• NPI Overview and Contingency
  
• Getting an NPI
  
• Sharing Your NPI With Aetna *
  
• Using Your NPI in HIPAA Standard Electronic Transactions
  
• Additional Resources
  

• 837 - Claim/Encounter
• 270/271 - Real-time Eligibility
• 276/277 - Claim Status Inquiry
• 278 - Precertification Add
• 278 - Referral Add

NPI Overview and Contingency

1. What is a National Provider Identifier (NPI)?
   An NPI is a unique 10-digit numeric identifier assigned to health care providers and organizations defined as covered entities under HIPAA. The NPI will be a permanent identifier assigned for life.
   
   
2. What are the significant dates associated with applying for and using an NPI?
   As soon as you have an NPI, we encourage you to share it with Aetna to allow us time to process your information. Delaying the sharing of your NPI may disrupt the processing of your electronic transactions.
   • May 23, 2007: The CMS regulation required all covered health care providers to obtain an NPI by this date. Failure to do so may be viewed as a violation of the good faith provisions of CMS' enforcement guidance.
   • August 31, 2007: We expect all providers to share their NPIs with us no later than this date. How to share your NPI with us.
   • January 31, 2008: By this date, NPIs should be included with or without legacy identifiers, in all HIPAA standard electronic transactions.
   • May 23, 2008: The contingency period ends and affected transactions must contain NPIs beginning on this date. Legacy identifiers (other than the billing provider's tax ID number on claims) will no longer be accepted.
   
   
3. Does CMS’ announcement regarding contingency plans mean that providers have an additional 12 months to obtain and begin using NPIs?
   No. Providers who have not yet obtained NPIs should do so immediately. Failure to obtain an NPI may be viewed as inconsistent with the good faith provisions of CMS’ contingency guidance.
   
   
4. What steps will Aetna take to ensure transactions are compliant with the NPI regulations after the compliance date of May 23, 2007?
   We implemented full support for NPIs in HIPAA transactions prior to the compliance date, and we strongly encourage providers to begin submitting all required data elements as soon as possible. We continue to communicate with providers to emphasize the importance of meeting their obligations to process transactions in accordance with the requirement of the HIPAA regulations. For more information on compliance procedures, see CMS' answer to question ID 2611 at http://questions.cms.hhs.gov.
   
   
5. Who should obtain an NPI?
   Any health care provider or organization defined as a covered entity under HIPAA is required to obtain an NPI. Providers who transmit health care information via HIPAA standard electronic transactions are covered entities under HIPAA, whether they transmit the transactions themselves or use a vendor to transmit them.
   
   Even if you don't send electronic transactions from your practice, an NPI may be needed to identify you in other situations, such as when another provider wants to refer a patient to you, a pharmacy needs to bill for drugs you prescribed, a hospital needs to bill for a patient you treated or admitted, or a lab needs to bill for services you ordered. You will also need an NPI if you bill Medicare on paper forms.
   
   
6. What is the difference between a covered entity and a non-covered entity?
   Health care providers who transmit standard electronic transactions (for example, claims submissions, referrals, etc.) are covered entities and are required by the HIPAA NPI regulations to apply for and receive an NPI prior to the May 23, 2007, compliance date. Acquiring an NPI is optional for non-covered entities (providers who do not submit standard electronic transactions).
   
   
7. What will an NPI do?
   It will:
   • Replace all other provider identifiers previously used by health care providers (for example, UPIN, Medicare/Medicaid numbers, etc.).
   • Establish a national standard and unique identifier for all health care providers.
   • Simplify health care system administration and encourage the electronic transmission of health care information.
   
   
8. What will an NPI not do?
   It will not:
   • Replace the tax identification number (TIN), which is an IRS requirement.
   • Convey information about the provider (for example, provider type, service location, etc.).
   • Guarantee reimbursement by health plans.
   • Enroll providers in health plans.
   
   
9. Where can additional information about HIPAA NPI regulations be found?
   • See the CMS website:
     http ://www.cms.hhs.gov/NationalProvIdentStand/
   • CMS has also consulted with the Workgroup for Electronic Data Interchange (WEDI) in the development of standards and for comments on data dissemination and other issues. WEDI has formed several workgroups consisting of representatives from all areas of the health care industry. See published "white papers" on various topics and other information on the WEDI website:
     www.wedi.org.
   • Information on the April 2, 2007 contingency plan announcement is available at
     http://www.cms.hhs.gov/NationalProvIdentStand/Downloads/NPI_Contingency.pdf.

