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Electronic Claims Transactions and HIPAA
In accordance with the Department of Health and Human Service (DHHS) Final Rule on the Health Insurance Portability and Accountability Act (HIPAA) of 1996, United Behavioral Health (UBH) is preparing for the implementation of standardized unique identifiers for health care clinicians and facilities. This unique 10-digit number is known as the National Provider Identifier (NPI).
The establishment of a standard NPI is designed to improve the effectiveness and efficiency of the health care industry. It sets forth standards and specifications for use in HIPAA-defined electronic data interchange (EDI) transactions.
UBH's Adoption and Use of NPI
UBH initiated its response to the provisions outlined in HIPAA in January of 2004. UBH is developing the appropriate documentation, ongoing compliance processes and system enhancements to be in full compliance by May 23, 2007. Starting in June 2006, UBH will begin collecting NPI data. We will provide periodic updates on our collection process.
Preview of NPI Enumeration
The Centers for Medicare and Medicaid (CMS) began processing the NPI enumeration1 on May 23, 2005. This was the date that health care clinicians and facilities could begin to apply for the NPI.
The DHHS contracted with FOX Systems, Inc., to create the National Plan and Provider Enumeration System (NPPES). The NPPES is intended to uniquely identify a health care clinician, hospital or clinic and assign an NPI number. Health care clinicians, facilities, health plans and clearinghouses that need NPI data in order to conduct standard transactions will be able to obtain such data directly from NPPES. Standard transactions include claims submissions, status inquiries and responses, eligibility inquiries and responses, referrals and remittance advices.
All health care clinicians and facilities (including mental health and substance abuse treatment providers) defined by HIPAA as a "covered entity" must use NPI data in all standard electronic transactions. Covered entities include clinicians, facilities and clearinghouses that furnish, bill for, or are paid for health care services in the normal course of business. Clinicians are expected to obtain an NPI number and share their NPI number with their business partners and associates including health plans and clearinghouses.
The compliance date for covered entities to obtain and use the NPI in standard transactions is May 23, 2007.
Additional compliance requirements include:
- Covered entities must communicate to NPPES any changes in their required data elements2 within 30 days of the change. Some examples of data elements include: mailing address, phone number, tax ID number, and licensure code.
- If covered entities use business associates to conduct standard transactions on their behalf, they must require their business associates to use NPIs appropriately.
NPIs may also be used for any other lawful purpose requiring the unique identification of a health care clinician or facility:
- To identify themselves in nonstandard health care transactions and on related correspondence (i.e., paper referrals and demographics)
- To identify other health care clinicians and facilities in health care transactions and on related correspondence
- To identify health care clinicians and facilities in patient records
Health plans and clearinghouses may use an NPI:
- To process transactions and in communication with health care clinicians and facilities
- To communicate to other health plans for coordination of benefits
- To create and process standard transactions in their internal files
How to Apply for an NPI
Clinicians and facilities may apply for an NPI in one of the following ways:
A complete list of approved and permissible uses of the NPI can be found in the Federal Register, Vol. 69, No 15, pg 3449 on Centers for Medicare and Medicaid (CMS) Web site under Latest News, National Provider (NPI) Final Rule published (http://www.cms.hhs.gov/hipaa/hipaa2/).
Updates and additional information about implementation of the NPI, including frequently asked questions are available under Latest News on CMS Web site (ttp://www.cms.hhs.gov/hipaa/hipaa2/).
For more information on HIPAA standard EDI transactions, including implementation guidelines, please visit the Washington Publishing Company Web site (http://www.cms.hhs.gov/providers/npi/default.asp).
1Enumeration – A process of capturing health care clinician data to uniquely identify a health care clinician and assign “NPI” – National Provider Identifier (a 10-digit numeric).
2Data elements – For a complete list of NPPES data elements, please reference the Federal Register/ Vol . 69, No 15/Friday, January 23, 2004/rules and regulations/pgs 3457-3460 on CMS Web site http://www.cms.hhs.gov/providers/npi/default.asp.
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