NATIONAL PROVIDER IDENTIFIER (NPI)
SPECIAL BULLETIN
for Medicaid, Children with Special Health Care Needs (CSHCN), and LTC providers
TEXAS MEDICAID BULLETIN
MAY 2006
NO. 196
This is a combined, special bulletin for all Medicaid, Children with Special Health Care Needs (CSHCN),
and Long Term Care providers. (Long Term Care providers will find information applicable to them
on the reverse side of this bulletin.) This bulletin is intended to notify providers of program changes
related to the National Provider Identifier (NPI) implementation occurring in May of 2007.
NPI Dual Strategy
The Submission of Legacy Provider
Numbers and National Provider
Identifiers
The Health Insurance Portability and Accountability Act
(HIPAA) of 1996 requires all health care entities (i.e.,
providers, clearinghouses, and large health plans) to
begin using National Provider Identifiers (NPIs) on
standard health care transactions by May 23, 2007. The
NPI eliminates the need for health care providers to use
different identification numbers to identify themselves
when conducting transactions with multiple health plans.
To prepare for the federal requirements mandated by
HIPAA, the Texas Medicaid & Healthcare Partnership
(TMHP) is implementing a transition strategy that will
allow Medicaid and CSHCN providers to submit both
legacy provider numbers (e.g., Texas Provider Identifier
[TPI], universal provider identifier number [UPIN], tax
identification number [TIN]) and NPIs on standard
electronic transactions during a transition period. This
transitional period, called NPI dual strategy, will begin
on June 1, 2006, and extend to the compliance date. This
strategy is transitional and only permissible until the
compliance date; afterward, legacy identifiers other than
required federal tax IDs must be discontinued. Effective
INSIDE
Acute Care Providers
NPI Dual Strategy
1
About the National Provider Identifier
2
How to Transition from a Paper to Electronic Submitter
3
Long Term Care Providers
See Reverse Side
May 23, 2007, in fields where the NPI is required, only the NPI
may be used to identify a provider.
The strategy for the dual use of NPI and provider identifiers
(legacy identifiers) was originally proposed by the Workgroup
for Electronic Data Interchange (WEDI) in a white paper
entitled “Dual Use of NPI and Legacy Identifiers.” The white
paper dated May 31, 2005, can be found at www.wedi.org. Due
to time constraints the WEDI proposal has been modified for
use in Texas.
The NPI dual strategy process is voluntary and allows the Texas
Health and Human Service Commission (HHSC) to collect
Continued on page 2
Current Procedural Terminology (CPT) is copyright 2005 American Medical Association (AMA) and Current Dental Terminology (CDT) is copyright 2004 American
Dental Association (ADA). All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT or CDT. The AMA and the ADA
assume no liability for the data contained herein. Applicable Federal Acquisition Regulation System/Department of Defense Regulation System (FARS/DFARS)
restrictions apply to government use.
Acute Care Providers
Continued from page 1
• Facility provider’s NPI, tax ID, and address
• Other provider A and/or B NPI and tax ID
data from providers and will facilitate a smoother
transition to NPI implementation.
Acute Care 837 Professional claims transactions will
accept:
Submission Methods
Providers may begin submitting electronic claims with
both provider numbers on June 1, 2006. To do so:
• Billing providers NPI, taxonomy, address, and tax ID
• Facility provider’s NPI, tax ID, and address
• Place the NPI in the Primary Identifier field
• Referring provider’s NPI, taxonomy, tax ID
• Place the current provider identifier (TPI or UPIN) in
the Secondary Identifier field
• Rendering provider’s NPI, taxonomy, tax ID at header
and/or detail level
Providers should refer to their Companion Guides for
detailed information regarding transaction acceptance
data. Revised TMHP Companion Guides can be accessed
at www.tmhp.com.
Acute Care 837 Dental claims transactions will accept:
• Billing provider’s NPI, taxonomy, address, and tax ID
• Facility provider’s NPI, tax ID, and address
Electronic transactions (837
Institutional claims, 837
Professional claims, and
837 Dental claims) are
still adjudicated using the
current provider identifier
number. The NPI will not be
returned on response transactions from TMHP.
• Referring provider’s NPI, taxonomy, and tax ID
• Performing provider’s NPI, taxonomy, and tax ID at
header and/or detail level
Acute Care 270 Eligibility Inquiry will accept:
• NPI
For more information, call the TMHP Contact Center at
1-800-925-9126 or the TMHP-CSHCN Contact Center
at 1-800-568-2413.
