Providers with NPIs are required to submit them on all claims. Claims billed without an NPI in NewMMIS will be denied. Providers are responsible for making sure their NPI information is on file with MassHealth prior to the NewMMIS implementation.

Each current MassHealth provider number will be assigned a corresponding NewMMIS provider number and service location. This NewMMIS ID is 10 characters, made up of a nine-digit base number and an alpha service location (e.g. 123456789A). This ID will be displayed on remittances advices along with the NPI and will be displayed on reports, etc. Only atypical providers should submit claims using the NewMMIS ID. All other providers must bill using the NPI.

MassHealth will process claims by mapping the NPI submitted on a claim to the NewMMIS provider number. As some providers have one NPI that corresponds to multiple NewMMIS provider numbers, MassHealth will crosswalk the NPI submitted on the claim to the correct NewMMIS provider number using the following claim data in the sequence listed below.

  • Claim Type/Type of Bill
  • Taxonomy
  • Address

Claim Type/Type of Bill

For institutional claims the type of bill will determine if the claims are billed for an inpatient or an outpatient provider.

Scenario: A hospital provider has one NPI for both current inpatient and outpatient NewMMIS provider numbers. The type of bill on the claim will determine which NewMMIS provider number to process.

Taxonomy

This should only be used when no other value can be used to map to a unique NewMMIS provider number.

Scenario: A hospital provider has one NPI corresponding to two NewMMIS provider numbers: Outpatient and a Hospital Licensed Health Center. The address is the same for each and the type of bill is the same. Therefore, the only unique attribute is taxonomy. A distinct taxonomy is used during claims submission to map to the correct NewMMIS provider.

It is critical that only those providers who have been instructed to do so use taxonomy when billing MassHealth.

Address (Doing Business Address (DBA) or Billing Address)

A provider with one NPI and multiple NewMMIS provider numbers can distinguish the unique service location by providing the DBA or billing address on the claim.

Address can use used to define where services are rendered when the type of bill and the taxonomy are the same. Providers with one NPI corresponding to multiple NewMMIS provider numbers are strongly encouraged to test claims submission prior to NewMMIS implementation.

If you have any questions about billing issues, or would like to confirm your NPI relationships on file with MassHealth, please contact MassHealth Customer Service at 1-800-841-2900.

Effective with the implementation of NewMMIS, providers will be required to submit claims with NPI only, except for Rest Homes and non-emergency transportation providers. Any paper or electronic claim that does not contain the NPI not be processed.

Dental Providers

MassHealth dental providers should contact the third-party administrator, Doral, at 1-800-207-5019 to report their NPI information or to obtain more information.

Pharmacy Providers

NCPDP will provide ACS (POPS) with the pharmacy providers' NPIs. Pharmacy Facts, Number 27 pdf format of pharmacy-fact-27.pdf provides further clarification. You must also report any other applicable NPIs to MassHealth, including NPIs for durable medical equipment, oxygen and respiratory therapy equipment, orthotics, and prosthetics.

Municipal Medicaid Providers

Municipal Medicaid providers should report their NPIs to UMass at 508-856-8631 or schoolbasedclaiming@umassmed.edu. UMass will collect your NPI and provide it to MassHealth.

Exempt Providers

Under the NPI Final Rule, only health-care providers that are "covered entities" are required to obtain and use an NPI. As nonemergency transportation providers and rest homes are not covered entities, these providers do not need to obtain or use an NPI in transactions with MassHealth.

NPI Resources

Recent MassHealth Publications Related to NPI:

Updates from the Centers for Medicare and Medicaid Services (CMS):
http://www.cms.gov/site-search/search-results.html?q=npi%20national%20provider%20identifier

https://nppes.cms.hhs.gov/NPPES/StaticForward.do?forward=static.npistart

CMS Bulletin (PDF) pdf format of npi-cms-bulletin.pdf

Questions

If you have any questions about NPI, contact MassHealth Customer Service.
This information is provided by MassHealth.