, NPI Implementation Overview The Health Insurance Portability and Accountability Act (HIPAA) of 1996 established the NPI as the standard unique identifier for health care providers and requires covered health care providers, clearinghouses, and health plans to use this identifier in HIPAA-covered transactions by May 23, On April 2, 2007, the Centers for Medicare & Medicaid Services (CMS) announced that it will allow contingency plans, not to extend beyond May 23, 2008, for entities that will not meet the May 23, 2007, deadline but who have demonstrated a good faith effort to meet the compliance date. As a result, NPI implementation will occur in phases for LTC providers. The intent of this special bulletin is to provide information regarding these different implementation dates and phases, and to detail the actions providers need to take to ensure a smooth transition to NPI. Providers should ensure their billing agency (vendor) is aware of and complies with the NPI requirements outlined in this bulletin. It is ultimately the provider s responsibility to ensure claims are submitted in accordance with all guidelines. INSIDE Long Term Care Providers 1 NPI Implementation Overview 1 NPI Contingency Period Announced 2 Atypical Provider Identifiers 3 Announcing TexMedConnect 5 Updated TMHP EDI Companion Guides 6 Vendor Testing Begins June New DADS Form NPI Information and Help 6 LTC Crosswalk Solution Developed for Claims Processing 7 Forms 8 DADS 1290 Claim Form 8 Quick Reference Guide 9 In order to avoid billing delays, LTC providers should have obtained their NPI or API (see page 3), and have reported their NPI to DADS by June 1, Copyright Acknowledgments Use of the American Medical Association s (AMA) copyrighted Current Procedural Terminology (CPT) is allowed in this publication with the following disclosure: Current Procedural Terminology (CPT) is copyright 2007 American Medical Association. All rights reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable Federal Acquisition Regulation System/Department of Defense Regulation System (FARS/DFARS) restrictions apply to government use. The American Dental Association requires the following copyright notice in all publications containing Current Dental Terminology (CDT) codes: CDT4/2007 [including procedure codes, definitions (descriptions), and other data] is copyrighted by the American Dental Association. (c) 2006 American Dental Association. All Rights Reserved. Applicable Federal Acquisition Regulation System/Department of Defense Acquisition Regulation System (FARS/DFARS) restrictions apply.

2 Long Term Care Providers NPI Contingency Period Announced Due to the CMS announcement on April 2, 2007 (see previous article), the Texas Health and Human Services Commission (HHSC) and TMHP have developed a phased approach to NPI implementation. Each phase is described in detail below. Phase One Began May 21, 2007 This first phase of the Contingency Period, called Enhanced Dual Strategy, began on May 21, 2007, and allows providers to submit an NPI in addition to a Contract Number on electronic transactions. Participation in Enhanced Dual Strategy is optional; providers may continue to submit claims with only the Contract Number. However, all providers are encouraged to submit an NPI when available. Electronic submitters, including third party billers, participating in the Enhanced Dual Strategy will notice the following changes: Claim transactions 837I/P/D include both the NPI (optional) and Billing Referral Number (optional) in addition to the Contract Number (required). Electronic Remittance & Status (ER&S) reports have been modified to include the NPI, Billing Referral Number, and Contract Number. To receive the Enhanced Dual Strategy version of the ER&S report, providers must contact the EDI Help Desk ( ). Eligibility verification requests include both NPI (optional) and Contract Number (required). However, the eligibility response has been modified to include the NPI, Billing Referral Number, and Contract Number. Both the NPI and Billing Referral Number are new to the response transaction, and a submitter that sends the NPI on the request must be prepared to accept the NPI and Billing Referral Number on the response. Throughout the Contingency Period, TDHconnect users may submit electronic transactions (837 and 270) with an NPI number in addition to the Contract Number. However, TDHconnect ER&S reports will not contain an NPI. Paper Claims During the Enhanced Dual Strategy phase, providers must continue submitting a Contract Number on all paper claims; an NPI is optional. The table below identifies NPI implementation milestones, including dates supporting Enhanced Dual Strategy: Date Milestone December 2006 NPI webpage released on the TMHP website at December 1, 2006 NPI submission to DADS began. January 1, 2007 TMHP accepts both the current Form 1290 and the NPI-supported Form 1290 (see article on page 6) with current Contract Numbers. March 2007 Enhanced Dual Strategy EDI companion guides available at May 14, 2007 NPI compliance EDI companion guides available. May 21, 2007 TDHconnect transactions 837 and 270 may continue to be submitted with an NPI in addition to the Contract Number. Note: TDHconnect ER&S reports will not contain an NPI. Electronic EDI transactions 837, 835, 270, and 271, and claim submissions available with NPI, Contract Number, and Billing Referral Number (Enhanced Dual Strategy). This does not include transactions submitted using TDHconnect. For questions, call the TMHP Call Center/Help Desk at Long Term Care Special Bulletin, No National Provider Identifier Special Bulletin

