All About the New CMS Form and NPIs

Tuesday, May 01, 2007
Posted in: Practice Management

If you are a practitioner who bills insurance, or plan to in the future, there are some changes you need to be aware of which take effect in a just a few months.  Remember that old, pink CMS -1500 (HCFA) form you had to use to bill insurance companies for your services?  As of April 1, you may no longer use that form to bill insurance.  Have you been using your license number, social security number, and/or Federal ID number on your invoices?  Beginning April 1 you will need to have obtained and be using a National Provider Identifier number (NPI).   

So, what are all these changes about, and why has no one been talking about them?  The truth is, people have been talking about this stuff since the advent of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).  While there was some amount of hype and fear surrounding new HIPAA Privacy regulations a few years back, most of us have forgotten or gotten used to the HIPAA rules.  But HIPAA went well beyond the Privacy Rule, and a major part of HIPAA has to do with the way electronic data is transmitted.  HIPAA aimed to create a national standard for the transmittal of health care information, and created certain standards to assure the privacy of that information.  One aspect of HIPAA included the creation of a huge national database of health care providers who would henceforth identify themselves (to payors and otherwise) by that number rather than by their physician license number or social security number.  This is where the NPI comes from. 

Most of us familiar with the letter of the law know that acupuncturists by and large are not obligated to be HIPAA-compliant, as we (1) are not Medicare providers, and (2) generally do not do electronic billing or transmit our patients’ health information electronically, both of which are major triggers for HIPAA coverage. But we also know that whatever laws or regulations affect Medicare providers affect us as well.  For instance, while we may not be covered as practitioners under Medicare, we still have to use the pink CMS -1500 form to bill insurance if we want to get paid.  ( CMS actually stands for “Centers for Medicare & Medicaid Services.”)  And now that the HCFA form and its rules are changing, we must change as well.  This is not a suggestion, it is a fact. 

So, what facts do you need to know now if you wish to continue billing medical insurance after April 1, 2007 ?  Here are some points to ponder: 

-As of January 1, 2007 , all insurance companies are required to accept both the existing CMS -1500 (HCFA) form and the new one (dated 08/05 on the bottom-right corner of the form). Practitioners may continue using the old form until the end of March 2007 if they wish. 

-As of April 1, 2007 , all claims submitted to insurance companies are required to be printed on the new HCFA form—the old form will no longer be accepted. 

-The new form requires use of the National Provider Identifier in reference to the provider/practitioner and those whom refer patients to the provider.

What can you do now?  Here are some action steps to be sure you are prepared for these changes: 

1. Get an NPI for yourself.  This can be done for free and acquired instantly through the Centers for Medicare and Medicaid Services’ National Plan and Provider Enumeration System.  Online, go to https://nppes.cms.hhs.gov/NPPES/Welcome.do , or do it on paper by calling 1-800-465-3203 . 
2. Pick up the new HCFA form from your favorite medical supplies vendor.  Doing a simple web search for “new CMS -1500 form” will yield plenty of sources.  I get mine directly from The Supply Center (thesupplycenter.com), as they not only specialize in serving our community, but they also know the latest rules and regulations as they relate to us.
3. Make sure that your billing software is or will be prepared for these changes before June 1, 2007 , and that if you are required to update or upgrade, you do it as far ahead of the deadline as possible.  Most practitioners are not prepared for these changes, and many software companies are behind as well, so there may be a bit of a backlog in getting your software upgraded.  If in doubt, check your software’s web site or call or email support to find out what you will need to do. 
   
   If you currently do or plan to do electronic billing, you may also wish to contact your billing clearinghouse to find out how prepared they are for the new forms.  Big clearinghouses like Emdeon (WebMD) may be well prepared, while smaller clearinghouses may not be. 

Finally, be aware that there is a lot of information out there on the web, much of it confusing and contradictory.  For example, in some places you will find that insurance companies have to accept the new form as of October 2006 and may accept only the new form as of January 1, 2007 .  That was later amended and extended to the current, above-stated dates. 

While the new form and NPI may seem stressful and burdensome now, don’t fret too much. You can always continue what you have been doing and wait for the insurance companies to reject your claims before you change.  In the mean time, keep this article handy until the information herein is helpful to you. 

 

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