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National Provider Identifier (NPI)

Medicare now accepting new CMS 1500 claim forms

Following a minor delay, the U.S. Centers for Medicare and Medicaid Services (CMS) has announced it will implement its new, revised Form CMS 1500 on January 1, 2007. The new claim form, formally known as the CMS 1500 (08-05), is designed to allow health care providers to use new National Provider Identifier (NPI) numbers when filing Medicare paper claims. The new CMS 1500 (08-05) will be required for the filing of Medicare paper claims effective April 2, 2007. Until that time, health care providers who file Medicare claims on paper will be able to use either the new CMS-1500 (08-05) or the present version of the form, formally known at the CMS-1500 (12-90).

The major difference between Form CMS 1500 (08-05) and Form CMS-1500 (12-90) is the addition of split provider identifier fields. The split fields will enable NPI reporting in the fields labeled as NPI and corresponding legacy identification number reporting in the unlabeled block above each NPI field. Legacy identifiers are pre-NPI provider identifiers such as: PINs (Provider Identification Numbers); UPINs (Unique Physician Identification Numbers); OSCARs (Online Survey Certification & Reporting System numbers); and NSCs (National Supplier Clearinghouse numbers) for durable, medical equipment claims. The CMS has informed health plans, clearinghouses, and other Medicare information support vendors that it should be able to handle and accept the revised Form CMS 1500 (08-05) by January 2, 2007. The current CMS 1500 (12-90) version of the claim form will be discontinued on April 2.  The CMS emphasizes that, henceforth, all rebilling of claims should be accomplished using the revised Form CMS-1500 (08-05), even though earlier submissions may have been on the current Form CMS-1500 (12-90).

Form CMS 1500 is one of the basic forms prescribed by the CMS for the Medicare program; although, it is now only accepted from physicians and suppliers that are excluded from the mandatory electronic claims submission requirements set forth in the federal Administrative Simplification Compliance Act (Public Law 107-105) and the federal regulation implementing that law (42 CFR 424.32). The introduction of the CMS 1500 (08-05) form is seen as another major step in the establishing of the NPI as the nation’s universally accepted health care provider identification number, replacing the myriad identification numbers now issued to health care providers by various public and private insurance plans.  The establishing of a nationally uniform system of identification numbers for health care providers is required under the federal Health Insurance Portability and Accountability Act (HIPAA). The federal government sees the NPI as one of the key elements in an overall plan to improve health care quality and reduce health care costs, mandated under HIPAA and the Administrative Simplification Compliance Act. Health care providers have been able to use NPIs on Medicare electronic claims since January 1, 2006, (albeit with the CMS strongly encouraging providers to continue using legacy identification numbers as a backup form of identification on claims). HIPAA will require the NPI be used on all Medicare claims and most other public and private health insurance claims effective May 23, 2007. After that date, all Medicare claims without NPIs will be rejected (in most cases with reason code 16 – “claim/service lacks information that is needed for adjudication”) in tandem with the appropriate remark code that specifies the missing information, the CMS emphasizes.  (A provision in the HIPAA legislation allows small health plans an additional year to comply with NPI guidelines. Thus, small plans may need to receive legacy provider numbers on coordination of benefits (COB) transactions through May 23, 2008. The CMS will issue requirements for reporting legacy numbers in COB transactions after May 22, 2007.) The CMS originally hoped to introduce the new version of the 1500 claim form earlier this year; however, necessary review held up release of the form.

The NPI of the billing provider or group is to be entered on Form CMS 1500 (08-05) in items:

􀂃24J (replacing item 24K, Form CMS-1500 (12-90));

􀂃17B (replacing item 17 or 17A, Form CMS-1500 (12-90));

􀂃32a (replacing item 32, Form CMS-1500 (12-90)); and

􀂃33a (replacing item 33, Form CMS-1500 (12-90)).

To help ensure proper processing of Form CMS 1500 (08-05) claims and avoid claim rejections, the CMS urges health care providers to take care to always enter the correct identifying information for any numbers entered on claims.

A Medicare Leaning Network Matters article (MM5060) on the implementation of the new CMS 1500 (08-05) claim form can be found on the CMS Web site at www.cms.hhs.gov/MLNMattersArticles/downloads/MM5060.pdf.

Additional NPI-related information can be found on the Web site at www.cms.hhs.gov/NationalProvIdentStand.

Reprinted from Optometry: Journal of the American Optometric Association, December 2005