3 Long Term Care Providers Phase Two Begins July 30, 2007 The second phase of the Contingency Period begins on July 30, 2007, and allows EDI submitters to submit electronic transactions in the following ways: NPI-Only Contract Number-Only Both NPI and Contract Number (dual strategy) Note: The date when the Contingency Period ends and NPIonly compliance begins has not yet been determined. Monitor future provider notifications for the exact date of full NPI implementation. R&S Reports Beginning with paper R&S reports dated August 3, 2007, TMHP will include a Contract Number, NPI, and Billing Referral Number for those providers who have supplied DADS with their NPI number. ER&S Reports EDI providers who wish to receive NPI and related data beginning with ER&S reports dated August 3, 2007, must contact the EDI Help Desk and have reported their NPI to DADS. Providers may elect to receive NPI data on ER&S (835) responses in one of two ways: NPI and Contract Number. Providers may call the EDI Help Desk to receive the ER&S in a dual format. The ER&S will include Contract Number, NPI, and Billing Referral Number. NPI-Only*. Providers may call the EDI Help Desk to receive the ER&S in an NPI-Only format. The ER&S will include NPI and Billing Referral Number. Providers who do not wish to receive NPI data on their ER&S reports or have not supplied their NPI to DADS will continue to receive only a Contract Number on ER&S reports. Paper Claims During the Contingency Period, providers must continue submitting a Contract Number on all paper claims; an NPI is optional. * Providers who receive the NPI-Only format of the ER&S (835) will receive the pending ER&S report (277P) with Contract Number, NPI, and Billing Referral Number. The table below identifies NPI implementation milestones supporting the second phase of the Contingency Period: Date July 30, 2007 August 27, 2007 November 2007 November 2007 Atypical Provider Identifiers Milestone NPI (optional) and Contract Number (required) for paper claims on the new NPI-supported Form Previous versions of the form will be returned to providers. EDI/Third Party Billers may submit NPI compliant transactions (does not apply to TDHconnect). MESAV functionality available on Existing TDHconnect functionality will continue to be available until November TexMedConnect available on Receive and submit NPI and Billing Referral Number for electronic transactions only via TexMedConnect (see page 5). For questions, call the TMHP Call Center/Help Desk at Providers who do not offer healthcare services are not required to apply for an NPI, but must notify DADS that they are an atypical provider. All contract numbers must be listed on the DADS Contract NPI/API Association form (see Reporting your NPI to DADS, on the following page). DADS will assign a ten character atypical provider identifier for each of the contracts listed. For each contract, the API will be the letter D and the 9 digit contract number (e.g., D ). Beginning with NPI implementation, claims submitted by atypical providers must include an API. Note: Only the NPI can be entered into TDHconnect. An API will not be accepted until TexMedConnect is implemented in November 2007 (see article on page 5). National Provider Identifier Special Bulletin 3 Long Term Care Special Bulletin, No. 205

4 Long Term Care Providers Reporting Your NPI to DADS To recognize a provider by the NPI, a match must occur between the DADS contract/provider number and the NPI. Before submitting claims with an NPI, contracted LTC providers must report their NPI to DADS. After the NPI application is complete and an NPI is assigned, providers should forward the notice received from either NPPES or FOX systems immediately to DADS, with a copy of the Contract NPI/API Association Form. The purpose of this form is to notify DADS of the NPI number the provider intends to use when billing for services. This form can be downloaded from the DADS website at html. When completing the Contract NPI/API Association Form, enter the following: Contract Number (the current number sent on claims) - multiple numbers may be reported on one form. NPI number Doing business as (DBA) name, if available Service group the service group reflects services provided (e.g., meals, Home and Community Based Services [HCS], Community Based Alternatives [CBA], Medically Dependent Children's Program [MDCP]), or the group number (2, 3, 7, etc). Note: The API field may be disregarded on the Contract NPI/API Association Form if the provider has been issued an NPI (see Atypical Provider Identifiers on page 3). DADS has established three reporting methods for NPI notifications: Fax: Send a copy of the NPI assignment letter and a completed Contract NPI/API Association form to DADS at (512) Forward a copy of the NPI assignment letter(s) and a completed Contract NPI/API Association Form to report.npi@dads.state.tx.us. Postal Mail Service: Send a copy of your NPI/API assignment letter and a completed Contract NPI/API Association Form to: Department of Aging and Disability Services PO Box , MC W-640 Austin, TX To avoid billing delays, providers that contract with DADS must have reported the NPI by June 1, After the NPI implementation, standard transactions must include an NPI/API for successful payment processing. For assistance concerning NPI/API, contact Waiver/ non-waiver services at , or Institutional services at In addition to reporting an NPI to DADS, providers should share their NPI with other providers, health plans, clearinghouses, covered entities, and state agencies that may need those NPIs. Did you know? Providers who contract with DADS must have reported their NPI to DADS or received an API before June 1, 2007, to prevent billing delays. DADS does not assign NPI numbers. On the NPPES application, Individual providers are licensed individuals such as doctors or nurses. Taxonomy codes are available online at The taxonomy codes for the majority of DADS providers are found in the non-individual section of the Health Care Provider Taxonomy guide. Select the taxonomy that best describes your business. NPPES or CMS Fox systems will send a letter or back to the provider assigning the requested NPI. Long Term Care providers that also provide acute care services (NF 80/20 cross over claims) must also report their NPI to TMHP at (NPI attestation). The Contract Number is also called a Provider number or Billing number. DADS will not send a confirmation that we have received your NPI. However, providers may confirm receipt at: providers/hipaa/npisearch.cfm. Long Term Care Special Bulletin, No National Provider Identifier Special Bulletin

