HH04: Medicare Billing Overview – NPI/PTAN/Provider Enrollment Copy
Ian V. Chestnut July 26, 2021
National Provider Identifier Standard (NPI) & PTAN & Provider Enrollment
NPI stands for National Provider Identifier
In order to get a NPI# you must go to https://nppes.cms.hhs.gov
NPPES stands for National Plan & Provider Enumeration System
- NPI is a unique identification number for covered health care providers. Covered health care providers and all health plans and health care clearinghouses must use the NPIs in the administrative and financial transactions adopted under HIPAA.
- The NPI is a 10-position, intelligence-free numeric identifier (10-digit number). This means that the numbers do not carry other information about healthcare providers, such as the state in which they live or their medical specialty.
- All covered providers must also share their NPI with other providers, health plans, clearinghouses, and any entity that may need it for billing purposes.
You need an Identity & Access Management System (I&A) User ID and Password to create and manage NPIs.
After successfully creating your I&A account, return to NPPES and use your I&A User ID and Password to log into NPPES where you can create and maintain the NPI data associated with your provider(s).
All Medical Providers or Suppliers, must register for an NPI before enrolling with Medicare.
https://nppes.cms.hhs.gov/NPPES/
NPI form topics
- Basic Information
- Reason
- Entity Type
- Identifying Information
- Individual
- Organization
- Certification Statement
- Contact Person
- Official Signatures
- Business Addresses and Other Information
- Mailing Address
- Business Location Address
- Other Provider Identification Numbers
- Provider Taxonomy Codes
Look at paper form for NPI
https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/CMS10114.pdf
Provider Enrollment
What is the 855A?
- The Medicare Enrollment Application for Institutional Providers.
- This form is also used to submit changes to your enrollment data.
- You can find the paper application at the following link:
https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/cms855a.pdf - Application fee for institutional providers for 2020 – $595
Topics needed to perform application
- Organizational information
- Supplier type
- Ownership Interest and/or Managing Control
- Physical location and “special Payments” address (Remittances)
- Vehicle information (Mobile)
- Change of Ownership (CHOW)
- Geographic location
- Acquisitions and Mergers
- Rendering healthcare services at a patient’s home
- Correspondence address
- Accreditation
- License and certification information
- Final adverse legal actions/convictions
- Organizational control
- Individual control
- Patient records storage location
- Billing agency
- Contact person
- Electronic funds transfer
- Required and/or supporting documentation
- Penalties for falsifying information
- Authorized & Delegated Officials
HH 36 month rule
Occurs when an individual or organization acquires more than a 50% direct ownership interest in a home health agency (HHA) during
- The 36 months following the HHA’s initial enrollment into the Medicare program
- The 36 months following the HHA’s most recent change in majority ownership
- If MAC determines that a change in majority ownership has occurred within either 36-month period and no exception applies, the case is referred to CMS for approval.
- If CMS agrees with MAC’s determination, the HHA’s billing privileges are deactivated and the HHA must enroll as an initial applicant.
Change of Information
Within 30 days
• A change in ownership
• An adverse legal action
• A change in practice location
Within 90 days
• Managing employees
• Authorized Official/Delegated Official
• All other changes
Electronic Funds Transfer (EFT) Authorization Agreement
Form CMS 588
Medicare Provider/Supplier Enrollment Applications
The Medicare enrollment application (CMS-855 or Internet-based Provider Enrollment, Chain and Ownership System (PECOS)) is an Office of Management and Budget approved form and is available in PDF fillable format. PECOS is the most efficient method for submitting your enrollment application.
Provider Enrollment, Chain, and Ownership System (PECOS)
Pecos website screen: https://pecos.cms.hhs.gov/pecos/login.do#headingLv1
Provider Transaction Access Number (PTAN)
- A PTAN is a Medicare-only number issued to providers by MACs upon enrollment to Medicare. When a MAC approves enrollment and issues an approval letter, the letter will contain the PTAN assigned to the provider.
- The approval letter will note that the NPI must be used to bill the Medicare program and that the PTAN will be used to authenticate the provider when using MAC self-help tools such as the Interactive Voice Response (IVR) phone system, internet portal, on-line application status, etc.
- The PTAN’s use should generally be limited to the provider’s contacts with their MAC.
- The NPI and the PTAN are related to each other for Medicare purposes