Billing NPI and Group NPI , provider number update from Medicaid

Starting in April 2011, electronic Florida Medicaid claims must be submitted with only an NPI in the billing/pay-to provider and the rendering/treating provider loops for providers who are required to obtain an NPI.  Electronic claims that include a Medicaid provider number in these loops will deny as of April 1, 2011.

Some providers are submitting electronic claims with both the Medicaid ID and the NPI on the claim, in the billing/pay-to provider loop and/or the treating/rendering provider loop.  In some cases, the Medicaid ID and NPI being submitted by providers do not match the identifiers that are on the provider’s Medicaid provider file, which will cause problems with claim adjudication when the April 1 changes requiring only an NPI go into effect.  Claims may deny or process for an incorrect provider if the NPI is not associated with the correct Medicaid ID.

To assist providers, claims that are being submitted with mismatched provider numbers in the billing/pay-to provider loop and/or the treating/rendering provider loop are posting the Explanation of Benefits (EOB) 1087, Adjustment Reason Code 208, and Remark Code N521 on paid claims with this problem.  If your paid claims do not post these explanations, stop sending the Medicaid ID on electronic transactions now.  The absence of these explanation codes is an indication that the data you are submitting on claims matches the data on the Medicaid provider file and that your claims will process correctly with only the NPI in these loops.

Provider ID and NPI Requirements

The Plan requires the use of the National Provider Identifier (NPI) on all claim submissions except for providers exempt from NPI requirement, both electronic and paper.

* If submitting claims electronically, there is a required field in the file format for the referring, rendering or facility NPI numbers. Providers are encouraged to verify that their software management tool or clearinghouse is placing it in
the correct field.

* Providers submitting paper claims should include their NPI on both CMS 1500 and UB-04 forms.

National Provider Identifiers Standard transactions such as claims submitted electronically to the Plan must include the referring, rendering or attending, billing and facility provider’s NPI, per requirements put forth in HIPAA’s NPI Final Rule Administrative Simplification.

The NPI and tax ID must be included with electronic and paper claim submissions for proper adjudication. More information about NPI is available on the CMS Web site

Claim Submission Format

Claims may be submitted to the Plan in one of the following formats:

* Electronic Claims Submission (EDI)

* CMS 1500 form

* UB-04 form

All providers are required to use the standard codes for ICD9, CPT and HCPCS, regardless of the type of submission.

The largest driver of payment turn-around time is the accuracy of the data on the claim, regardless of whether it is an electronic or paper claim submission. To assist providers in submitting the correct data in the correct fields on a claim, the Plan has prepared claim  submission guidelines. These guidelines identify key fields the Plan requires to be filled for claims processing as well as the data source to complete the field.

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