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Provider Update Newsletter
August 2006, Volume 166
 

All Providers

HIPAA National Provider Identifier (NPI)
Radiology Management
SFY 2007 Medical Assistance Financial Calendar
 

Dental Providers

Dental Local Code Conversion

HIPAA National Provider Identifier

The Centers for Medicare & Medicaid Services (CMS) is pleased to announce the
availability of a new identifier for use in the standard electronic health care transactions.
The National Provider Identifier (NPI) will be the single provider identifier, replacing the
different provider identifiers you currently use for each health plan with which you do
business. This identifier, which implements a requirement of the Health Insurance Portability
 and Accountability Act of 1996 (HIPAA), must be used by most HIPAA covered entities,
which are health plans, health care clearinghouses, and health care providers that conduct
electronic transactions for which the Secretary has adopted a standard (i.e., standard
transactions).

The NPI is one of the steps that CMS is taking to improve electronic transactions for health
care. National standards for electronic health care transactions encourage electronic commerce
in the health care industry and simplify the processes involved to reduce the administrative
burdens on health care providers.

With national standards and identifiers in place for electronic claims and other transactions,
health care providers will be able to submit transactions to any health plan in the United States.
Health plans will be able to send standard transactions such as remittance advices and referral
authorizations to health care providers. These national standards will make electronic data
interchange a viable and preferable alternative to paper processing for health care providers
and health plans alike.

To date, CMS has adopted and implemented the following HIPAA standards: electronic
health care transactions and code sets, privacy, security, and the national employer identifier.

CMS has begun to implement the NPI. Back on January 23, 2004, the Secretary published a
Final Rule that adopted the NPI as this identifier. As of the compliance dates listed on the next
page, HIPAA covered entities must use NPIs to identify health care providers in standard
transactions. These transactions include claims, eligibility inquiries and responses, claim status
inquiries and responses, referrals, and remittance advices.

Health care providers include individuals, such as physicians, dentists, and pharmacists, and
organizations, such as hospitals, nursing homes, pharmacies, and group practices. Health care
providers who transmit health information electronically in connection with any of the standard
transactions are required by the NPI Final Rule to obtain NPIs, even if they use business
associates, such as billing agencies, to prepare the transactions.

The NPI will replace health care provider identifiers that are in use today in standard transactions. Implementation of the NPI will eliminate the need for health care providers to use different
identification numbers to identify themselves when conducting standard transactions with
multiple health plans. Many health plans, including Medicare, Medicaid, and private health
insurance issuers, and all health care clearinghouses must accept and use NPIs in standard
transactions by May 23, 2007.

Small health plans have until May 23, 2008. After those compliance dates, health care providers
may use only their NPIs to identify themselves in standard transactions, where the NPI is called for.

You are able to apply for your NPI in one of three ways:

• You may apply through an easy web-based application process, which began
  May 23, 2005 by clicking here

• You may prepare a paper application and send it to the entity that will be assigning the NPI
  (the Enumerator) on behalf of the Secretary, which began July 1, 2005. A copy of the
  application, including the Enumerator’s mailing address, is available by clicking here. You
  may also call the Enumerator for a copy. The phone number is 1-800-465-3203 or TTY
  1-800-692-2326.

• With your permission, an organization may submit your application in an electronic file. This
  could mean that a professional association or perhaps a health care provider who is your
  employer could submit an electronic file containing your information and the information of
  other health care providers. This process has been available since the fall of 2005.

 

Radiology Management

The Radiology Management Prior Authorization Program initially scheduled for implementation
on July 1, 2006 with MedSolutions Inc. has been delayed until September 1, 2006. Prior
Authorizations for CT, MRI, and PET scans will not be required until September 1, 2006.
During this time period the Department of Human Services will take into account the input recently
received from the provider community and will consider the possibly of alternative program plans.
Your cooperation with the change is appreciated. Please refer to the DHS website by clicking here
for any updates regarding the prior authorization program.

 

SFY 2007 Medical Assistance Financial Calendar

Click here to view a copy of the July 2006 – July 2007 Payment and Processing,
 

 

Dental Local Code Conversion

With the recent Local Code Conversion the old local code X9920 (Behavior Management) has
been changed to D9920 which will now require Prior Authorization.

This code is used when a second staff member is needed to treat the client. Some situational
examples would be if a client was wheelchair bound and an assistant would be needed to transfer
the client into the treatment chair or for a client that has autism and a second assistant is needed to
help manage the clients needs.

When filling out the PA Request Form please clearly state why a second assistant is needed. You
will receive written notification of the request outcome. If you have any questions please contact
your provider representative Ashley Cunningham at 401-784-3832.