• General Questions
• Applying for NPI
• Reporting your NPI to N.C. Medicaid
• Updating and Verifying your NPI with DMA records
• Carolina ACCESS
• Taxonomy
• Filing Claims
• Other

General Questions

1. What is a National Provider Identifier (NPI)? The NPI is a standard provider identifier that will replace the different provider numbers used in standard electronic transactions today.  The NPI was adopted as a provision of HIPAA. The NPI Final Rule was published on January 23, 2004 and applies to all health care providers.
2. How can providers learn more about NPI? The Centers for Medicare and Medicaid Services (CMS) has created a slide presentation to answer many NPI questions.  You can access the viewlet here.  Additional information, including frequently asked questions (FAQs), can be found on the CMS Web site and on this DMA website.
3. What is the NPI compliance date? The original compliance date of May 23, 2007 was extended one year.  All covered entities are now required to be compliant by May 23, 2008.
4. Who must get an NPI? HIPAA requires that covered entities (i.e., health plans, health care clearinghouses, and those health care providers who transmit any health information in electronic form) use NPIs in standard transactions. 
5. How do providers know if they are eligible to receive an NPI?
   All health care providers, as defined in 45 C.F.R. § 160.103, are eligible to obtain an NPI. Entities that do not provide health care (for example, non-emergency transportation services) are not required to obtain an NPI because they do not meet the definition of "health care provider."
6. Do health care providers need to apply for an NPI to submit claims to N.C. Medicaid? Yes, if you meet the definition of a covered entity (i.e., health plans, health care clearinghouses, and those health care providers who transmit any health information in electronic form).  As of the NPI implementation, the NPI will be the only health care provider identifier that can be used for identification purposes in standard transactions by covered entities, including North Carolina Medicaid. In addition, N.C. Medicaid will require the NPI on paper claims submitted on or after NPI implementation.
7. Which providers have been identified as atypical by N.C. Medicaid? Atypical providers are those who do not provide healthcare services. Providers must determine if they meet the definition of atypical.
8. As a prescribing provider, do I need to share my NPI with pharmacies? Yes. Pharmacies will need the prescribing provider’s NPI in order for their claim to process. 
9. Do group providers need an NPI? Providers may obtain an organizational NPI for their group provider number. N.C. Medicaid recommends that providers obtain an NPI for each Medicaid provider number used today.
10. If a provider has seven different offices, are they supposed to subpart? While N.C. Medicaid cannot require providers to enumerate a certain way, N.C. Medicaid recommends that providers obtain an NPI for each Medicaid provider number they currently use.   Refer to the State Medicaid Director’s letter for guidance.
11. If providers have multiple Medicaid group provider numbers, will they receive separate payments? Providers will receive a separate RA and separate payment for each Medicaid provider number. The 835 transaction will only contain the NPI. The paper RA will contain both the NPI and the Medicaid provider number.
12. Will state facilities be required to subpart? N.C. Medicaid recommends that providers obtain an NPI for each Medicaid provider number used today.
13. If providers currently have both group and attending provider numbers, how many NPI numbers are required? N.C. Medicaid recommends that providers obtain an NPI for each Medicaid provider number used today.
14. Do group and individual numbers need to be linked? Currently, claims do not deny if the individual provider is not linked to the group. The process is not going to change with the implementation of NPI.
15. If a provider has a Home Health and CAP practice, will they be required to get an NPI for both? Although it is not required, N.C. Medicaid recommends that providers obtain an NPI for each Medicaid provider number used today.

Applying for your NPI

1. How do providers apply for an NPI? CMS has established a National Plan and Provider Enumeration System (NPPES) for providers to obtain their NPI(s).  For additional information and to complete an application, visit National Plan and Provider Enumeration System (NPPES).
2. How do providers obtain a copy of the NPPES Certification? Visit the NPI Registry to print a copy of your NPI information.
3. What can providers do if they did not report all health care provider numbers on the original NPI application? Providers have the option of amending the original NPI application at any time by contacting the enumerator or logging into the NPPES website.

