QUESTION: Under what circumstances will a claim be rejected when using the National Provider Identifier (NPI)?
ANSWER: Claims will be rejected if:
• The NPI included in a claim or claim status request does not meet the content criteria requirements for a valid NPI (begins with 1,2,3, or 4; 10-digits long with no special characters; check digit is correct); this affects:o X12 837 and Direct Data Entry (DDE) screen claims (DDE claims are submitted to Medicare Intermediaries only);o National Council of Prescription Drug Plan (NCPDP) claims (submitted to Medicare DMERCs only);o Paper claims on the revised CMS-1500 form and on the UB-04 form;o Claims submitted using Medicare’s free billing software;o Electronic claim status request received via X12 276 or DDE screen; ando Non-X12 electronic claim status queries, pending elimination of the HIPAA contingency plan for the HIPAA 276/277 format;
• A submitted NPI reported cannot be located in Medicare files;
• The NPI is located, but a legacy identifier reported for the same provider in the transaction does not match the legacy identifier in the Medicare file for that NPI;
• Claims include the NPI but do not have a taxpayer identification number (TIN) reported for the billing or pay-to provider in electronic claims received via X12 837, DDE screen (FISS only), or Medicare’s free billing software; and
• Claims that do not meet Medicare submission requirements, HIPAA implementation guide requirements, or Medicare program reuirements for reasons unrelated to NPIs.
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ANSWER: Claims will be rejected if:
• The NPI included in a claim or claim status request does not meet the content criteria requirements for a valid NPI (begins with 1,2,3, or 4; 10-digits long with no special characters; check digit is correct); this affects:o X12 837 and Direct Data Entry (DDE) screen claims (DDE claims are submitted to Medicare Intermediaries only);o National Council of Prescription Drug Plan (NCPDP) claims (submitted to Medicare DMERCs only);o Paper claims on the revised CMS-1500 form and on the UB-04 form;o Claims submitted using Medicare’s free billing software;o Electronic claim status request received via X12 276 or DDE screen; ando Non-X12 electronic claim status queries, pending elimination of the HIPAA contingency plan for the HIPAA 276/277 format;
• A submitted NPI reported cannot be located in Medicare files;
• The NPI is located, but a legacy identifier reported for the same provider in the transaction does not match the legacy identifier in the Medicare file for that NPI;
• Claims include the NPI but do not have a taxpayer identification number (TIN) reported for the billing or pay-to provider in electronic claims received via X12 837, DDE screen (FISS only), or Medicare’s free billing software; and
• Claims that do not meet Medicare submission requirements, HIPAA implementation guide requirements, or Medicare program reuirements for reasons unrelated to NPIs.
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