National Provider Identifier (NPI) Update

NPI Guidelines

Effective May 23, 2008, all providers covered by HIPAA, including physicians, dentists, pharmacists, hospitals, nursing homes and medical groups who transmit health information electronically are required to use their National Provider Identifier (NPI) on electronic claims and other transactions. This applies to all 837 transactions, whether submitted through a clearinghouse or via direct submission.

If claims and other electronic forms are submitted without a Billing Provider NPI on or after May 23, 2008, they will be rejected. Providers will then be required to correct and resubmit documents. When appropriate, a Rendering Provider NPI will be required if different than the Billing Provider NPI. Affinity will accept, and prefers to receive, dual file submissions (those containing both NPI and legacy IDs).

Please note that until June 23, 2008, we will accept claims that contain non-matching NPI numbers (NPI numbers submitted on claims that do not match the NPI numbers in our system). If you have a non-matching NPI number, we will indicate this error on your Explanation of Payment (EOP) report. You will need to fax your correct NPI number to us as soon as possible. After June 23, we will reject claims that contain non-matching NPI numbers. Please refer to the technical specifications below for more details.

How to Report your NPI to Affinity

If you have already obtained your NPI from the National Plan and Provider Enumeration System (NPPES) and have not yet advised Affinity, please provide us with this information. You may do so by contacting your provider relations representative or by completing the Provider Information Update Form and faxing it to 718.794.7808. Upon receipt of your NPI information, we will update our system within 3 business days. Also, be sure to advise your software vendor, billing service and/or clearinghouse of your NPI.

How to Apply for an NPI

Health care providers can apply for their NPI online, by phone or mail:

• Via Internet : https://nppes.cms.hhs.gov/NPPES/StaticForward.do?forward=static.instructions
• Phone: 1-800-465-3203 or TTY 1-800-692-2326
• E-mail: customerservice@npienumerator.com
• Mail:
  NPI Enumerator
  P.O. Box 6059
  Fargo, ND 58108-6059

For More NPI Information

The Web sites listed below provide additional NPI information.

CMS Enumeration Site

NPI Application

Frequently Asked Questions

If you have any questions, please contact Customer Service at 866.247.5678, Monday through Friday from 8:00 a.m. to 8:00 p.m., and on Saturdays from 9:00 a.m. to 3:00 p.m.

NPI-Related Technical Specifications

Electronic Submissions

NPIs must be reported within the appropriate provider loops on all electronic transactions submitted to Affinity Health Plan:

• NM108 qualifier will be "XX" for NPI submission
• NM109 field should contain the10-digit NPI
• Tax Identification Number (TIN) is required in REF segment when NPI reported in NM109
• REF02 qualifiers are "EI" for TIN or "SY" for SSN
• REF03 field should contain Provider or Facility TIN or SSN

Dual File Submissions

Affinity prefers to receive submissions containing both NPI and legacy IDs. For these submissions, please include your Affinity legacy information as follows:

• REF02 qualifier is "G2" for Legacy ID
• REF03 field should contain your Affinity Provider Number

Paper Claim Submissions

The NPI should be displayed as follows:

• For CMS 1500, Box 24j for Rendering Provider; Box 33a for Billing Provider
• For UB04, Box 56 for Facility; Box 76 for Attending Physician; Box 77 for Operating Physician; Box 78 and 79 for other provider types

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