Reporting your NPI to N.C. Medicaid

1. Do health care providers need to report their NPI(s) to Medicaid? Yes. It is a requirement for health care providers to report their NPI(s) to N.C. Medicaid.
2. How do I report my NPI(s) to N.C. Medicaid? N.C. Medicaid is currently collecting the NPI numbers from Medicaid providers via the NPI and Address Database.  New providers will report their NPIs on their provider enrollment applications instead of the NPI and Address Database. Providers must also submit a copy of the certification letter from the National Plan and Provider Enumeration System (NPPES).
3. Can I report more than one NPI per Medicaid Provider Number? No.  The N.C. Medicaid mapping solution is designed to allow only one NPI per Medicaid Provider Number.
4. Can I report the same NPI for a group and individual provider? No. Providers should verify that the same NPI is not on file for both a group and an individual Medicaid Provider Number (MPN). This reporting error will result in unresolved claims (non-payment).  An individual NPI cannot be used by an organization.  The organization must have its own NPI.  An example of an organization is a corporation (LLC, PLLC). 
   Some individual providers who have incorporated have two MPNs, one for the individual and one for the corporation, but they have only reported one NPI.   This type of enrollment requires two distinct NPIs. If this scenario applies to you, please report your additional NPI as soon as possible via the NPI and Address Database.
5. If the provider receives an email instead of a letter on the enumerator’s letterhead, is the email acceptable as the NPPES certification? Yes, providers need to send to DMA the certification notice they receive from NPPES. It can be a letter or an email printout if the NPI was obtained electronically.  DMA requests the following information on the NPPES certification: NPI, taxonomy, Medicaid provider number, and full address with ZIP +4.

Updating and Verifying your NPI with DMA records

1. How do I verify and make corrections to my NPI? Visit the NPI and Address Database. If a correction is needed, print the form and make the corrections in the “Corrected Information” column. Sign and date the form and fax to DMA Provider Services at (919) 715-7140.
2. If the NPI appears on the Remittance and Status Report (RA), does that mean that I do not need to verify our NPI information? No.  The NPI on the RA comes from the provider database.  This tells you that the NPI is on file with DMA; however, it will not tell you if the NPI is being submitted on your claims.  Providers should still verify that their NPI is being submitted on claims and verify the address information on file with DMA.

Carolina ACCESS

1. Will Carolina ACCESS referrals switch to using the NPI? Yes. Providers must obtain the NPI of the Carolina ACCESS PCP or referring provider.
2. Do we ask for a group or individual NPI for Carolina ACCESS/referrals? In order to determine whether to obtain the group or individual NPI for the referral, refer to the recipient’s Medicaid Identification card.  If a group name is listed on the card as the Primary Care Provider (PCP), obtain the group NPI.  If an individual’s name is listed as the PCP, obtain the individual’s NPI. 
3. Will there be an NPI for Carolina ACCESS overrides? The Carolina ACCESS override process is not changing.  Providers will continue to use the override number issued by NC Medicaid on claims.   On CMS 1500 claims, this number is placed in block 17a or electronic equivalent.  On UB claims, this number is placed in FL 78 or electronic equivalent.

Taxonomy Codes

1. What is the purpose of Taxonomy codes? The taxonomy will play an important role in the NC Medicaid mapping solution.  The NPI contains no intelligence; however, the Taxonomy code represents a provider’s type and specialty. The mapping solution’s goal is to determine the appropriate Medicaid Provider Number for claim adjudication. Therefore, N.C. Medicaid strongly recommends that providers use the table on the DMA website when choosing an appropriate taxonomy code.
2. Which taxonomy code is appropriate for providers to use? Taxonomy codes and their descriptions are listed on the Washington Publishing Company website: http://www.wpc-edi.com/taxonomy. The provider must determine which taxonomy to use.
3. Which Taxonomy code is appropriate for my claims? NC Medicaid strongly recommends that providers refer to the recommended taxonomy codes for NPI mapping table when selecting a taxonomy code. However, this list is not all inclusive.  If your provider type and specialty is not on the recommended list, select the most appropriate taxonomy code from the Washington Publishing Company’s website located here: http://www.wpc-edi.com/taxonomy.
4. Will claims deny today without the NPI and Taxonomy? All claims must contain an NPI and Taxonomy (except pharmacy) beginning May 23, 2008.   However, prior to May 23, 2008, N.C. Medicaid is testing with claims that contain NPI, MPN, and Taxonomy to ensure that they map correctly.  Providers are strongly encouraged to submit this data in order to be included in the testing process.
5. What if my Taxonomy code for the billing and attending provider is the same? As of the date of this publication, only one taxonomy code is allowed per claim.  Therefore, enter the attending provider’s taxonomy.
6. What Taxonomy Code should we use for CAP services? At this time, DMA does not have a recommended taxonomy code for CAP services. Providers should select what is the most appropriate taxonomy code from the Washington Publishing Company web site located at http://www.wpc-edi.com/taxonomy.
7. Do I need to report a taxonomy code change to DMA?  No. Simply begin using the new taxonomy code on claims.
8. Does the taxonomy code on my claims need to match the taxonomy code on my NPPES certification? No.
9. Is a taxonomy code required on a claim for a referral? No.  Referring taxonomy codes are not required for NC Medicaid.
10. Is there a different taxonomy for DME provider numbers?DMA recommends the following taxonomy code for DME claims: 332B00000X.
11. What taxonomy do providers use for Community Support services? DMA recommends the following taxonomy code for Community Support: 251S00000X.