Getting an NPI

1. Who can apply for an NPI?
   • Individual health care providers, such as physicians, dentists and pharmacists.
   • Organizational health care providers, such as hospitals, pharmacies, group practices, laboratories, ambulatory care facilities and nursing homes.
   
   
2. How can a health care provider apply for an NPI?
   The Centers for Medicare & Medicaid Services (CMS) has contracted with a vendor to administer the assignment of NPIs and deal with health plans and providers on issues concerning unique identification.
   
   There are only three ways a health care provider can apply for an NPI:
   • Complete the application online at https://nppes.cms.hhs.gov . Estimated time to complete the NPI application is 20 minutes.
   • Call 1-800-465-3203 to request a paper application.
   • With the provider's permission, an organization may submit the application in an electronic file on behalf of the provider.
   
   
3. Will nonparticipating provider NPIs be collected by Aetna?
   Yes, we encourage all providers to obtain, share and use their NPI, regardless of their participation status or transaction submission method.
   

Sharing Your NPI With Aetna - Two Ways to Share

Through our secure website
You can notify us of individual and organization NPIs associated with your practice or facility through the “Update Profiles” section of our secure website. This self-service option is ideal for individual providers or groups who do not have multiple NPIs or subparts. Once you're logged in to the secure website, select “Update Profiles,” then “Add/Update National Provider Identifier (NPI).”

Not registered for our secure website? Go to www.aetna.com and select “for Health Care Professionals,” “Physician Self-Service” and “Register Now!” Follow the prompts. Please note, there will be a 10-day wait to access the “Update Profiles” section as well as some other features on the website.

Through file transfer
We've also created a file transfer spreadsheet for larger, more complex physician groups, hospitals, IPAs, and other providers who are sharing multiple NPIs at once. This spreadsheet allows submission of individual, entity and subpart NPIs in one file and is based on the format designed by the industry Workgroup for Electronic Data Interchange (WEDI). Please be sure to complete all required data fields and answer all required questions. This helps us understand how the NPIs will be used.

Please click on the below link and complete the short form to request a spreadsheet. Within 24 hours you will receive a secure e-mail with the spreadsheet file attached. Please complete all required fields and return it via secure e-mail to PDSDallas@aetna.com.

Request Spreadsheet *

A single spreadsheet can be completed for multiple groups, clinics and providers. Please group providers by their practices on the spreadsheet.

As you prepare to submit your NPI, you should know:

• Your NPI entity type (organizational or individual).
• If an organizational NPI, the level at which the NPI has been enumerated (for example, per TIN, service location, billing organization, provider type or specialty).
• Which provider(s) are affiliated with the NPI(s) you are submitting.
• Which subpart you plan to use when conducting business with Aetna.
• If you are enrolled in ERA/EFT, which NPI you want returned in your ERA(s).

Note: While we plan to accept transactions with dual provider numbers (numbers used currently and the NPI), we do not plan to rely on that approach for populating NPIs into our system.

Each NPI we receive will go through a validity test to ensure it is formatted properly. When NPPES shares its NPI data, we will use it for further validation. We will not require a copy of your confirmation notice from NPPES.

Using Your NPI in HIPAA Standard Electronic Transactions

1. How do I use my NPI?
   Currently, health care providers can use their NPI on electronic transactions adopted by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Additionally, health care providers will need an NPI so that they can be identified on electronic transactions performed by other entities. For example, pharmacies must use the NPI of the prescribing physician to submit a claim. Also, health care providers will need the NPIs of referring physicians to submit their own claims electronically. Hospitals will need the NPIs of admitting and attending physicians to submit electronic claims to a health plan. We strongly urge providers to share their NPIs with these other entities.
   
   
2. What HIPAA standard electronic transactions have been revised to include the NPI?
   • Electronic Remittance Advice
   • Claim Encounter
   • Real-time Eligibility
   • Claim Status Inquiry
   • Precertification Add and Referral Add
   • NCPDP - Pharmacy
   
   
3. When will Aetna be ready for testing?
   We will not test NPI submissions directly with health care providers. In conjunction with our trading partners (that is, vendors and clearinghouses), we have developed recommendations for approaches providers can use to ensure the NPI will not adversely affect their transactions.
   
