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Medicare Bulletin--Electronic Data Interchange (EDI)
Attention Sole Proprietors: Are you preparing for NPI?
All providers should be preparing for National Provider identifier (NPI), getting enumerated, determining their vendor readiness, and preparing their billing systems.
How will you know if you have potential NPI issues? Start using your NPI as soon as you are able.
The electronic media claims (EMC) system review every claim for a number of pre-pass edits to ensure that claim data is valid; this includes NPI validation and verification. Your Batch Detail Control Listing returns information regarding NPIs sent on your electronic claims; validating the structure of the NPI and verifying the NPI or NPI/legacy number combination are on the crosswalk.
A common issue in electronic claims occurs when the provider is a sole proprietor with Medicare Part B. The solo practice is incorporated, has a tax ID, and has obtained an organizational NPI as well as an individual NPI for the provider. If an individual provider has 2 NPIs (one for organization, one for provider) but only 1 Medicare Provider number, a new CMS 855 application may be necessary. Conversely, a sole proprietor who is unincorporated yet has a tax ID should enumerate only an individual NPI under their Social Security Number.
Another common issue occurs when there are multiple sole proprietors who share a common tax ID and pay-to name. If the pay-to organization has obtained an organizational NPI and each solo has their own NPI, as new CMS 855 application may be necessary to establish a group. Not sure if you need a new MCS 855 application? Call Provider Enrollment at: 877-908-8476.
It is extremely important to use the Legal Business name used when applying for the NPI. The Legal Business name is the name reported to the IRS. Also, be sure to add any of your current legacy ID numbers, Medicare PIN, UPIN, etc. when applying for an NPI or if you need to update your record within NPPES.
The NPI enumerator Website is: NPPES.cms.hhs.gov/NPPES/Welcome.do
Once you have updated NPPES and you still continue to receive the informational errors on your report, please contact the EDI Hotline for assistance at: IL, MI, WI: 877-567-7261 MN: 952-885-2811, 952-885-2881, or 952-885-2882
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