NPI numbers with different states

[GWAE]

Hi all, I just found this forum today while searching for an answer. I am hoping someone can help me as I have been at wits end over this. I have called NPPES, Medicare WV, Medicare PA, and Highmark and no one can give me an answer to what seems to be an easy question.

Anyways, I recently started doing the billing for a Group practice that has a location in PA. About a year ago they began working in West Virginia. Medicare of PA and Medicare of WV are in different jurisdictions so they had to get credentialed with Medicare of WV which they did. This practice sees patients in a hospital and also in an office setting. The office is not their office. They use it for an afternoon 1 day a week.

When they see patients in the hospital I put the hospital NPI and address in box 32, send it to Medicare of WV and Medicare pays just fine. Whenever they see patients in the office I put the group NPI and the physical WV address and send it to Medicare of WV. Claims keep denying saying the facility is incorrect. From what I have gathered it is denying because the NPI is registered to a PA practice location which means the claims should be billed to PA Medicare.

So now to the question. What is the solution to get these paid? Here are the options that I am guessing at, maybe one of them is correct or maybe one of you have a better idea.

1. Get a second group NPI based out of WV but that would also require new credentialing with all the WV insurance companies.

2. Use the NPI of the groups office that they are sharing.

3. Keep the box 32 as is and just send the claims to PA Medicare.

My first thought was #2 but the owner of the practice doesn't think that is correct. I tried to explain to him that it is no different that putting the hospital NPI there.

Please help.

[RichardP]

1.  A legal entity that has acquired an NPI Number may also acquire NPI Numbers for its subparts if it wants to do so.

2.  A legal entity that has acquired an NPI Number must notify Medicare of the physical address of any additional locations where it practices Medicine.  One NPI Number can cover business conducted at multiple locations - so long as those additional addresses are on file with Medicare.  But - as Point 1 states - a unique NPI Number can be obtained for each additional address if the parent organization wants to do so.
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Re. Point 2:  NPI Number for sub-parts of a Legal Entity that has its own NPI Number:  See Page 2 of this pdf file.

http://www.hipaaspace.com/Medical_Billing/Coding/National_Provider_Identifier/Codes/NPI_1083912778.pdf

Many organization health care providers who apply for NPIs are not legal entities themselves but are parts of other organization health care providers that are legal entities (the "parents").  Here are three examples of organization health care providers that may be considered subparts and may apply for NPIs if so directed by their "parents":
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You state that the additional locations are in other states, and imply that they are also in different MAC Jurisdictions.  So - see this first link for an indication that there is something that you must do other than just give Medicare the addresses of the additional locations.  I will leave it up to you to ferret out what that something is from the second link - Chapter 15 of Medicare's Program Integrity Manual.  It's only 448 pages long.  But search on key words and you should find what you need.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8019.pdf

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/pim83c15.pdf

[Michele]

I believe Richard is right.  It sounds like Medicare was not notified of the office location in WV.

This practice sees patients in a hospital and also in an office setting. The office is not their office. They use it for an afternoon 1 day a week.

  You mean in WV right?  So they 'rent' office space from another practice for 1 afternoon a week.  If this is the case it is an office location for them even though they are only there one afternoon a week and another practice uses it the rest of the time.  When billing for patients seen at this office box 32 should contain your provider's practice name, the address of the WV office that they are using, and their group NPI.

When they see patients in the hospital I put the hospital NPI and address in box 32, send it to Medicare of WV and Medicare pays just fine. Whenever they see patients in the office I put the group NPI and the physical WV address and send it to Medicare of WV. Claims keep denying saying the facility is incorrect. From what I have gathered it is denying because the NPI is registered to a PA practice location which means the claims should be billed to PA Medicare.

It doesn't matter if the NPI is registered to a provider whose main practice location and correspondence address are in PA as long as that provider has notified Medicare of that WV location.  Like Richard pointed out, a unique NPI can be obtained but it is not required.  Basically that does not appear to be what the problem is in this situation.

If Medicare is aware of the WV location and the correct information is in box 32, let us know. 

[GWAE]

Thank you for the replies. I spoke with the person who did their credentialing and she said the address used was the address that I am using. I asked her for a copy of the AP to verify but she has not sent it to me.

I since the claims are sent electronically does it matter if the address that is actually put in the box matches? I would assume they just pull the NPI. I am off until Tuesday so I guess I will call Medicare again to see what they say. I spoke with the contracting dept the other day and she was the most useless person that I have spoken to yet.

[RichardP]

... does it matter if the address that is actually put in the box matches? ...

Yes it matters, if I understand your question correctly.  That is one of the major reasons the NPI system was developed.

In order for a provider to get paid by Medicare, the Employer ID Number (EIN), the NPI Number, and the physical office address provided on the claim sent to Medicare must match exactly what is on file with Medicare.  When additional work locations are added, those addresses must be provided to Medicare before any work done there will be paid.  These requirements are not altered according to whether the claim is filed on paper or electronically.

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