   We have deployed a self-service test approach for real-time transactions so our EDI vendors, national account and direct-connect providers can test independently on their own schedules. We suggest providers initially contact their clearinghouse or vendor to discuss what assistance they can provide with testing.
   
   
4. Will NPI change the way Aetna pays claims and to whom?
   NPI will not cause any changes to claim adjudication. Aetna currently uses the tax identification number and provider name and address information. The NPI will now also be used to identify the appropriate provider.
   
   
5. How will claims adjudicate if a provider has dual roles and no longer submits legacy identifiers?
   We will use the same data we use today to identify the provider. Our systems and transactions contain crosswalk logic to identify the best PIN/TIN/Service Location, and will favor the PCP PVN over the Specialist PVN if the provider is the member's PCP. It will favor the Specialist PVN if the provider is not the member's PCP.
   
   
6. Will Aetna continue to maintain old and generate new legacy numbers?
   We plan to continue to maintain old and generate new legacy identifiers in our systems since they are needed for other processes not encompassed by the NPI regulation.
   
   
7. Will Aetna require the NPI on paper claims?
   Regulations only require the use of NPIs on electronic transactions. However, the current professional and institutional paper claim forms (CMS [previously HCFA] 1500 version 12/90 and UB-92) have been revised to allow NPIs to be included, and CMS strongly encourages all health care providers to obtain and use their NPIs regardless of the submission method. We can accept, but do not require, NPIs on the revised forms (CMS 1500 version 08/2005 and UB-04).
   
   We do not enforce the use of the legacy ID numbers; however, to assure timely, accurate claim payment, it is recommended that paper forms be completed with either the NPI or the legacy ID.
   
   
8. How will Aetna manage the transition to the new CMS 1500 and UB-04 claim forms?
   We encourage submission of claims electronically, but we are able to accept the new 08/2005 version of the CMS 1500 12/90. We also accept the new UB-04 form and will continue to accept the UB-92. The new forms contain changes to allow NPIs to be sent. Additional information on the new forms is available at www.nucc.org and www.nubc.org.
   
   
9. Will Aetna send the legacy identifier, the NPI or both on paper Explanation of Benefits (EOBs)?
   We do not plan to include NPIs on paper EOBs at this time.
   
   
10. Will the NPI from the claim be included on the payee's electronic remittance advice, or will Aetna derive the NPI from its internal database?
    ERAs will include the billing provider's NPI (or pay-to provider, if present), unless you request otherwise. You can request that the payee NPI on the ERA be an NPI you shared with us. Please view the ERA changes document that outlines changes effective in August 2007.
    
    
11. When will NPIs be sent on ERAs?
    We will send the payee level NPIs in ERAs when:
    • The clearinghouse or vendor initially receiving the ERA from Aetna has told us they are ready to process ERAs with NPIs; and
    • The provider has shared the payee level NPI they want on their ERA. See “Request Spreadsheet” under “Sharing you NPI with Aetna.”
    
    We will send the rendering provider's NPI at the detail level on the ERA when:
    • The payee NPI is sent on the ERA (see above), and Aetna has recorded the NPI of the rendering provider in our provider database.
    
    
12. If an electronic remittance advice (ERA) can have a different NPI than submitted on the claim, how can I tell which claim the ERA is responding to?
    The submitter's claim number (from CLM01 in an 837 EDI claim) is required to be returned in the CLP01 element in the 835, and this is not affected by the NPI regulations or related changes. The 835 ERA implementation guide states the following about the CLP01:
    
    
    “This data element is the primary key for posting the remittance information into the provider's database. We also recommend that it be used for that purpose rather than matching by provider Ids.”
    
    Matching remittances to claims using the provider ID is normally not necessary and will be especially complicated during the transition from current ID use to NPI.
    
    
13. Will new agreements need to be signed for Electronic Funds transfer (EFT) and Electronic Claims (ECM)?
    No, new agreements will not need to be signed as a result of NPI. For providers who receive Electronic Remittance Advice (ERA) from Aetna, we will be asking for confirmation of the NPIs to be used at the payee level.
    
    
14. Will Aetna require the referring physician's NPI on claims?
    No. While Aetna does not require this info for claim adjudication, it may be necessary under HIPAA regulations.
    