5 Long Term Care Providers Announcing TexMedConnect Because TDHconnect is not fully NPI-compliant, TMHP will introduce a new claims filing application, TexMedConnect, which will be located on the TMHP website. This new application will implement in November 2007 and will use current technology to enable faster processing of electronic transactions for: Claims Submission: - Professional - Institutional - Dental - Nurse Aide Training (NAT) MESAV requests Claim Status Inquiry (CSI) Adjustments ER&S TexMedConnect will be implemented in two phases. Phase One will begin on August 27, 2007, and will include the MESAV functionality currently offered by TDHconnect. The current MESAV functionality offered by TDHconnect will continue to be available until the NPI contingency ends. Until November 2007, claims submission, adjustments, CSI, and ER&S transactions will continue to be processed through TDHconnect. Effective November 12, 2007, phase two will begin and all transactions will be processed through TexMedConnect. Creating an Account on the TMHP Website Before using TexMedConnect, LTC providers must set up an administrator account on the TMHP website. To create an account, select Activate My Account from the I would like to link in the upper-right hand corner of the TMHP homepage ( LTC providers who create accounts have the responsibility to administer access to the secure pages of the website that contain Protected Health Information (PHI) linked to their Long Term Care Provider Number and NPI. Each provider account must be controlled and monitored through a provider administrator chosen by the provider or their management-level office staff. Provider Workshops To ensure providers are equipped to use this new online application, TMHP is conducting free workshops in October 2007: Date City Location October 2 Austin MCC Building October 3 Corpus Christi Science and History Museum October 3 Laredo Laredo Medical Center October 3 Amarillo TTUHSC October 4 Houston United Way TGC Community Resource Center October 9 Abilene Abilene Civic Center October 10 Edinburg Echo Hotel & Conference Center October 11 El Paso Region 19 Education Service Center October 16 Fort Worth Fort Worth Botanical Garden October 18 Brownsville UT-Brownsville October 22 Dallas Charlton Methodist Hospital October 23 San Antonio Norris Conference Center Balcones Heights October 23 Plano Plano City Centre October 23 Houston MHMRA Conference Center October 25 Tyler Ramada Tyler Conference Center October 25 Mc Allen South Texas College Workshop invitations, including times for each location above, will be mailed in September All providers are encouraged to attend this free workshop. Workshop training materials for TexMedConnect will be available on the TMHP website at For more information, call the TMHP Call Center/Help Desk at National Provider Identifier Special Bulletin 5 Long Term Care Special Bulletin, No. 205

