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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, please contact MassHealth Customer Service at 1-800-841-2900.
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.
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 are atypical providers (e.g. rest homes and non-emergency transportation providers).
You may apply at the National Plan & Provider Enumeration System (NPPES).. 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.
A taxonomy code identifies the type of services or specialty that a health-care provider offers to patients. Taxonomy codes can be located at
Yes, the Web site has an average turnaround time of 12 to 14 hours.
If you have questions about the process for obtaining an NPI, you may call the National Plan and Provider Enumeration System (NPPES) Enumeration Center at 1-800-465-3203.
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. MassHealth providers report their NPI within the enrollment application and/or the NPI Supplemental Form.
You may send the following information about you or your agency, business, or practice, as applicable, to MassHealth at firstname.lastname@example.org:
You may also download a spreadsheet from www.mass.gov/masshealth/npi, and email it to email@example.com.
MassHealth will mail a data summary letter to the doing-business-as address or email the data summary to the email 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 email address and phone number.
For group practices you must report the NPI associated with that group practice.
Yes. MassHealth will reject claims that do not contain an NPI.
Under the NPI Final Rule, only health-care providers that are "covered entities" are required to obtain and use an NPI. If these providers have obtained an NPI, they may report it to MassHealth and they may enter that information on their claims.
MassHealth dental providers must contact the dental third-party administrator, DentaQuest at 1-800-207-5019 for instructions on how to file NPI information.
Municipal Medicaid providers should report their NPIs to UMass at 508-856-8631 or firstname.lastname@example.org. UMass will collect your NPI and provide it to MassHealth.
NCPDP will provide ACS (POPS) with the pharmacy providers' NPIs. Pharmacy Facts, Number 27 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.
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.
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.
The NPI of the attending physician is not required on claim form no. 10 or its electronic equivalent.
Providers must report the seven-digit MassHealth PCC referral number in this field for claims for services referred by the member's PCC.
No, the PA forms are not changing at this time.
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.
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.
No, providers should follow the current billing process.
No, this process is not changing.
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.
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/.
Yes, MassHealth will follow the CMS guidance for the use of the CMS-1500 form.
Resubmittals must be submitted on the new form with the appropriate NPI after May 23, 2007. If necessary, submit with the TCN.
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.
Version 1.76. Enter the NPI in the appropriate provider file maintenance screen.
Follow the implementation guide. They should be entered in the appropriate NM109 field.
They may contact the EDI Helpdesk at 1-800-841-2900.
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.