NPI

1. NPI NPI Committee Meeting 9-29-05

2. Whitepapers • Workgroup for Electronic Data Interchange (WEDI) NPI Whitepapers Approved • NPI and Clearinghouses, PBM’s and Vendors • NPI and Health Care Providers • NPI and Health Plans • Dual use of NPI and Legacy Identifiers • NPI Overview • NPI Registration Process • WEDI NPI Whitepapers Pending • Implementation planning, timing and sequencing • Pharmacy Industry • EFI (Bulk Enumeration) • Dissemination • Atypical Service Providers • Independent Clinical Laboratories

3. News • NPI Subpart Medicare NPI Policy Paper is not ready yet, is still being looked at by various entities • NPI Dissemination – later this year, but probably early next year • CMS and X12 are working together to make the X103 (new guide ID to be identified) to be used for both bulk enumeration and data dissemination processes. • No temporary or “dummy” NPI’s slated to be created. We will discuss how this will affect us

4. News • Electronic File Interchange (EFI) specifications • All policy decisions regarding the EFI specs have been made by the CMS EFI team • The EFIO Certification Statement form has been forwarded to legal counsel (CMS/HHS) for review and approval • CMS is still expecting that December 5, 2005 will be the date for the system to be ready • CMS Roundtable teleconference on NPI postponed from September 14, 2005 – not yet rescheduled

5. NPIOI • WEDI announced in August its launching of its National Provider Identifier Outreach Initiative (NPIOI), an effort designed to serve as the focal point for information related to the planning, transition, and implementation of the NPI. • The intent of the WEDI NPIOI is to create a national coordinated strategy that: 1)helps ensure early awareness across all covered entities and affected organizations; 2) provides a consistent level of understanding regarding the regulations; and 3) promotes the sharing of information regarding NPI planning, transition and implementation experiences, approaches, and timelines. • Vanderbilt will seek budgetary approval to become a WEDI member, which has just recently become mandatory in order to continue to receive important NPI/HIPAA information.

6. CMS 1500 • NUCC (National Uniform Claim Committee) conducted research in June 2005 with providers (41), payers (26) and vendors (19) on use of the NPI on the CMS 1500 claim form. • Those that responded: Vendors such as McKesson and Misys; Payers such as CMS, United Health and Highmark; Providers such as Mayo and Cleveland Clinic • When asked how much time would be needed to prepare for the NPI on the 1500 by October, 2006, most said 1 year. • Most would need a transition period of at least 4 months and indicated they could be ready by February, 2007.

7. Suggested changes to 1500 form • Barcode header removed • NUCC logo and approval info added to left side of header • Box 17A split to accommodate Other ID# and NPI of the referring/ordering phys • Box 24C changed to EMG • Box 24D wide by 3 bytes • Box 24E narrower by 3 bytes • Box 24I now ID Qualifier field • Box 24J COB field removed • See draft form and more at: http://www.nucc.org/draft1500/

8. UB-04 • The UB-04 has an NPI field • Health care providers will be required to use the new form to process health care claims beginning in 2007, when the current UB-92 form and data set will be discontinued. • Providers will be able to transition to the new form between March 1 and May 22, 2007, when both the new and current forms/data sets will be accepted, but must begin using the new form and data set by May 23, 2007. • Health plans, clearinghouses and other information support vendors must be ready to handle and accept the new form and data set by March 1, 2007. The NUBC, which maintains the standard billing data set for health care providers, revised the form and data set to better align with HIPAA. • See draft form and more at: http://www.nubc.org/public/whatsnew/UB-04Proofs.pdf

9. Type 1 and 2 NPI’s • Type 1: NPI’s with an “entity type code” of 1 will be issued to health care providers who are individual human beings: physicians, nurses, dentists, chiropractors, pharmacists, physical therapists, among others. Type 1 NPI’s are assigned for life, unless circumstances justify deactivation. • Type 2: NPI’s with an “entity type code” of 2 will be issued to organizations: hospitals, home health agencies, clinics, nursing homes, residential treatment centers, laboratories, ambulance companies, group practices, HMOs, suppliers (who deal in durable medical equipment, supplies related to healthcare, prosthetics and orthotics) and pharmacies. Group practices will be considered organizational health care providers. An organizational NPI is not linked to the NPI of individual providers who are members of the organization or group.