6 Long Term Care Providers Updated TMHP EDI Companion Guides Two versions of the TMHP EDI companion guides are currently available in the File Library on the TMHP website at Enhanced Dual Strategy companion guides were posted in March 2007, and include updates for the May 21, 2007, implementation. NPI-only companion guides were posted in May 2007, and include updates for the NPI implementation on July 30, Companion guides are intended for trading partner use in conjunction with the ANSI ASC X12N National Implementation Guide. The ANSI ASC X12N National Implementation Guide can be accessed at Insurance_40.asp. Refer to the TMHP Connectivity Guide for specific instructions regarding connectivity options: Library/File Library/ EDI/TMHP EDI Connectivity Guide.pdf For questions regarding EDI please contact the TMHP EDI Help Desk at (Option 3) or in Austin, call (Option 3). Vendor Testing Begins June 2007 Vendor testing for NPI-only readiness begins in June 2007 and is open to all electronic submitters of the following transactions: Claim Submissions ER&S Reports MESAV Claim Status Inquiry All providers are encouraged to begin vendor testing as soon as possible. Contact the TMHP EDI Help Desk for more information on vendor testing. New DADS Form 1290 On January 1, 2007, TMHP began accepting the new NPI-supported DADS Form 1290 (dated January 2007) in addition to the current claim form (dated January 2005). The new Form 1290 includes Box 1 (NPI No.) to enter the NPI/API. The Provider/Contract Number (Box 2) will continue to be required on both forms. Both forms can be used until July 30, Claims received on or after July 30, 2007 on the old form, will be returned to the provider. The table below indicates the requirements for each provider field: No. Field Name Description 1 NPI The NPI/API (optional during the contingency period) of the provider billing for the services rendered. 2 Contract No. The Contract Number (required) of the provider billing for the services rendered. A copy of this form is available on page 8 of this bulletin. NPI Information and Help Providers may visit the DADS website at tx.us/providers/hipaa/index.html for a list of frequently asked questions and other resources related to NPI. For assistance with NPI issues, providers may contact the TMHP Call Center/Help Desk at (Option 1). The following websites may also be helpful: National Plan Provider Enumeration System: The NPI Enumerator assigns NPIs and assists health plans and providers with issues relating to unique identification. Centers for Medicare and Medicaid Services (CMS): The CMS website includes educational materials on NPI and its implementation and provides answers to common NPI questions. Long Term Care Special Bulletin, No National Provider Identifier Special Bulletin

7 Long Term Care Providers LTC Crosswalk Solution Developed for Claims Processing Beginning May 21, 2007, the NPI will be incorporated into many TMHP processes, including MESAV, claims, and other transactions. However, Contract Numbers will continue to be assigned and used. If a provider has multiple Contract Numbers, TMHP will use a Billing Referral Number to correctly identify the provider for claims processing purposes, as illustrated in the table below: NPI Billing Client Contract No. Referral No John Doe Jane Doe Jane Doe The Billing Referral Number is linked to the Contract and Client Numbers, and will automatically be returned in the authorization section of a MESAV response. The Billing Referral Number will be required on claims only for those providers who have multiple Contract Numbers. Claims received without the Billing Referral Number will be rejected. National Provider Identifier Special Bulletin 7 Long Term Care Special Bulletin, No. 205

8 Forms Section A Header Information Long Term Care Claim DADS Form 1290 January NPI No. 2. Contract No. 3. Provider s Name 4. Address 5. Area Code and Telephone No. 6. Client/Medicaid No. 7. Patient Account No. 8. Client Last Name 9. Client First Name 10. Client Middle Initial 11. Client Suffix Name This information is for a VA individual residing in a VA facility This information is for an individual requiring AI/Copay This information is for expedited PAS use only. 12. VA Indicator 13. Billed Applied Income/Copay 14. Service Group 15. Service Code 16. Fund Code 17. Billed Amount 18. Billing Month/Year Section B Nurse Aide Training 19. NAT SSN 20. Service Group 21. Bill Code 22. Patient Days % Medicaid Medicare Private 23. Begin Date (mm/dd/yyyy) 24. End Date (mm/dd/yyyy) 25. Training Hours 26. Number of Units 27. Unit Rate 28. Line Item Total Section C Line Item Information (Note: Negative Number of Units should appear as Show parts of units as decimal fractions.) Line 29. Begin Date (mm/dd/yyyy) 30. End Date (mm/dd/yyyy) 31. Rev Code 32. Proc Code Qual Modifiers Proc/Item Code POS Code 36. TID 37. Rendering Provider Name 38. Number of Units 39. Unit Rate 40. Line Time Total I certify that this information is true, accurate and complete to the best of my knowledge. I understand that claiming for services not actually provided constitutes fraud. 42. Signature 43. Date Claim Total: 41. Long Term Care Special Bulletin, No National Provider Identifier Special Bulletin

9 Forms TMHP NPI CONTINGENCY Quick Reference Guide for Long Term Care Providers National Provider Identifier Special Bulletin 9 Long Term Care Special Bulletin, No. 205

10 Notes Long Term Care Special Bulletin, No National Provider Identifier Special Bulletin

11 Notes National Provider Identifier Special Bulletin 11 Long Term Care Special Bulletin, No. 205

12 NATIONAL PROVIDER IDENTIFIER (NPI) SPECIAL BULLETIN for Long Term Care (LTC) Providers NPI Contingency Period Announced! See page 2 LONG TERM CARE SPECIAL BULLETIN NO. 205 JUNE 2007 PLACE POSTAGE HERE ATTENTION: BUSINESS OFFICE

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