4010 to 5010

1. 4010 to 5010 DMH NPI and Taxonomy Edits

2. Providers and Service Scenarios • Kinds of Providers • County owned-and-operated facilities • County contracted providers • County contracted facilities • Fee-for-service providers • Service Scenarios • Service provided outside of the patient’s home • In-home services

3. 5010 NPI Locations • Pay-to Provider NPI has been eliminated • Billing Provider NPI • Service Facility Location NPI • Rendering/Attending Provider NPI

4. Billing Provider NPI • Report only county NPIs in Billing Provider Loop • Report the “most specific subpart” NPI of your county organization relevant to the service • Do not report a county NPI in the Service Facility Location or Rendering Provider Loops • Notify DMH of all county NPIs you will use when billing (for inclusion in the DMH Provider File)

5. Service Facility Location • For a provider external to the county organization • County-contracted Facility • Report the facility’s “most specific subpart” NPI • Notify DMH of all county-contracted NPIs used for billing (for inclusion in the DMH Provider File) • Fee-for-Service Provider • Report the location NPI if available • In-home services • Report the patient’s address*

6. Rendering/Attending Provider NPI • Identifies the person rendering the service • May not be a subpart NPI of the county • A county employee is not a “subpart” • Taxonomy code will be used for the: • Fee-for-service Provider Edit • Medi-Medi Dual Eligibility Edit • No longer necessary to report a hospital taxonomy code to identify Mode 12 services

7. In-home Services • Place of Service = “12” • Report patient’s home address in the SFL • For county-contracted facilities report: • The facility’s NPI in the claim level SFL • Patient’s home address in the service-level SFL • Leave the service-level NPI blank

8. County Provider Validation • The DMH Provider File Lookup uses the: • County code • County’s federal Employer Id Number (EIN) • Revenue code (inpatient claims only) • NPI in the Billing Provider loop • Procedure code and modifiers • Date of service

9. Contract Provider Validation • The DMH Provider File Lookup uses: • County code • County’s federal Employer Id Number (EIN) • Revenue code (inpatient claims only) • NPI in the Service Facility Location loop • Procedure code and modifiers • Date of service

10. Fee-for-Service Provider Validation • Claim Note: “FFS”, “SED-FFS” or “FFS-SED” • Rendering Provider Taxonomy Code prefix: • 103 - Psychologist • 104 - Licensed Clinical Social Worker • 106 - Marriage Family Therapist • 163 - Registered Nurse • 193 - Mixed Specialty Practice* (will be phased out) • 207 - Physician • 208 - Psychiatrist • 363 - Nurse Practitioner / Physician’s Assistant • 364 - Nurse Specialist

11. Quiz #1 County Owned Facility • For services provided by a county operated facility, what should be reported in: • Billing Provider Loop? • Service Facility Location Loop? • Rendering Provider Loop?

12. Quiz #2County Contract Facility • For a service provided by a county contract facility, what should be reported in the: • Billing Provider Loop? • Service Facility Location Loop? • Rendering Provider Loop”?

13. Quiz #3Fee-for-Service Provider • For a service provided by a Fee-for-Service provider, what should be reported in the: • Billing Provider Loop? • Service Facility Location Loop? • Rendering Provider Loop”?

14. Medi-Medi Dual Eligibility Edit • Requires Medicare COB information for most H2010 and H2015 services when the Rendering Provider Taxonomy Code begins with: • 103 Psychologist • 104 Social Worker • 207 Physician • 208 Physician • 363 Nurse Practitioner/Physician’s Assistant • 364 Nurse Specialists

15. Medi-Medi Dual Eligibility Edit • Requires Medicare COB information for most H2010 and H2015 services when the Rendering Provider Taxonomy Code begins with: • 103 Psychologist • 104 Social Worker • 207 Physician • 208 Physician • 363 Nurse Practitioner/Physician’s Assistant • 364 Nurse Specialists

16. DMH Provider NPI and Taxonomy Edits • Questions?