The following questions and answers were derived from various provider training sessions conducted by MassHealth to explain how the NPI requirement affects MassHealth providers. If you have questions about using your NPI after reviewing this information, the NPI Web page, and All Provider Bulletin 164 pdf format of    all-164.pdf  , please contact MassHealth Customer Service at 1-800-841-2900.

Getting an NPI

  1. What is an NPI?
  2. Who needs to get an NPI?
  3. Where do I get my NPI?
  4. What is a taxonomy code and how do I get it?
  5. Will the NPI Web site application give you the NPI number fast?
  6. What if I have questions about getting a NPI?

Reporting Your NPI

  1. How do I report my NPI to MassHealth?
  2. How do I know MassHealth has received my NPI(s)?
  3. Which tax ID/FEIN or SSN do I report if I work in a group practice?
  4. Will MassHealth reject claims that do not have an NPI?

Exceptions to NPI Requirement

  1. Do all providers need an NPI?
  2. I am a dental provider. To whom must I provide my NPI?
  3. I am a municipal Medicaid provider. To whom must I provide my NPI?
  4. I am a pharmacy provider. To whom must I provide my NPI?

General NPI Billing Questions

  1. Will my remittance advices show my NPI?
  2. Can a rest home or a nonemergency transportation provider that has a NPI report it to MassHealth and enter the NPI on its claims?
  3. Is the NPI required in the attending physician field on claim form no. 10 or its electronic equivalent?
  4. If I am providing services to a member enrolled in the Primary Care Clinician (PCC) Plan, what number should I use for the PCC referral number?
  5. Are the PA forms going to change?
  6. For a group practice with individual doctors, how should the provider bill using NPI?
  7. When does a provider need to use a taxonomy code?
  8. Are home health agencies required to enter the rendering provider number?
  9. Does the provider need to enter the NPI on prior-authorization forms?

Paper Billing Questions

  1. Have the MassHealth claim forms been updated with NPI and taxonomy fields?
  2. Will MassHealth accept the UB-04 claim form?
  3. CMS extended the use of CMS-1500 forms until 6/1/07. Is MassHealth going to follow this?
  4. Do resubmittal claims need an NPI?
  5. Do I need to do anything different when billing paper Medicare crossover claims that don't cross over on their own?

Electronic Billing Questions

  1. What version of PCSS has the new fields?

  2. Programmers do not know where to put the NPI on electronic claims?
  3. Who can programmers contact for help?
  4. For electronic claims, is the tax ID required?

Getting an NPI

1. What is an NPI?
NPI stands for national provider identifier. The Administrative Simplification requirement of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandates that health-care providers acquire and use a national provider identifier (NPI), effective May 23, 2007. NPIs are 10-digit numbers that uniquely identify health-care providers. This number is what you will use to identify yourself to any health insurance company in the United States.

2. Who needs to get an NPI?
If you are a health-care provider as defined by the federal Centers for Medicare & Medicaid Services (CMS), you need an NPI. The only providers excluded from getting an NPI for MassHealth are rest homes and nonemergency transportation providers.

3. Where do I get my NPI?
You may apply at
https://nppes.cms.hhs.gov/NPPES/Welcome.do. Also, the www.mass.gov/masshealth site includes instructions for applying for an NPI, enumeration guidelines, changes to billing and enrollment procedures, upcoming events, an electronic copy of the NPI Request Document tool, instructions for submittal, FAQs, and taxonomy codes.

4. What is a taxonomy code and how do I get it?
A taxonomy code identifies the type of services or specialty that a health-care provider offers to patients. Taxonomy codes can be located at
http://www.wpc-edi.com/content/view/515/229.

5. Will the NPI Web site application give you the NPI number fast?
Yes, the Web site has an average turnaround time of 12 to 14 hours.

6. What if I have questions about getting a NPI?
If you have questions about the process for obtaining an NPI, you may call the Enumeration Center at 1-800-465-3203.

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Reporting Your NPI

The following questions and answers apply to all providers who are required to have an NPI, except pharmacy, dental, and municipal Medicaid providers. See
Exceptions to NPI Requirement for information about reporting NPIs to MassHealth for these providers.

1. How do I report my NPI to MassHealth?
You may send the following information about you or your agency, business, or practice, as applicable, to MassHealth at
npi@mahealth.net:

  • provider name;
  • provider doing-business-as address;
  • tax identification number or social security number;
  • MassHealth provider number(s);
  • NPI(s); and
  • taxonomy code(s).

You may also download a spreadsheet from www.mass.gov/masshealth/npi, and e‑mail it to npi@mahealth.net.

2. How do I know MassHealth has received my NPI(s)?
MassHealth will mail a data summary letter to the doing-business-as address or e‑mail the data summary to the e-mail address given by the provider. Providers should not submit their claims with their NPI until they have received the data summary letter and that letter correctly lists the relationship among your seven-digit MassHealth provider number(s), your NPI(s), and if applicable, taxonomy code(s). If you have not yet received your data summary letter, continue to bill MassHealth using your seven-digit MassHealth provider number as outlined in All Provider Bulletin 164.

If MassHealth has any questions about the information you submitted, we will contact you. Please remember to fill out the contact information at the bottom of the spreadsheet, including your e-mail address and phone number.

