June 15, 2007

BC-07-13
HP-07-10
SA-07-10

HHA-07-10
DC-07-10

National Provider Identifier (NPI) – Contingency Plan and Procedures - UPDATE

Changes have been made to the section of this newsletter titled ACUTE CARE HOSPITALS WITH MEDICARE EXCLUDED PSYCHIATRIC OR REHABILITATION UNITS. 

All other information remains as originally published May 16, 2007.

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In this newsletter you will find details about BCBSKS' implementation of the national provider identifier.  This includes

• Contingency Plan
• NPI "ONLY" Readiness – Providers Must Notify BCBSKS
• One-To-One Match vs. One NPI/Multiple Legacy Numbers
• Web Security – BCBSKS Web Provider Profile
• Provider Name
• Provider Address (including correspondence, remittance advice and payment addresses)
• Web vs. Paper Remittance Advice
• Payment and Remittance Advices (RAs)
• Acute Care Hospitals with Medicare Excluded Psychiatric or Rehabilitation Units
• Reporting Secondary Provider Information – Includes Attending Provider, Operating Physician and Other Provider Information (UB-92/UB-04, 837I)
• New Providers After May 23, 2007
• Share Your NPI or Report Changes  

CONTINGENCY PLAN

Blue Cross and Blue Shield of Kansas, a leader in the healthcare industry in the state of Kansas, is prepared to meet by the May 23, 2007 mandated deadline, all the HIPAA requirements for the implementation of national provider identifiers.

In early April 2007, the Department of Health and Human Services (DHHS) provided guidance to covered entities regarding contingency planning for NPI implementation. This guidance allows covered entities (including health plans and covered health providers) who are actively working towards NPI compliance to establish contingency plans in order to facilitate compliance with their trading partners.

In recognizing the needs of healthcare providers, trading partners and other affected entities and to ensure a smooth transition to NPI, Blue Cross and Blue Shield of Kansas announces the following three stage NPI implementation contingency plan:

STAGE 1:  Beginning May 23, 2007, BCBSKS will accept claims (electronic and paper) that show the billing and performing provider numbers with:

• Legacy provider number only;
• Legacy provider number with NPI;
• NPI only*.

During Stage 1, BCBSKS encourages providers to begin or continue sending both legacy and NPI numbers. 

*Providers should not submit NPI "only" claims until after they have contacted BCBSKS and verified their NPI readiness. More information about this appears below.

STAGE 2:  Implementation date to be announced but could be as early as July 1, 2007.

BCBSKS is monitoring the number of claims received that report the billing and performing providers with either (1) NPI with legacy provider number; or (2) NPI only*.  Once we determine that this number is sufficient, BCBSKS will begin rejecting claims (electronic and paper) that do not include an NPI.  This date could be as early as July 1, 2007. 

Providers will be notified before we implement Stage 2 and begin rejecting claims that do not include an NPI. 

*Providers should not submit NPI "only" claims until after they have contacted BCBSKS and verified their NPI readiness.  More information about this appears below.

STAGE 3:  Implementation date to be announced.

For billing and performing providers, an NPI number will be the only identifier accepted on electronic or paper transactions. 

All providers will be expected to submit claims showing only their NPI.  Legacy numbers will not be accepted. 

NOTE: Until May 23, 2008, BCBSKS will continue to accept UPINs for the secondary provider numbers.  More information appears below.

PROVIDERS MUST REPORT NPI "ONLY" READINESS

During Stage 1 and Stage 2, if a provider is ready to submit claims and transact all other business by NPI "only", they must notify BCBSKS.  When notified, BCBSKS and the provider will determine the actual effective date for NPI "only" transactions and from that point on all transactions will reflect only the national provider identifier. 

This includes but is not limited to:

• Claim submission – billing and performing providers. Claims received after the NPI "only" start date that include a legacy provider number will be rejected. (Does not apply to secondary provider numbers.)
• Remittance advices – paper and electronic
• Eligibility and benefit inquiries (270/271) - web or batch
• Claims status inquiries (276/277) – web or batch

This notification is required during Stages 1 and 2.  When Stage 3 is implemented, all transactions by all providers will be conducted with NPI only.

Institutional providers who are ready to conduct business with NPI "only" should contact:

• Donna Bartee, institutional provider relations (785) 291-8692 or 1-800-432-0216 ext. 8692

ONE-TO-ONE MATCH vs. ONE NPI/MULTIPLE LEGACY NUMBERS

One-to-One Match

In this newsletter, the term one-to-one match is used to identify providers who obtained a separate NPI for each existing BCBSKS provider number.  When a one-to-one match exists, providers will see very few differences in how BCBSKS reports information to you or how you access information via our Web site.

One NPI/Multiple Legacy Numbers

This term is used to identify providers who have chosen to use the same NPI for more than one BCBSKS provider number.  When this occurs, there will be differences in how information is reported or viewed.

