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NPI Provider Enrollment

Provider Enrollment Application Changes Due to NPI

Effective February 15, 2008, in accordance with Centers for Medicare & Medicaid Services (CMS) requirements, the Department of Health Care Services (DHCS) is revising all provider enrollment application forms to accommodate the National Provider Identifier (NPI). The Medi-Cal program is discontinuing the practice of assigning a Medi-Cal provider number, also referred to as a legacy number. Implementation of the NPI, including the discontinuation of all legacy numbers, is a requirement of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). However, the Denti-Cal program may continue to assign legacy numbers to providers to be used in coordination with the NPI beyond February 15, 2008.

Information in this provider bulletin is effective February 15, 2008, and published based on the

authority granted by Welfare and Institutions Code (W&I Code), Section 14043.45(c) and supersedes the previous provider bulletin titled “Revised Application Form Requirements, and Procedures due to National Provider Identifier (NPI) Implementation,” that stated an effective date of May 23, 2007.

As part of this implementation, the NPI is being adopted as the provider number for Medi-Cal

providers. Consequently, as of February 15, 2008, any reference in California Code of Regulations (CCR), Title 22, referring to Medi-Cal provider numbers shall be considered to refer to the NPI.

Enrollment Procedures and Requirements

When requesting enrollment, applicants must submit any NPIs used at the business location with the appropriate revised application forms listed below to enroll as a Medi-Cal provider.

DHCS will not process any application package or form without valid NPI verification. Applicants

must submit verification of each NPI submitted to DHCS with any application package. When

submitting a Medi-Cal Supplemental Changes form (DHCS 6209), the applicant must include

verification for any new NPIs submitted to DHCS. If the applicant or provider is directly billing for

services (for example, not only rendering services as a member of a provider group), the business

address on the NPI verification must match the business address identified on the application

package.

Acceptable verification includes:

• An NPI notification letter from the National Plan and Provider Enumeration System (NPPES).

• An NPI notification e-mail from NPPES.

• An NPI notification from the Electronic File Interchange Organization (EFIO) via letter

• or e-mail; or

• A screen print from the NPI Registry.

By submitting one or more NPIs to DHCS, applicants and providers are attesting that they will

comply with the NPI requirements established by the NPI Final Rule and as CMS has specified since and may specify in the future. Failure to register NPI(s) in accordance with CMS requirements may result in delayed payment of claims submitted to Medi-Cal. The following revised forms are required for all application and disclosure packages received by

DHCS on or after February 15, 2008.

All references to these forms in CCR, Title 22, Division 3, are amended to reflect the February 2008 version:

• Medi-Cal Durable Medical Equipment Provider Application (DHCS 6201)

• Medi-Cal Orthotics and Prosthetics Provider Application (DHCS 6202)

• Medi-Cal Provider Group Application (DHCS 6203)

• Medi-Cal Provider Application (DHCS 6204)

• Medi-Cal Pharmacy Provider Application (DHCS 6205)

• Medi-Cal Medical Transportation Provider Application (DHCS 6206)

• Medi-Cal Disclosure Statement (DHCS 6207)

• Medi-Cal Provider Agreement (DHCS 6208)

• Medi-Cal Supplemental Changes (DHCS 6209)

• Medi-Cal Physician Application/Agreement (DHCS 6210)

• Medi-Cal Rendering Provider Application/Disclosure Statement/Agreement for

• Physician/Allied/Dental Providers (DHCS 6216)

• Successor Liability with Joint and Several Liability Agreement (DHCS 6217)

• Medi-Cal Nonphysician Medical Practitioner and Licensed Midwife Application

(DHCS 6248)

Atypical Providers

Providers who are not eligible to receive an NPI (“atypical providers”) are not required to submit an NPI and should instead enter the word “atypical” in the NPI field. These atypical providers receive a unique Medi-Cal provider number once the application is approved.

Taxonomy Codes

Each applicant must submit all taxonomy codes provided in their original application to CMS/NPPES.

Use of the Medi-Cal Benefits Identification Card Number for Billing

All providers are expected to use the 14-character Medi-Cal identification number from the

recipient’s Benefits Identification Card (BIC) or paper ID card when submitting claims. The ID

number is located on the front of the card and consists of a 9-digit Client Index Number, a Check

Digit and a 4-digit issue date. The issue date is used to deactivate cards that have been reported as lost or stolen.

Instructions for Entering Recipient's Medi-Cal ID Number on Claim Forms

Instructions for entering the 14-character BIC ID number on claim forms are found in the following

provider manual sections:

• Form Name Provider Manual Section

• Appeal Form (90-1) Appeal Form Completion

• Claims Inquiry Form (CIF, 60-1) CIF Completion

• CMS-1500 Completion

• Resubmission Turnaround Document

• (RTD, 65-1)

• Resubmission Turnaround Document (RTD) Completion

• Please see Benefits Identification, page 5

• Medi-Cal Update – Program and Eligibility January 2008

• Use of Social Security Numbers for Billing Prohibited Beginning February 1, 2008

• Effective for dates of service on or after February 1, 2008, most providers may no longer bill

• Medi-Cal or the Child Health and Disability Prevention (CHDP) program using a recipient’s Social

• Security Number (SSN). Claims submitted with a recipient’s SSN for a date of service on or after

          February 1, 2008 will be denied.

Please refer to the December 2007 Medi-Cal Update for information on billing exceptions.

New Denial Message

A new denial message has been developed for the paper Remittance Advice Details (RAD):

RAD code 0046: Social Security Number (SSN) not permitted for billing Medi-Cal.

Pharmacy claims submitted with a recipient’s SSN will be denied with reject code 07 (missing or

invalid cardholder [recipient] identification number) and denial code 0046.

Use of the 9-digit Client Index Number for Billing Claims submitted with a valid 9-digit Client Index Number will continue to be accepted. The Medi-Cal claims processing system currently only validates the first nine digits of the BIC ID. Changes to process the full 14-digit BIC ID for claims and reporting (for example, RADs) will be

implemented in 2008.

All providers are expected to use the Medi-Cal identification number from the recipient’s BIC or

paper ID card when verifying eligibility, billing Medi-Cal or submitting a Treatment Authorization

Request (TAR).

Medi-Cal recognizes the importance of protecting the identity and health information of recipients

and strongly encourages all providers to avoid using a recipient’s SSN whenever possible.

Please see future Medi-Cal Updates for more information.

Provider Enrollment Update

Effective for dates of service on or after January 1, 2008, per Assembly Bill 1226, guidelines for

provider enrollment in the Medi-Cal program have been updated. Provisions of the bill affect all

providers and amend the laws the Department of Health Care Services (DHCS) uses to review

provider applications for participation in the Medi-Cal program.

If a provider’s application for enrollment is denied for failure to disclose fraud or abuse, or failure to address deficiencies after DHCS has conducted additional inspections, they will be ineligible to reapply to the Medi-Cal program for a period of three years. Ineligibility will begin on the date of the denial letter, whether or not the applicant files an appeal.

If a provider’s application is returned by DHCS as “deficient,” applicants are now allowed 60 days to resubmit their corrected application package instead of 35 days.

This information is reflected on manual replacement page prov guide 6 (Part 1).