3. Which tax ID/FEIN or SSN do I report if I work in a group practice?
If you are submitting an NPI for a group practice provider (MassHealth provider number begins with 97), you must report the federal tax ID associated with the group practice. For individual health-care providers within the group, you must report the individual SSN associated with each provider.

4. Will MassHealth reject claims that do not have an NPI?
MassHealth will not reject claims because the claim does not contain an NPI if the provider has a signed contingency plan on file with MassHealth. The plan must be in writing and detail the provider's process to get an NPI. Refer to
All Provider Bulletin 164 pdf format of    all-164.pdf  for more information.

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Exceptions to NPI Requirement

1. Do all providers need an NPI?
Under the NPI Final Rule, only health-care providers that are "covered entities" are required to obtain and use an NPI. Nonemergency transportation providers and rest homes are not covered entities, so these providers do not need to obtain or use an NPI in transactions with MassHealth. If these providers have obtained an NPI, they may report it to MassHealth and they may enter that information on their claims.

2. I am a dental provider. To whom must I provide my NPI?
MassHealth dental providers must contact the dental third-party administrator, Doral, at 1-800-207-5019 for instructions on how to file NPI information.

3. I am a municipal Medicaid provider. To whom must I provide my NPI?
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.

4. I am a pharmacy provider. To whom must I provide my NPI?
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 providers of durable medical equipment, oxygen and respiratory therapy equipment, orthotics, and prosthetics.

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General NPI Billing Questions

1. Will my remittance advices show my NPI?
Until further notice both paper and electronic 835 remittance advices will be issued with your current MassHealth provider number. It is expected that the 835 remittance advices will reflect NPI information in the future.

2. Can a rest home or a nonemergency transportation provider that has a NPI report it to MassHealth and enter the NPI on its claims?
Rest homes and nonemergency transportation providers are not required to have an NPI, but if they have one, they may enter it on their MassHealth claims.

3. Is the NPI required in the attending physician field on claim form no. 10 or its electronic equivalent?
The NPI of the attending physician is not required on claim form no. 10 or its electronic equivalent.

4. If I am providing services to a member enrolled in the Primary Care Clinician (PCC) Plan, what number should I use for the PCC referral number?
Providers must report the seven-digit MassHealth PCC referral number in this field for claims for services referred by the member's PCC.

5. Are the PA forms going to change?
No, the PA forms are not changing at this time.

6. For a group practice with individual doctors, how should the provider bill using NPI?
The group's NPI must be entered as the NPI and the individual physician's NPI must be entered as the rendering provider's NPI.

7. When does a provider need to use a taxonomy code?
A taxonomy code is not required if there is only one NPI and one MassHealth provider number. A taxonomy code is required on claims only if MassHealth specifically directs the provider to enter the taxonomy code.

8. Are home health agencies required to enter the rendering provider number?
No, providers should follow the current billing process.

9. Does the provider need to enter the NPI on prior-authorization forms?
No, this process is not changing.

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Paper Billing Questions

1. Have the MassHealth claim forms been updated with NPI and taxonomy fields?
Yes, MassHealth has modified its paper claim forms to include fields for NPI and taxonomy code. The only change is the addition of the new fields. All requests for MassHealth claim forms are being filled with the revised claim forms. Providers should use the revised forms, and discard supplies of the old forms.

2. Will MassHealth accept the UB-04 claim form?
MassHealth has adopted the UB-04 claim form to replace the UB-92 claim form (for hospital claims). Providers can obtain supplies of the UB-04 from their regular forms vendor. Please do not submit your claims on the UB-92. They will be returned to the provider unprocessed. Instructions for completing the UB-04 claim form will be posted on the MassHealth Web site by the end of June. In the interim, providers should refer to the abbreviated instructions for completing the UB-04 at
www.mass.gov/masshealth/.

3. CMS extended the use of CMS-1500 forms until 6/1/07. Is MassHealth going to follow this?
Yes, MassHealth will follow the CMS guidance for the use of the CMS-1500 form.

4. Do resubmittal claims need an NPI?
Resubmittals must be submitted on the new form with the appropriate NPI after May 23, 2007. If necessary, submit with the TCN.

5. Do I need to do anything different when billing paper Medicare crossover claims that don't cross over on their own?
When crossover claims are not electronically crossed over to MassHealth by the coordination of benefits contractor (COBC), or need to be rebilled on paper, be sure to include your Medicare legacy number in addition to your NPI on the paper Explanation of Medicare Benefits (EOMB). If your Medicare legacy number does not already appear on the EOMB, write it legibly on the EOMB. If you do not list your Medicare legacy number on the EOMB, you may experience a delay in the processing of your crossover claim.

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Electronic Billing Questions

1. What version of PCSS has the new fields?
Version 1.76. Enter the NPI in the appropriate provider file maintenance screen.

2. Programmers do not know where to put the NPI on electronic claims?
Follow the implementation guide. They should be entered in the appropriate NM109 field.

3. Who can programmers contact for help?
They may contact the EDI Helpdesk at 1-800-841-2900.

4. For electronic claims, is the tax ID required?
If the companion guide lists it as a required field, then it must be submitted. If required information is not submitted, then the provider may receive a rejected 997 back.

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This information is provided by MassHealth.