Minnesota HIPAA Collaborative

1. 1 Minnesota HIPAA Collaborative What We Know About Atypical Providers Ann Wandersee MN Department of Human Services

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3. 3 Who is eligible for an NPI? All healthcare providers are eligible to obtain an NPI Healthcare providers Hospital, critical access hospital, skilled nursing facility, CORF, hospice, home health agency Healthcare services Physician services, hospital services, drugs, psychologist services, home dialysis services, DME and medical supplies, ambulance diagnostic services, eyeglasses, PT, OT, ST etc.

4. 4 What is an �atypical provider�? From the preamble of the Final Rule Individual or organization that provides nontraditional services that are indirectly healthcare related Must determine if the individual or organization provides any services that fall within definition of healthcare If no, and does not provide other services or supplies that bring it within the definition of �healthcare provider� then not a healthcare provider under HIPAA and not eligible for an NPI

5. 5 Atypical Service Examples Non-emergency transportation Physical alterations to living quarters for the purpose of accommodating disabilities Vehicle modifications Some Medicaid Home and Community Based Services Habilitation Respite services

6. 6 How to Determine if you are an Atypical Provider Must evaluate the service as well as the entity providing the service Consider the definition of a healthcare provider Does the organization provide or bill healthcare services as defined in law in the normal course of business? If the service is not a healthcare service and the provider does not meet the definition of a healthcare provider then an NPI will not be assigned

7. 7 WEDI SNIP White Papers WEDI and NMEH created a list of entities that are considered to be atypical, including: Custodial care facilities Adult day care provider Assisted living facility Massage therapist

8. 8 Purpose of the WEDI SNIPWhite Paper Education Document types of atypical providers Gain industry consensus and agreement on certain types of providers and the need for an NPI Includes list of provider examples Describes the services they render Review alternative approaches to enumeration

9. 9 Atypical Providers Today Health plans assign legacy provider identification numbers for all providers including atypical providers Some atypical providers are currently paid through an organization MN DHS assigns provider numbers for atypical providers contracted by Medicaid MCOs

10. 10 How will atypical providers be enumerated? Some may obtain an NPI Continue to use legacy numbers Enumerate on a national, regional or health plan level

11. 11 Atypical Provider Enumeration In the absence of a regional or national enumerator, atypical providers: Face diverse enumeration rules and regulations for each payer Variances in definition of atypical vs. covered healthcare Different billing rules for organizations providing both non-medical services and covered healthcare services Billing requirements for border providers will be non-standard

12. 12  Atypical Provider Enumeration  Impact on Coordination of Benefits Lack of standardization Impact on crossover processes Costly for provider and health plan Difficulty determining duplicate billings

13. 13 DHS Approach to Atypical Providers DHS has determined which providers are atypical based on the WEDI white paper Create a 10-digit number with a leading alpha character based on the current 9-digit provider identification number Put edits in place so an atypical provider can not submit an NPI to DHS 10-digit number will be communicated to atypical providers DHS will not support the �WEDI Dual Use Strategy� for atypical providers

14. 14 Regional Approach DHS would enumerate all atypical providers in MN DHS 10-digit number could be used by all MN payers Each payer would still require enrollment in their program MN payers are reviewing the proposal Difficulty in consistent nomenclature and defining provider types Difficulty matching providers from one payer to another

15. 15 Regional Enumeration Discussions have been limited to payers in the MN HIPAA Collaborative Other payers need to be included in the discussions Payer impact analysis needs to be completed Payer systems would need to be modified Communication plans need to be developed Is there enough time?

16. 16 National Enumeration National enumeration Unique number Provides administrative savings Facilitates COB Provides consistent definition of atypical providers and non-traditional services Provides a database of numbers Database is maintained

17. 17 Alternate Solutions National enumeration is the best option Best meets provider and payer needs Providers and payers need time for systems modifications Payers need contingency plans Timing is everything

18. 18 Resources MN HIPAA Collaborative www.mnhippacollab.org Workgroup for Electronic Data Interchange www.wedi.org Ann Wandersee ann.wandersee@state.mn.us