WEB SECURITY – BCBSKS Web Provider Profile

One of the most frequent questions we receive is: “When NPI is implemented, will I need to set up a new provider profile using my NPI?”  The answer is "no".  BCBSKS will still be able to use your existing user name and password to validate your security and determine what Web features you can access.

When you established your provider profile, you included the following information:

• provider number
• indicated if it was “institutional” or “professional”
• included either the billing provider tax ID number or billing provider social security number.

Using this profile, you were then able to access the secure HIPAA transactions relating to that provider number.  This includes claim status, eligibility, precertification and referral.

When NPI is implemented, BCBSKS will be able to use the same provider profile to determine the information that you can have access to. 

In the BCBSKS system, if the provider number you used to set up the provider profile:

• has an NPI loaded, it is considered HIPAA compliant and you will be allowed access to all secure HIPAA transactions for that NPI. 
• does NOT have an NPI loaded, it will not be considered HIPAA compliant and no access will be allowed to the HIPAA transactions.  These users will only be able to view the public information appearing on the BCBSKS Web site.     

After you notify BCBSKS that you're ready to conduct NPI "only" transactions, starting on the agreed upon effective date all transactions (including Web transactions and inquiries) will be conducted and reported with the national provider identifier.

PROVIDER NAME

One-to-one match – no change.  The name that is associated with your existing BCBSKS provider number is the same name that we have for your NPI.

One NPI/Multiple legacy numbers – An NPI can have only one name in the BCBSKS system.  As necessary, BCBSKS has synchronized the names on our provider file.

EXAMPLE:  XYZ Hospital is using the same NPI for two existing BCBSKS provider numbers.  The names we currently have on file for these numbers are:

• XYZ Hospital
• XYZ Hospital ER Doctors

In this example the NPI name will be XYZ Hospital and anytime that BCBSKS reports a provider name, this is the name that will show.  This includes Web, remittance advice, provider directory, checks, etc.

PROVIDER ADDRESS (including correspondence, remittance advice and payment addresses)

BCBSKS currently has and will continue to keep three separate mailing addresses.  This includes correspondence, remittance advice and payment. 

One-to-one match – no change.  The correspondence, RA and payment address that we currently have on file for your existing BCBSKS provider number is the same addresses that we’ll use for your NPI.

One NPI/Multiple legacy numbers – An NPI can only have one address for correspondence, a separate one for RA and also a separate address for payment.  As necessary, BCBSKS has synchronized the addresses in our provider file.

EXAMPLE:  XYZ Hospital is using the same NPI for two existing BCBSKS provider numbers.  The addresses we currently show for these numbers are: (C=correspondence, R-remittance, P=payment)

• XYZ Hospital
• C=123 Avenue, Rural City, KS
• R=123 Avenue, Rural City, KS
• P=P.O. Box 67, Rural City, KS
• XYZ Hospital ER Doctors
• C=456 Avenue, Rural City, KS
• R=456 Avenue, Rural City, KS
• P=P.O. Box 67, Rural City, KS

For this example the NPI addresses will be:

• C=123 Avenue, Rural City, KS
• R=123 Avenue, Rural City, KS
• P=P.O. Box 67, Rural City, KS

WEB VERSUS PAPER REMITTANCE ADVICE

Providers choose to either receive their remittance advice in the mail or to access it from the BCBSKS Web site.

One-to-one match – no change.  You’ll get the RA the same way you’re  getting it today.

One NPI/Multiple legacy numbers –

• If all of the existing BCBSKS numbers that are tied to this one NPI are all getting the RA the same way (all off the Web or all through the mail), there’s no change and that will continue.
• If, however, part of the existing numbers is set up to get it off the Web and part is still getting it through the mail, the NPI will be set up to show that the provider will obtain the RA off the Web.  

PAYMENT AND REMITTANCE ADVICES (RA)

BCBSKS will continue to issue separate payments and remittance advices for:

BCBSKS

• Premier Blue
• FEP

During Stage 1 and Stage 2 of the NPI implementation process, if a provider is ready to submit claims including only their NPI, they need to notify BCBSKS.  When notified and starting with the agreed upon effective date, all transactions (including Web transactions and inquiries, payments, remittance advice, etc.) will be conducted and reported with the national provider identifier.
 
One-to-one match – the RA will continue to show the legacy provider number.  Once the provider notifies BCBSKS that they are NPI "only" ready, the RA will show the NPI number. 

One NPI/Multiple legacy numbers - the RAs will continue to show the legacy provider numbers.  Once the provider notifies BCBSKS that they are NPI "only" ready, the RA will show the NPI number.

For providers who are NPI "only" ready and who are using one NPI for multiple legacy provider numbers, transitioning the remittance advices to NPIs will occur in two phases.

PHASE 1 - starting May 23, 2007 for NPI "only" providers with one NPI/multiple legacy numbers:

• Level 1 – RAs will show the NPI
• Level 2 – there will be separate RAs and checks issued for each line of business (LOB).
• LOB 1 - Facility/institutional provider payments (billed using the UB-92/UB-04 claim format {837I}), or
• LOB 3 - Professional payments (billed using the CMS 1500 claim format {837P})
• Level 3 – under each LOB, we will then generate separate RAs and checks based on each of the different local provider numbers that are assigned to this NPI.  (If searching a RA for information about a specific patient or account, be sure to search through the complete document.)