10. EFI (formerly Bulk Enumeration) • If multiple organizations are EFI submitters for the same provider • It is expected that the system will de-duplicate applications, as they come in • What are the plans for Medicare to pursue bulk enumeration for some providers, and then the issues/consequences of having an ‘overlap’ with other EFI organizations? • This is still under review by Medicare

11. Bulk Enumeration • EFI bulk enumeration can benefit providers • Ensure all your employed providers comply on time • Ensure you get paid without delay (on your end) • But EFI bulk enumeration does not solve all challenges • Referring and attending physicians and organizations are not all included • Still need to share NPIs with other companies • Can lead to duplicate NPIs for individual providers • Does not promote “ownership” of the NPI data

12. Bulk Enumeration Needs • In order to EFI bulk enumerate, providers will require: • A single, consolidated Provider Master File • Permission from every individual provider • Does credentialing and provider enrollment processes exempt us from going back to each individual provider every time and obtain specific written and signed authorization? • Strong communication to ensure individuals do not enumerate themselves • A strategy for enumerating sub-parts • Patience –system still not available • Ability to identify and manage duplicate NPIs

13. Dissemination • Dissemination has been defined as NPI-related data made available from NPPES to individuals/entities. • VUMC sent a question to the WEDI NPI forum in 9-05: “Does anyone know when we as providers will be able to view the data in the NPPES before we apply, to ensure that we are not duplicating (in cases such as when a physician practices at multiple hospitals, for example)?  It would be a great resource for learning NPI's for our referring physicians as well.”

14. Duplication • What we learned: • “NPPES has edit logic that will often determine that there is a second application for the same provider, but the tests may not always spot the duplicate. It depends on the type of provider (individual vs. organizational), license numbers, and other data. As I understand it, an entity applying for an NPI on behalf of a provider must have authority to do so, and a provider should not grant such authority to an entity if it has already applied or to two different entities to act on its behalf.” • We have to wait until 2006 to find out

15. Dissemination • WEDI • NPI Dissemination means the ‘disclosure’ of data from a federal data system • Controlled by Federal Privacy Act • Requires publication of a Notice to define data dissemination approach • Notice expected to be published by Q4, 2005

16. Dissemination Approach from WEDI • NPI Dissemination (NPPES) approach will need to define: • WHO is eligible to obtain NPI-related information from NPPES • WHAT data (data elements) may be obtained from NPPES • HOW data will be provided to requester • Legal aspect (Data Use Agreement) • Technical aspect (Data file format) • Data Use Agreement is most common method used by CMS to disclose information from their data systems (e.g., Medicare data for research) • Data Use Agreement usually defines who can access data, data handling requirements, what can/can’t be done with data (internal use, re-release issues, other), final disposition of data, etc. • Key defining element is the “Privacy Statement”

17. Legal implication on Dissemination • Important relationship between NPI Privacy Statement and the Privacy Statement contained in the CMS-855 Provider Enrollment Form • Data from Medicare Provider Enrollment form is governed by CMS-855 Privacy Statement • Data from NPPES is governed by Privacy Statement in NPI Application/Update Form • Providers filling in CMS-855 form will be able to use form to authorize CMS to apply for NPI on behalf of provider • Categories of entities who may be able to request information from the Medicare Provider Enrollment data are different from NPPES Statement • Need to look closer at inter-relationship between two Privacy Statements

18. Dissemination • Dissemination availability for January 2006 at the earliest • “CMS heard the warnings about the impossibility of running NPPES as a "black hole" available only to a selected few, while the whole industry was trying to implement standard transactions that relied on them exclusively.  But because the NPI has a regulatory designation as a private identifier, they are having to conjure all kinds of legalistic firehoops to get it approved.” •  ”One thing I did hear from several reliable sources is that CMS will NOT include an individual practitioner's SSN in the disseminated data set.  So cross off crosswalk #1.” • “ If I'm right, the good news is that more of us will have access to the data we need.  The other news is that we won't know who, what, how or when for several more months.” • “The really bad news is that none of the data attributes of the NPI in the NPPES will be verified data. Thus, it is a certainty that dirty data will be disseminated.”

