Page last Modified on January 25, 2008
General
Who is required to get an NPI? I need to request a prior authorization for a physician in a group practice.
Do I use the group's NPI or the physician's NPI when requesting the PA?
What do I do about a prior authorization (PA) opened under an existing API/NPI when I enroll with a new NPI?
Physician Assistants (PAs) Nurse Practitioners Community Service Board (CSB) Long Term Care and Subparts NPI Compliance May 23, 2008 Transportation Group Practice Enrollment & Billing
Virginia Medicaid requires all of its participating healthcare providers to obtain and use an NPI
in lieu of their legacy Medicaid Provider Identification number for all standard transactions
(ARS, Claims, Prior Authorization), including paper claims.
Where do we get an NPI?
You must obtain your NPI from the National Plan and Provider Enumeration System (NPPES).
The web address is www.nppes.cms.hhs.gov
Once an NPI is obtained, can a provider start using it?
As soon as the provider enrolls their NPI with Virginia Medicaid via First Health’s
Provider Enrollment Unit and has received confirmation that their enrollment was successful
they may use their NPI for all transactions.
Healthcare providers - Complete the NPI Attestation form and mail it to First Health Provider
Enrollment Unit (PEU)
Provider NPI Attestation Form (pdf)
http://www.dmas.virginia.gov/downloads/pdfs/npi-Healthcare_Attest_frm.pdf
Atypical providers - Complete the API Attestation form and mail it to
First Health PEU
Atypical Provider NPI Attestation Form (pdf)
http://www.dmas.virginia.gov/downloads/pdfs/hpa-npi_Atypical_Enum_Letter.pdf
If a healthcare provider with an NPI moves to a new location, must the healthcare provider notify the enumerator of its new address?
Yes. They must notify the enumerator of changes in any of the information that it furnished on its application
for a NPI, and must do so within 30 days of the change. Providers need to contact the First Health PEU and provide
them with the new information.
Will a healthcare provider’s NPI ever change?
The NPI is meant to be a lasting identifier, and would not change based on changes in a healthcare provider’s name,
address, ownership, membership in health plans, or taxonomy classification. There may be situations where use of an
NPI for fraudulent purposes results in a healthcare provider requesting a different NPI; such situations will be
investigated and a different NPI may be assigned to the requesting healthcare provider.
Are NPI group numbers required?
In concurrence with the transition to the NPI, DMAS is mandating the
enrollment of Group Practices. Group Practice enrollment allows multiple
fee-for-service practitioners to bill and be paid under one Group Practice NPI.
All individual practitioners in the Group Practice must be enrolled in the
Virginia Medicaid Program and have an individual NPI (Type 1). In addition, the
Group Practice must enroll in the Virginia Medicaid Program and have an
organization type NPI (Type 2)
Are schools eligible to receive an NPI?
Yes, Schools are considered healthcare
providers and are eligible for an NPI. DMAS will require the use of NPI's on all
transactions, including paper claims, no later than May 23, 2008.
The prior authorization should be requested using the rendering (servicing)
provider's NPI. Do not request the prior authorization using the NPI for the
group practice.
If you have prior authorizations opened under an existing API/NPI and you enroll a new NPI, you will need to contact KePro and request
that a new PA be opened under the new NPI.
This same process was in place prior to the NPI when a provider would enroll with an additional Medicaid Provider Identification Number (PIN).
A request had to be made open to a new prior authorization under the new PIN, and close the original prior authorization under the old PIN, before
the claim could be billed under the new PIN.
Because DMAS will pay Physician Assistants when billed secondary to Medicare, DMAS will enroll Physician
Assistants as part of a group practice as a Medicare Crossover only provider. Services provided by Physician
Assistants which are not crossing over from Medicare should continue to be billed by the physician.
Nurse Practitioners are eligible to receive an NPI according to CMS guidelines. DMAS directly enrolls the
following Licensed Nurse Practitioners into the Fee-for-Service Medicaid Program: Family, Women's Health,
Pediatrics, Obstetrics/Gynecology, Geriatric, Adult, Neonatal, Acute Care, Psychiatric and Certified Nurse Midwives.