PHASE 2 – Applies to NPI "only" providers – one NPI/multiple legacy numbers.  The implementation date is yet to be determined.  We will begin working on Phase 2 immediately after Phase 1 is implemented on May 23rd.

In this Phase, we will:

• Level 1 – pay at the NPI level.
• Level 2 – there will be one RA and check issued for line of business 1 claims (Blue Cross) and one RA and check for line of business 3 claims (Blue Shield).
• Level 3 – no longer applies.

ACUTE CARE HOSPITALS WITH MEDICARE EXCLUDED PSYCHIATRIC OR REHABILITATION UNITS

UPDATE:  BCBSKS had originally understood that all inpatient claims that grouped to a psychiatric or rehabilitation DRG would be billed with the NPI for the excluded unit. We have since learned that this is not correct and that care provided in and billed with the hospital acute NPI could in fact group to a psychiatric or rehabilitation DRG.  We have therefore updated our procedures to reflect this change.  See # 2, 4 and 9 listed below.

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If you’re an acute care hospital with a Medicare excluded psychiatric and/or rehabilitation unit, you have separate Medicare provider numbers and are required to bill separate inpatient claims to Medicare for care provided in these units.  You also obtained separate NPIs for these excluded units.

With the implementation of NPI, BCBSKS is changing its billing instructions and reimbursement for inpatient care provided in excluded units.

1. This change is effective for claims received by BCBSKS starting May 23, 2007, that have a 2007 service date.  (NOTE: This does not apply to claims processed to final adjudication prior to May 23, 2007 or to claims with a 2006 service date.  For those claims, please continue to report your acute hospital provider number and/or NPI.)
2. The hospital determines the residency of the patient, acute versus excluded unit and will pre-certify the admission and bill the claim with the applicable NPI.
3. Hospitals will bill a separate inpatient claim for each different NPI.
4. When hospitals pre-certify an inpatient admission, they must identify if the patient is acute or if they reside in the excluded unit.  The billed claim should match the pre-certification.
5. If the patient is admitted to acute care and later transferred to the excluded psychiatric or rehabilitation unit (or vice versa), split the inpatient claim and bill multiple claims using the separate NPIs.
6. If you have a patient that is admitted acute and later transferred to the excluded unit or vice versa, you must pre-certify the care in each unit.  Just like today, you use the online system to pre-certify acute care but the pre-certification of psychiatric or rehabilitation services must be done by telephone.
7. If a patient is treated at your hospital as an outpatient and is admitted as an inpatient before midnight of the following day, the outpatient services must be included on the inpatient claim.  This rule applies to inpatient acute, rehabilitation or psychiatric admissions.
8. The payment allowance for care in an excluded psychiatric or rehabilitation unit will be a per diem per day. A separate letter has been sent to affected providers.
9. The payment allowance for psychiatric or rehabilitation care billed with the acute hospital NPI will continue to be based on the DRG.
10.  If you are a hospital that has a unique contractual arrangement with BCBSKS, your allowance will continue to be based on that contract.
11.  If you allow us to do auto deducts under your acute hospital provider number, we’ll also do auto deducts under your excluded unit number.
12.  PIP – periodic interim payments will be handled as follows: 
    1. PIP will apply only to the acute hospital number.  The weekly payment amount may need to be adjusted after the rehabilitation and/or psychiatric payments are removed.
    2. Rehabilitation and psychiatric checks will be based on actual claims paid.
    3. PIP payments do not apply to swing bed numbers.         

Reporting Secondary Provider Information - Includes Attending Provider, Operating Physician and Other Provider Information (UB-92/UB-04, 837I)

• BCBSKS will continue to accept UPINs (including the generic UPINs i.e. SLF000, OTH000) in the secondary provider number fields.  Secondary provider fields include attending provider, operating physician and other provider.   
• If you are ready to start reporting NPIs in these fields, you may do so any time.
• On May 23, 2008, BCBSKS will no longer allow UPINs in these secondary fields.  At that time, you must report NPIs.
• Once you convert to using NPIs in these fields:
• you may on rare occasions need to bill for services that can be performed without a physicians orders or for services ordered by a provider who does not have an NPI.  In these cases and only these cases, you may report your NPI in the attending physician NPI field. 
• if you do not know the NPI for the attending provider or operating physician, do not use your NPI.  You must contact the provider/physician for this information.

NEW PROVIDERS AFTER MAY 23, 2007

Starting May 23, 2007, any new providers will be expected to submit claims with NPI "only".   

SHARE YOUR NPI OR REPORT CHANGES

Most institutional providers have already furnished their NPI and taxonomy code information to BCBSKS.  If you haven’t, please do so immediately.  You also need to notify us of any changes in your information,     
FAX this information to 785-290-0734, ATTN: Nicole Dodds. 

Drb