Filing Claims

1. Do we need to use the qualifiers on electronic claims? Qualifiers are not required on the NCECS Web tool.  They may be required by software vendors or clearinghouses.  Contact your vendor or clearinghouse to verify whether or not they are required.
2. When will NCECSWeb save the Taxonomy code in List Management? Adding the taxonomy code to the list management function will be a post NPI implementation consideration.
3. Where do providers list the NPI and taxonomy on the current claims? N.C. Medicaid is currently accepting the NPI on the 837 transaction. Refer to the Implementation Guide and DMA’s Companion Guide for instructions for including the NPI on the 837. For paper claim requirements, refer to the December 2006 Claim Form Special Bulletin.
4. Home Health providers are required to list the attending provider’s UPIN on their claim forms. The UPIN’s are supplied through a published website. Will providers be required to change this to the provider’s NPI and will they be published on a website? Yes, the NPI is replacing the UPIN and must be reported on these claims. At this time, N.C. Medicaid is not aware of a website which will publish NPIs.
5. Can health care providers use the NPI when submitting claims to North Carolina Medicaid prior to NPI implementation? Yes.  N.C. Medicaid encourages providers to begin submitting both the National Provider Identifier (NPI) and taxonomy along with the Medicaid provider number on electronic claims. If your software is not updated to submit the NPI number, please contact your clearinghouse or software vendor as soon as possible to obtain the appropriate updates. Please ensure that you keep the capability to submit the Medicaid provider number along with the NPI. N.C. Medicaid will continue to process claims using the Medicaid provider number until NPI is implemented.
6. In Which field on the UB-92 does the NPI need to be entered? N.C. Medicaid no longer accepts the UB-92 claim form as of 4/25/08.
7. What if the referring provider is atypical? If the referring provider is atypical, continue to submit the MPN as the referral number. Verify the referring provider’s atypical status by entering their MPN in the NPI and Address Database. If the provider is atypical, the query results will include the word “atypical” below the Medicaid provider number.
8. What is the impact for Medicare crossover claims? As long as the Medicare number is submitted on the crossover claim, it will be used.  Therefore, providers need to ensure that their Medicare to Medicaid crosswalk information is current.  Once the claims are submitted with NPI only, NC Medicaid will be mapping crossover claims.  Refer to the March 2008 bulletin for more information.
9. When do I need to complete the service facility location field on my claim? If the service was rendered in a location other than the billing address, this field should be completed.  However, this field is not required if the service was rendered in the recipient’s home.  Service facility location is an important part of the NPI mapping solution, especially when one NPI represents many MPNs at different locations.  Example: one NPI represents physician offices in Raleigh, Greensboro, and Burlington.  Each location has a different MPN. In order to map to the correct MPN, service facility location information is needed.
10. What if the service facility and billing addresses are the same? If the addresses are the same, only complete the billing address field.
11. When should I begin submitting claims without my Medicaid Provider Number? DMA encourages all providers to continue to submit their NPI, Medicaid Provider Number (MPN), and taxonomy. (Pharmacies must submit their NPI only.) Once it is determined that the NPI submitted on the claim is mapping correctly to the MPN submitted by the provider,  DMA will notify the billing provider by mail (Provider Ready letter) that it is ready to receive claims without the MPN.
12. What is an unresolved claim? An unresolved claim is a claim submitted with NPI and Taxonomy (no MPN) that could not be mapped to one MPN.   These claims will deny and providers will receive an unresolved report.  Providers are encouraged to continue submitting claims with an NPI, MPN, and Taxonomy until your ready notice is received in order to avoid unresolved claims. 
13. Will the adjustment request form, the resolution inquiry form, or prior approval request forms change as a result of NPI? No. Continue to submit these requests the same way you do today.
14. If providers do not subpart, to which group number will payment be issued? The claim will be adjudicated through a mapping solution to determine which Medicaid provider number is associated with that particular NPI.  The paper Remittance and Status Report (RA) will reflect the group Medicaid provider number as well as the NPI.

Other

1. Will prior approval forms (FL-2) be updated to include the NPI? Until otherwise notified, continue to complete the FL-2 forms using the Medicaid provider number.
2. How will Medicaid use the NPI with Value Options and CCME? Until otherwise notified, health care providers need to continue using the Medicaid provider number on prior approval requests.
3. Will the HIPAA crosswalk codes translate with the new NPI EOB codes?
   They have already been crosswalked and are available in the crosswalk file on the DMA web site. See the HIPAA page.
4. How do I verify my Zip+4? Visit www.usps.com and use the zip code lookup function.  Providers should also visit the NPI and Address Database to verify that your zip+4 is on file with DMA.  If not, it can be added by completing the correction form located on the database.

Updated August 8, 2008