These Licensed Nurse Practitioners are required to obtain an NPI prior to enrolling in the Virginia Medicaid Program.
In situations where the Nurse Practitioner elects to bill, or currently bills using the MD's ID Number, DMAS would
NOT require the Nurse Practitioner to obtain an NPI.
Enrollment of Licensed Nurse Practitioners was discussed in a separate August 1, 2007 Medicaid Memo.
DMAS crosswalked each Medicaid ID to an NPI. The CSB will use their NPI to submit claims for
services as they do now in lieu of their Medicaid ID. In the scenario mentioned, you would bill for the clinic
option services and SPO services using only the Agency NPI.
In addition, DMAS would recommend that organizations follow the Medicare guidelines with respect to subparts.
Each location or line of business that is separately surveyed or certified by Medicare should obtain an NPI as a subpart.
Please refer to the following guidance:
cms.hhs.gov/NationalProvIdentStand/npi_fs_subparts_030606.pdf
cms.hhs.gov/NationalProvIdentStand/Medsubparts01252006.pdf
For organizations that do not subpart, DMAS will be able to accommodate transactions for multiple locations and
multiple types of service using a single NPI.
DMAS has also determined that we will allow healthcare providers who provide both typical healthcare
services (home health) and atypical non-healthcare services (personal/respite care) to bill all services
using the NPI that is assigned to the provider for healthcare services.
We are a practice with only one physician. The Medicaid and Tax ID numbers
are associated with the practice name. Do we need to get an NPI number for the
practice and another for the physician?
The physician is eligible to obtain a Type 1 Individual NPI. The practice is
eligible to obtain a Type 2 Organization NPI if it is a legal entity (if it has
its own Federal Taxpayer ID and is not a sole proprietorship that uses the
owner's SSN). You should enroll as a group practice with a single physician so
that DMAS can properly adjudicate Medicare Crossover claims.
A Medicaid provider's NPI will be linked to the Medicaid PIN in VAMMIS. The adjusted claim information
should be submitted with the provider's NPI. Our system will match the current NPI with the Medicaid PIN the claim
was originally processed under and allow the claim to be corrected under the NPI.
DMAS encourages you to obtain a separate NPI for the ambulance services. Hospitals that use the same NPI for both
the acute care services and ambulance services will be required to submit taxonomy codes on all claims submitted
using this NPI.
2. We are a not-for-profit organization that submits bills to Medicaid for certain services. We have several
providers that have their own NPIs and they assign the benefits to our organization. We are not a Group Practice,
why do we need to obtain an Organization NPI?
The preamble to the NPI Final Rule states: "[G]roup healthcare providers are entities composed of one or more
individuals (members), generally created to provide coverage of patients’ needs in terms of office hours, professional
backup and support, or range of services resulting in specific billing or payment arrangements."
If multiple practitioners assign their benefits to an organization or share the same Federal Tax ID Number (EIN) for
Billing and Tax/1099 purposes, then the organization is acting as a Group Practice with respect to Billing/Payment arrangements.
Group Practices are considered a covered provider and are required to obtain a Type 2 Organization NPI under the NPI Final Rule.
DMAS is mandating that these providers enroll with Virginia Medicaid as a Group Practice. The group's Type 2 Organization
NPI will be used to enroll the Group Practice. Each individual practitioner in the group will need a Type 1 Individual NPI.
A Reassignment of Benefits Form will need to be completed for each practitioner in the group in order for DMAS to pay benefits
to the group, as well as to affiliate the practitioner with the group
As of May 23,2008 payers can no longer use their proprietary IDs which currently identify these types of
billing and payment relationships. Because an individual provider can only have one NPI, yet they may potentially have their
own practice as well as belong to one or more Group Practices, DMAS needs to enroll Group Practices in order to properly identify
the correct billing relationship when processing claim submissions.
The National Plan and Provider Enumeration System (NPPES) requires a Taxonomy Code for an NPI application to be processed.
Where do I get the Taxonomy information?
The NPPES has multiple screens that provide for selection of a provider type code and classification name / area of specialization.
Certain taxonomy selections will require you to enter your license number and the state where the license was issued. A list of
taxonomy selections that require license information is supplied by the application. There are also NPI Application Help screens
to assist you.
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