    
15. When can providers submit a claim or other electronic transaction using only the NPI?
    Aetna will always require the billing provider's TIN on claims. You may now include your NPI on claims as well. Currently Aetna-assigned provider identification numbers are not usually required on claims. Some institutional claims require the Medicare Provider Number (MPN), and those claims will continue to require the MPN until we can support the use of taxonomy codes on those claims.
    
    For real-time transactions, (eligibility and benefits inquiry, claim status inquiry, referral add and inquiry and precertification add and inquiry) if we have been informed of the provider's NPI and it has been loaded into our provider database, legacy identifiers will not be needed. Providers will need to verify that any system vendors or clearinghouses they use are also ready to pass transactions with NPI only.
    
    Click here to share your NPI with Aetna.
    
    
16. What should I do if I get an error message when I try to transmit my NPI in a real-time transaction?
    If you get an error message when using your NPI in a real-time transaction, please use your legacy identifier until you have shared your NPI with Aetna.
    
    
17. Will providers still be able to send currently used IDs, such as PIN, PVN and TIN, in electronic transactions after the NPI compliance date?
    To be compliant with the regulations, covered entities must use the NPI of any health care provider (or subpart) that has been assigned an NPI to identify that health care provider in HIPAA standard transactions. The use of other IDs is only permitted to identify:
    
    • An entity or individual “as a taxpayer” using the TIN (for example, Social Security number or employer identification number (EIN)). This exception only applies to billing/pay for providers in claims and payees in remittance advices. An NPI must be used to identify covered health care providers “as providers” in these situations.
    • “Noncovered health care providers.” (For example, a referring provider who does not carry out any electronic transactions is a noncovered provider who may have chosen not to obtain an NPI.)
    • Individuals and entities who are not considered health care providers (also known as “atypical providers”).
    • Providers acting in a way that is not considered to be a “provider” role, such as information submitter or receiver or utilization management organization.
    
    For more information, see CMS' answer to question ID 5816 at http://questions.cms.h hs.gov.
    
    
18. What will happen to claims and other electronic transactions submitted with a legacy identifier (other than tax ID on claims) after May 23, 2008?

A. They will be rejected because including legacy IDs as secondary IDs is not compliant with the regulation. The only secondary ID the NPI regulations allow with an NPI is the tax ID for the billing provider on claims and remittance advices. For more information, see CMS' answer to questions ID 5815 and 5816 at http://questions.cms.hhs.gov. (Use the "search" feature to search by FAQ ID number.)


19. Will Aetna require taxonomy codes for claims adjudication?
    To be compliant with the regulations, use of a Medicare Provider Number is not permitted on electronic claims. Because of this, we will require an NPI or NPI and taxonomy code on institutional claims where the submission of a Medicare Provider Number is currently required by Aetna. Depending on your current set-up, you may or may not be required to submit a taxonomy code to Aetna. Aetna will be expecting providers to submit with the appropriate identifiers as Medicare requires below:
    
    
    Per the Medicare claims processing manual, institutional providers that currently bill Medicare using more than one legacy identifier in order to identify subparts of their facility are required to submit a taxonomy code on all of the claims they submit to Medicare. Medicare legacy identifiers are six-digit Medicare provider numbers, also called OSCAR numbers. Taxonomy codes shall be reported by these facilities whether or not the facility has applied for individual NPIs for each of their subparts. Institutional providers that do not currently bill Medicare for subparts are not required to use taxonomy codes on their claims to Medicare.
    
    For situations where a provider is unable to send his or her claim electronically, the billing facility Taxonomy code should be formatted on the UB04 paper claim form in field 81cc preceded with the qualifier B3.
    
    

    Additional Resources

    Still have questions?
    We've developed a course to bring you up-to-speed on everything you need to know about NPIs, including step-by-step instructions on how to obtain one, how to use it when submitting HIPAA standard transactions and how we're preparing as well. You'll find the course on our Education Site for Health Care Professionals.

    Log in to the secure website, available through www.aetna.com, and select the “Education” link on the top navigation bar to reach the Education home page. Select “Enter” to go to the Education site. The first time you access the site, you'll be asked to complete a one-time registration. Once your information is verified, select the Course Catalog on the left navigation bar to find courses.

    Not registered for our secure website? Go to www.aetna.com, choose “for Health Care Professionals,” “Physician Self-Service,” and “Register Now!” Follow the prompts.

    In addition, we continue to provide information on NPI through our provider newsletter, OfficeLink Updates^®, as well as through direct outreach and communications, and industry events.