NPI or National Provider Identifier is a unique 10 digit identification number required by healthcare providers across the US. This number is mandatory by HIPAA (Health Insurance Portability and Accountability Act of 1996) and is used in standard transactions for identifying all covered doctors, nurses, dentists, hospitals, labs, clinics, suppliers of DME etc. The NPI number can also be used to search for a healthcare providers' National Plan & Provider Enumeration System (NPPES) information. NPI contains only the name and business address. It is not necessary that all healthcare providers have a license but all licensed ones who are HIPAA covered entities, have the NPI.
Often, DME claims are denied due to various NPI issues. Nonetheless, they can be dealt with by incorporating simple measures and checks in the DME claim forms before submitting to Medicare DME. CMS requires that all DME claims for payments upon submission must include the NPI of the ordering physician or referring provider. On the CMS 1500 form, the providers must enter the ordering/referring provider's name in field 17 along with the NPI number in field 17b. To resolve such issues it is imperative to link the provider's National Supplier Number to the NPI number. This can be done by adding the supplier number as one of the identifier's on the NPI enumerator's website and henceforth resubmitting the claim.
Another reason of DME claims being rejected over NPI issues could be if the ordering/referring provider number and the NPI mentioned on the DMEPOS claim is not enrolled with adequate information in PECOS (Provider Enrollment, Chain & Ownership System); i.e. the information in PECOS is invalid, missing, mismatched or incomplete. It is important to obtain the accurate NPI, enter the name and fill in all the valid information as exactly as it appears in PECOS records, and resubmit the claim. One can use the CMS Ordering Referring Report to verify the ordering/referring provider name and NPI, and check the status/clarification of denial.
For Medicare DME claims, the ordering physician is the one who wrote the prescription. The physician has to be enrolled in PECOS and should be active. One can check the Interactive Voice Response (IVR) system or CMS list for the same. Also, for DME claims, one must use the NPI number of the ordering provider who should be an individual-physician, not a group NPI number. This implies that the qualifier in the electronic claim form is 1 person and not an organization. Also, claims to be paid must be filed or resubmitted within one year of the service provided.
DME billing must occur in a HIPAA compliant manner. DME billing requires that NPI number for the referring professional (not a DME provider) is included in all claims submitted for timely and accurate reimbursements.