Providers who decide to submit their HIPAA-compliant
electronic claim and eligibility transactions (837I, 837P,
837D, and 270) as part of the NPI dual Strategy process
should verify with their software vendor the availability
of fields for the NPI and taxonomy code (see About the
National Provider Identifier, below for information on
taxonomy codes).
About the National
Provider Identifier
An NPI is a 10-digit number assigned randomly by
the National Plan and Provider Enumeration System
(NPPES). The NPI is:
Note: TDHconnect will not be updated to accept an NPI
on acute care electronic transactions during this dual
strategy period.
• All numeric
• First digit will be 1, 2, 3, or 4
The following data will be accepted during the dual
strategy period.
• Tenth digit is the check digit (used to validate the NPI)
Acute Care 837 Institutional claims transactions will
accept:
There is no link to individuals from group practices or to
group practices from individuals.
• Billing provider’s NPI, taxonomy, address, and tax ID
All health care providers are eligible for an NPI. In terms
of NPI assignment, an individual, sole proprietor, or sole
proprietorship is an Entity Type I (person) and is eligible
for a single NPI. This identifier must be used by HIPAA
• Attending provider’s NPI, taxonomy, and tax ID
Texas Medicaid Bulletin, No. 196
2
National Provider Identifier Special Bulletin
Acute Care Providers
covered entities (health plans, health care clearinghouses,
and health care providers) that conduct electronic transactions. Health care providers who are not considered
covered entities may also apply and be assigned an NPI.
data element during the NPI Dual Strategy period for
electronic transactions. Providers will not receive an
electronic rejection if the taxonomy code submitted does
not match the provider type or specialty that is on file for
the provider’s TPI.
National Provider Identifier Subparts
Organizations (hospitals, pharmacies, and groups) are
considered Entity Type II (non-person). Subparts of organization health care providers are eligible to be assigned
NPIs, and NPIs must be obtained for, or by them, if
they would be considered a covered health care provider
if they were a separate legal entity. The subpart may or
may not be located in the same location or have the same
taxonomy as the covered organization that it is affiliated
with.
Paper Claims
In some situations it is
possible for subparts of
hospitals to receive an
NPI in order to conduct
standard transactions on
their own behalf. Covered
organization health care
providers are responsible for
determining if they have
“subparts” that need to have
NPIs. If such subparts exist,
the covered organization
health care provider must ensure that the subparts obtain
their own unique NPIs, or they must obtain them for
them.
How to Transition from a Paper to
Electronic Submitter
During the dual strategy period, paper billers must
continue to put their current provider identifier along with
their NPI in the appropriate fields on paper claim forms.
Paper claims with only NPIs will be denied. Further
information regarding paper claim submissions and the
NPI as it relates to NPI implementation will be published
in the future.
HHSC and TMHP
encourage providers to
submit claims and other
requests electronically.
Providers can participate
in the most efficient
and effective method of
submitting requests to
TMHP by submitting
through the TMHP
Electronic Data Interchange (EDI) claims processing
system. TMHP uses the HIPAA compliant ANSI
ASC X12 4010A file format through secure socket
layer (SSL) and virtual private networking (VPN)
connections for maximum security. Providers can access
TMHP’s electronic services through www.tmhp.com,
TDHconnect, vendor software, and billing agents.
Additional information related to the NPI standards
can be found on the Centers for Medicare & Medicaid
Services website at www.cms.hhs.gov/NationalProvIdentS
tand/01_Overview.asp#TopOfPage.
Taxonomy
Providers who wish to transition from paper billing to
electronic billing should decide how they will submit their
claims to TMHP. Providers can either use software to
submit files directly to TMHP or use a billing agent (e.g.,
billing companies, vendors, or clearinghouses) who can
submit files on the provider’s behalf.
The provider taxonomy is a nine-digit code set that
codifies provider type and provider area of specialization
for all medical related providers. The National Uniform
Claim Committee (NUCC) maintains the taxonomy
code set. The taxonomy will be required for use on all
standard transactions by May 23, 2007. A provider
may have more than one taxonomy code, depending on
the provider’s area of specialization; it is not a unique
number per provider. The taxonomy code is an optional
National Provider Identifier Special Bulletin
For more information, contact the TMHP EDI Help
Desk at 1-888-863-3638.
3
Texas Medicaid Bulletin, No. 196
NOTES