November/December 2007

CMS now requires NPI/PIN validation
for Part B claims

As of Oct. 31, 2007, the Centers for Medicare & Medicaid Services (CMS) requires all Medicare Part B contractors to reject Part B claims if they include a National Provider Identifier/Provider Identification Number (NPI/PIN) combination that cannot be matched to an NPI/PIN combination in the Medicare NPI crosswalk. The NPI/PIN combination may be used to identify the Billing, Pay-to or Rendering Provider. This applies to claims that are submitted by corporations that physicians and non-physician practitioners have formed or to physicians and non-physician practitioners who bill Medicare directly.

As part of the process of obtaining NPIs, physicians and providers furnished the National Plan and Provider Enumeration System (NPPES) with legacy numbers. The NPI crosswalk validates incoming Medicare claims to ensure they contain a legacy number, such as a Medicare PIN, as well as an associated NPI. If the NPI/PIN combination on the claim does not match what’s in the NPI crosswalk, the Part B contractor must reject the claim.

Use compatible NPIs and PINs

If you enrolled in Medicare as an individual and obtained a Medicare PIN as an individual, use your individual NPI with your individual PIN when submitting Medicare claims.

Some incorporated physicians and non-physician practitioners have obtained an individual (Entity Type 1) NPI for the physician or non-physician practitioner and an organization (Entity Type 2) NPI for the corporation. If you bill Medicare with your corporation’s NPI, you must pair it with your corporation’s Medicare PIN. Pairing your corporation’s NPI with your individual PIN, or your individual NPI with your corporation’s PIN, will result in your claims being rejected.  

Ensure claims are coded correctly

Follow these tips to ensure your Medicare claims are not rejected:

  • Check your information in the NPPES to ensure that the NPI(s) were properly obtained; e.g., if you are a sole proprietor, you should have obtained an NPI as an Individual (Entity type 1), not as an organization (Entity type 2).

  • Ensure that the NPPES data are correct, and that the NPPES record(s) contains the Medicare legacy identifier(s) that was assigned to the provider to whom the NPPES record belongs. Medicare uses this information in building the Medicare NPI crosswalk. For example, a physician/practitioner applying for an NPI would list his/her Medicare PIN in the "Other Provider Identifiers" section of the NPI application—not the PIN of the group in which he/she is a member. To view or edit your NPPES record, go to https://nppes.cms.hhs.gov on the CMS website. For assistance, call the NPI numerator at (800) 465-3203.

For more information

CMS recently issued a Medicare Learning Matters (MLN) article for physicians and non-physician practitioners addressing this subject in detail.   You can download the article at http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0744.pdf.