19. Models for NPI dissemination • NPPES to Individual Provider • Individual provider requesting NPI-related information about another individual/organization provider • NPPES to Provider Organization • Organization requesting NPIs from individual/organization providers • NPPES to Plans/Clearinghouses • Request for individual/ organization providers in plan networks, clearinghouse lists • NPPES to Other Public Health Agencies

20. Pharmacy • NCPDP version 5.1 does not support dual identifiers • Need the NPI in real-time to not disrupt patient care • NCPDP will become an EFI submitter • Pharmacies only provider group that already have a unique identifier. • NCPDP has enumerated pharmacies for 20 years • Industry reliant on NCPDP Pharmacy Database which is licensed to PBMs, health plans, manufacturers (rebates), informatics companies and others • NCPDP 2006 initiatives will include disseminating NPI’s to chains/individual pharmacies and new taxonomy codes. • Email distributed to VUMC retail pharmacy representatives which describes NCPDP philosophy.

21. MDS • NPI requirement on the Minimum Data Set (MDS) reporting by Nursing Homes • By October, 2005, the NPI field will be available on the MDS form (but not required). • By May, 2007, the MDS form will eliminate all of the proprietary provider identifiers (such as UPIN, Medicare, BCBS, Public Aid ID’s, etc…) that are currently present. • Section W will have this additional field – see other items to be added at: http://www.cms.hhs.gov/quality/mds20/SectionW.asp • MDS is NOT a HIPAA transaction, not subject to HIPAA, and as such can adopt to use the NPI. While the NPI could be required to be used earlier on MDS, there is no indication thus far.

22. Credentialing • If there is no credentialing-type verification done by Fox Systems, Inc., how do we know, once CMS is only handing out NPIs, that the provider has been thru the CMS credentialing process and has been approved by CMS as a Medicare provider?   • As things stand now, you won't know.  The NPI contains no intelligence that indicates the relationship with any Payer (and this includes CMS). There is no such thing as a "Credentialed NPI".  The Provider registers (using the NPI and other appropriate documentation) with various other entities, and if that entity accepts that the documentation is true and adequate, it records the registration on their database. 

23. Medical students, interns, residents and fellows are eligible for NPI’s • A Healthcare Provider Taxonomy Code for classifying medical students is available for use. Medical students should select this code when applying for NPIs • Interns are licensed allopathic or osteopathic physicians who have not entered into a residency or fellowship. They would select the Healthcare Provider Taxonomy Code for General Practice (208D00000X), within the Allopathic and Osteopathic Physicians category, when applying for NPIs • Residents and fellows would select the Healthcare Provider Taxonomy Code within the Allopathic and Osteopathic Physicians category that describes those specialties when applying for NPIs.

24. VUMC’s tasks • Finalize project plan and implementation strategy • Cleanse existing provider data files • EFI bulk enumerate or collect NPIs from NPPES and apply for gap? • Who will update systems initially and ongoing? • Strategy for obtaining new NPIs in the future • Vendor Systems • Identify affected systems • Perform gap analyses • NPI • Taxonomy codes – who will maintain and promulgate to others? • Payer and clearinghouse timelines; requirements • Sub-part identification • Managed care contracts • Type 1 and Type 2 entities -who will apply for each type? What about sub-parts?

25. Issues/Questions • No Surrogate/Temporary NPIs – how will this impact us? • Plan Requirements – may need NPI before compliance date (Medicare, as of 10-3-05, says the NPI is not required in October 2006 but by May 2007). • Vendors – when will they have NPI and taxonomy codes available? • When will clearinghouses be storing these? Will they override our NPI’s on our claims? • Who will keep the NPI table updated? Who will need access to the table? Should this be a web page? • How will we seek individual provider’s approval? Where will this be stored?

26. THANK YOU! • Was this useful? • When should I follow up with each of you? • When should we meet again? • Contact Grace Upleger at 322-2841 if there are any questions or comments or visit the VUMC HIPAA webpage at: https://www.mc.vanderbilt.edu/HIPAA