ENS NPI Strategy Overview

ENS has created check digit logic using the Luhn Check Digit and will edit every NPI received for validity. If the NPI that is received is not a valid NPI, the transaction will reject at ENS prior to submission to the Payer.

ENS NPI Claims Submission

For X12 Claim submissions, ENS will support the submission of the NPI and Legacy Identifiers. Based on Payer readiness, ENS will forward the NPI and/or Legacy Identifiers on to the Payer. We do not anticipate requiring provider testing for NPI submission. If you do intend to require testing, please contact your ENS Account Representative.

In order for ENS to guarantee appropriate processing of claims containing NPI data, the Payer must be receiving the ASC X12N 4010A1 format. Unless otherwise notified by the Payer, ENS will utilize the following guidelines when submitting the NPI and Legacy Identifiers:

• The NPI must appear in the NM109 and the corresponding ‘XX' qualifier in the NM108 element in the associated Loop.
• The provider Legacy ID and the provider Tax ID/SSN must be contained in the REF segments in the applicable Loop.
• After May 23, 2007 , claims will still require the Tax ID/SSN in the REF segments in the applicable Loop.

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 ASC X12N 837 v4010A1 Professional
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ASC X12N 837 v4010A1 Institutional
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ENS supports the dual use strategy approach as defined by WEDI Strategic National Implementation Process (SNIP). Claims submitted from October 2, 2006 , through May 22, 2007 , may contain both the NPI and Legacy Identifiers.

During the dual submission period, Payers will continue to receive claims both with and without NPI in the same file. It is probable that claims will contain NPI at the Billing and Rendering Loops, but legacy identifiers for the other provider types within the same claims.

It is important to note that if the NPI is submitted, the NPI will be contained within the NM109 segment both during the dual submission (unless otherwise specified by the Payer) period and after May 23, 2007 . The Billing Provider Tax ID will continue to be a required data element within the 837 transaction. The Payer's transaction system must be modified to look for the Tax ID at the Billing Provider ( Loop 2010AA) REF*EI or REF*SY. EI indicates Employer Identification Number and SY indicates Social Security Number. All other Payer legacy identifiers will continue to be provided within the REF segments with the appropriate qualifiers.

ENS will implement the dual use strategy within the following timelines to Governmental Payers: *ENS will follow this timeline for Governmental Payers unless otherwise notified by the Payer for an alternative timeline for NPI submission.

• Medicare – September 1 through May 22, 2007
• Medicaid – November 1 through May 22, 2007
• Blue Shield – January 1, 2006 through May 22, 2007

For Commercial Payers between December 1, 2006 , through May 22, 2007 , ENS will allow for the submission by the submitter of both the NPI and Legacy Identifiers; however, the NPI will only be forwarded to those Commercial Payers who have indicated their readiness to receive the NPI. ENS will suppress the NPI on submissions to Commercial Payers who have not indicated that they are ready to receive the NPI. Please contact your Account Representative regarding your timeline to accept the NPI. ENS will require roughly 2 to 3 weeks to modify your customized payer format. Once ENS has modified your payer format, ENS will indicate on the ENS Claims Payer List that ENS is sending you NPI data. ENS will accept claims that do not contain an NPI unless otherwise instructed by the Payer.

ENS NPI Solution for Real-Time Transactions

ENS provides submitters a two different means by which to trade Real-Time transactions with Payers. Integrated clients submit X12; ENS also provides customized User Interface for web-entry. Request transactions from web-entry clients are translated into X12 for transmission to the Payer. X12 response transactions are then translated into the User Interface for the client to view.

 X12 270/271 Eligibility

For X12 270/271 transactions, ENS will support the submission and receipt of the NPI and Legacy Identifiers. ENS will forward the NPI and/or Legacy Identifiers on to the Payer as received. ENS will process 270 requests that do not contain an NPI unless otherwise instructed by the Payer.

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ASC X12.281/282 270/271 v4010A1 Healthcare Eligibility/Benefit Inquiry and Response
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User Interface Eligibility Transactions

As of 1/1/07 , ENS will be available to be contacted by Payers to add an NPI field to the customized User Interface to allow the users to enter the NPI on the screen to be sent to the Payer. Once contacted, ENS will require roughly 2 weeks in order to get the screen enhancement made and implemented in production. We will keep the existing Provider Identifier on the screen to be submitted as a Secondary Identifier.

X12 276/277 Claim Status

For X12 276/277 transactions, ENS will support the submission and receipt of the NPI or Legacy Identifiers. The 276/277 Implementation Guide allows for one identifier. ENS will forward the NPI or Legacy Identifiers on to the Payer as received. ENS will process 276 requests that do not contain an NPI unless otherwise instructed by the Payer.

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ASC X12.316/317 276/277 v4010A1 Healthcare Claim Status Request and Response
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User Interface Claim Status Transactions

As of 1/1/07 , ENS will be available to be contacted by Payers to add an NPI field to the customized User Interface to allow the users to enter the NPI on the screen to be sent to the Payer. Once contacted, ENS will require roughly 2 weeks in order to get the screen enhancement made and implemented in production. We will keep the existing Provider Identifier on the screen. The NPI and existing Provider Identifier will be mutually exclusive allowing one identifier or the other.

X12 and User Interface 278 Referrals/Authorizations

For the ENS 278 Payer connections, ENS will work with each Payer individually on their NPI readiness with the 278 transaction. Notations regarding the readiness of the Payers will be made on the ENS Referrals/Authorization Payer List and an NPI field will be added to the User Interface for our non-X12 clients.

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ASC X12.336 278 v4010A1 Healthcare Service s Review Request for Review and Response
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ENS NPI Solution for 835 Transactions

ENS has defined two areas necessitating action of which we have structured our primary strategy that will assist in transitioning to the NPI for 835 transactions to include; Enrollment and Communication.

Enrollment –

• ENS’ strategic improvement to the current ERA Online Enrollment process will be to expand the existing provider database by adding a feature to the ERA Online Enrollment process to enroll new and re-enroll existing providers through this method with their NPIs.  Providers will be able to enroll multiple NPIs for each of their subparts, if necessary.  ENS will then be able to accurately cross-reference the existing provider information for conversion purposes.

• ERA Re-Enrollment for existing ENS clients to the payer will be handled on a per payer request.  Notifications will be posted accordingly.

Communication - 

• Users will be responsible for informing ENS when a new NPI has been issued by completing the Enrollment of the NPI through the ERA Online Enrollment process.  Through the ERA online Enrollment process there will be a feature that can be selected to only enroll NPIs for the 835 electronic transactions.

• The ENS ERA website for viewing and downloading ERAs will be enhanced with an additional field that will display the provider NPI along with the existing field which identifies the TIN.

• ENS will continue to communicate any and all NPI changes that may surface as we move forward to streamline the NPI process.

** Please note:

The submitter’s claim identifier number (837 - CLM01) is currently required to be returned in the CLP01 element in the 835.  This is not affected by the NPI regulations or related changes.  The 835 ERA Implementation Guide states the following regarding the CLP01:  “This data element is the primary key for posting the remittance information into the provider’s database.”