QUESTION: Under what circumstances will a claim be rejected when using the National Provider Identifier (NPI)?
ANSWER: Claims will be rejected if:
• The NPI included in a claim or claim status request does not meet the content criteria requirements for a valid NPI (begins with 1,2,3, or 4; 10-digits long with no special characters; check digit is correct); this affects:o X12 837 and Direct Data Entry (DDE) screen claims (DDE claims are submitted to Medicare Intermediaries only);o National Council of Prescription Drug Plan (NCPDP) claims (submitted to Medicare DMERCs only);o Paper claims on the revised CMS-1500 form and on the UB-04 form;o Claims submitted using Medicare’s free billing software;o Electronic claim status request received via X12 276 or DDE screen; ando Non-X12 electronic claim status queries, pending elimination of the HIPAA contingency plan for the HIPAA 276/277 format;
• A submitted NPI reported cannot be located in Medicare files;
• The NPI is located, but a legacy identifier reported for the same provider in the transaction does not match the legacy identifier in the Medicare file for that NPI;
• Claims include the NPI but do not have a taxpayer identification number (TIN) reported for the billing or pay-to provider in electronic claims received via X12 837, DDE screen (FISS only), or Medicare’s free billing software; and
• Claims that do not meet Medicare submission requirements, HIPAA implementation guide requirements, or Medicare program reuirements for reasons unrelated to NPIs.
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Showing posts with label NCPDP. Show all posts
Showing posts with label NCPDP. Show all posts
Tuesday, June 23, 2009
Sunday, June 21, 2009
Electronic claim for Medication Therapy Management Program services
QUESTION: When a Provider submits an electronic claim for Medication Therapy Management Program services, to a health plan, including a Part D drug plan, should they use the NCPDP 5.1 standard or must they use the X12N 837P standard, under HIPAA?
ANSWER: Please note that this FAQ has been revised to include a HIPAA enforcement addendum as of October 22, 2007.
To bill MTM services, covered entities should use the American Standards Committee (ASC) X12N 837P Version 4010/4010A1. We articulated in our January 28, 2005 Final Rule on the Medicare Prescription Drug Benefit that we viewed Medication Therapy Management (MTM) as a clinical service (70 FR 4194, 4231). Therefore, claims for MTM would be considered professional health care claims rather than retail pharmacy drug claims. Pursuant to the Health Insurance Portability and Accountability Act (HIPAA) of 1996, the ASC X12N 837P was adopted as the transaction standard for professional health care claims. Therefore, similar to physician clinical services, if MTM providers bill Part D sponsors electronically for MTM services, such billing claims must be transmitted using the ASC X12N 837 P Version 4010/4010A1. Part D Sponsors are not precluded from using the NCPDP 5.1 system edits as a method to identify targeted beneficiaries, or provide applicable information at the point of service to pharmacists or other MTM providers responsible for providing the MTM services, but the health care claim must be transmitted using the ASC X12N 837P.
Enforcement Addendum-10/22/07
While CMS adheres to its foregoing interpretation of the regulations requiring that MTM retail pharmacy services be reported using the X12N 837P standard, we recognize that x industry practice included NCPDP, Version 5.1 standard for billing of such services. CMS will not to take enforcement action against covered entities that use NCPDP, Version 5.1 pharmacy claim for MTM, supplies or services.
The final rule adopting new versions of the X12 and NCPDP standards allows for the use of either x12 or NCPDP for billing pharmacy supplies and services, and MTM.
For more information : Join our exclusiveFREE Email Coding News Alert Mailing List http://www.codinginstitute.com/
ANSWER: Please note that this FAQ has been revised to include a HIPAA enforcement addendum as of October 22, 2007.
To bill MTM services, covered entities should use the American Standards Committee (ASC) X12N 837P Version 4010/4010A1. We articulated in our January 28, 2005 Final Rule on the Medicare Prescription Drug Benefit that we viewed Medication Therapy Management (MTM) as a clinical service (70 FR 4194, 4231). Therefore, claims for MTM would be considered professional health care claims rather than retail pharmacy drug claims. Pursuant to the Health Insurance Portability and Accountability Act (HIPAA) of 1996, the ASC X12N 837P was adopted as the transaction standard for professional health care claims. Therefore, similar to physician clinical services, if MTM providers bill Part D sponsors electronically for MTM services, such billing claims must be transmitted using the ASC X12N 837 P Version 4010/4010A1. Part D Sponsors are not precluded from using the NCPDP 5.1 system edits as a method to identify targeted beneficiaries, or provide applicable information at the point of service to pharmacists or other MTM providers responsible for providing the MTM services, but the health care claim must be transmitted using the ASC X12N 837P.
Enforcement Addendum-10/22/07
While CMS adheres to its foregoing interpretation of the regulations requiring that MTM retail pharmacy services be reported using the X12N 837P standard, we recognize that x industry practice included NCPDP, Version 5.1 standard for billing of such services. CMS will not to take enforcement action against covered entities that use NCPDP, Version 5.1 pharmacy claim for MTM, supplies or services.
The final rule adopting new versions of the X12 and NCPDP standards allows for the use of either x12 or NCPDP for billing pharmacy supplies and services, and MTM.
For more information : Join our exclusiveFREE Email Coding News Alert Mailing List http://www.codinginstitute.com/
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