NPI - Providers
NPI Education
How to Get Your NPI
Visit the National Plan and Provider Enumeration System (NPPES) or call 1-800-465-3203 for a paper application.
NPI Readiness
Effective May 17, 2008, Availity is requiring that all connected payers
process any X12 HIPAA standard electronic transactions according to one
of the following options.
The options of NPI readiness are as follows:
- Legacy ID Required
- NPI allowed
- Legacy identifier required
- Dual ID
Allows all of the following scenarios:
1. NPI only
2. Legacy identifier only
3. NPI and Legacy identifiers
- NPI per Mandate
- NPI required per mandate under HIPAA regulations
- Legacy identifier not allowed
- NPI per Mandate. Legacy ID also allowed.
- NPI required per mandate under HIPAA regulations
- Legacy identifier also allowed
- Available for EDI and B2B only
As noted above, all payers
either accept or mandate use of the NPI.
- If you send a transaction without an NPI to a payer who is following Option 3 or 4, the transaction will be rejected.
- If you send a transaction with a Legacy ID to a payer who is following Option 3, the transaction will be rejected.
- Tax ID is not considered a
Legacy ID when used to identify the provider as a taxpayer for
reporting to the IRS. Please be aware when this ID is required.
Rejection of claims can affect
timely payment of your claims. Please communicate with health plans you
bill and pay attention to information you receive from health plans.
You must be aware of each specific health plan’s NPI requirements
and enforcement date.
Availity is making every effort to confirm and communicate the status
of our connected payers. For our most up-to-date list, please review
the NPI Readiness of these payers.
Availity’s NPI Validation Rules
In order to support each
payer’s readiness for NPI, Availity must validate transactions
according to Option specific rules. Options 3 and 4 are new and
currently active. Please select one of the new options for validation
details.
- Option 3 (pdf) – NPI per Mandate
- Option 4 (pdf) – NPI per Mandate. Legacy ID also allowed.
All web transactions
are formatted according to the payer’s NPI readiness. If an NPI
is required by the payer, the NPI field will be required on the screen.
Availity will not manipulate EDI/B2B transactions
in order to make them compliant for the payer’s requirements.
Availity will validate all incoming EDI transactions according to the
payer’s NPI readiness. Availity will reject transactions if
identification numbers do not follow the payer’s requirements.
- If a payer requires an NPI, Availity will not add a provider’s NPI and submit to the payer.
- If a payer does not allow Legacy IDs, Availity will not strip the Legacy ID and submit to the payer.
Availity has built its
reputation on transaction compliance and will not be removing
legacy identifiers from transactions. By not removing legacy
identifiers, this tradition continues, ensuring that our
customers' data is secure, accurate, and in the format required by
our payers.
NPI Specific EDI Error Messages
| Error |
When is this active? |
Error Message |
What does this mean? |
| Invalid NPI Format (NM1 Segment) |
Now active and will continue to be active for ALL NPI Readiness Options – 1,2,3 and 4. |
The National
Provider ID (NPI) submitted is not in the valid NPI format. Please
correct and resubmit. Providers can apply for an NPI online at https://nppes.cms.hhs.gov. |
The NPI
submitted was not in the proper format. It must be a 10-digit number (9
numeric digits followed by one numeric check digit). This will occur
any time you send the ‘XX’ qualifier in NM108 and send an
improperly formatted NPI in NM109. |
| NPI is Missing (NM1 Segment) |
Effective May 18, 2008 for all payers in NPI Readiness Option 3 or 4. |
The National Provider ID (NPI) is
required for this payer. Expected value for NM108 is 'XX.' Please add
the Provider’s NPI to this claim and resubmit the claim(s) for
processing. Providers can apply for an NPI online at https://nppes.cms.hhs.gov. |
The valid qualifier sent for an
NPI in NM108 is ‘XX.’ You will receive this message if you
send any qualifier other than ‘XX’ when NPI is mandated for
use. |
| Legacy ID Not Allowed (REF Segment) |
Effective May 18, 2008 for all payers in NPI Readiness Option 3. |
The legacy
identifier, <Decode of the REF01>, may not be used for this payer
after the National Provider ID (NPI) is mandated for use. Please
correct and resubmit. |
The
payer’s legacy identifier is not allowed for payers following NPI
Mandate guidelines. Note – State license numbers (0B) will
continue to be accepted. |
| Tax ID/SSN is Missing (REF Segment) |
Now active and will continue to be active for ALL NPI Readiness Options – 1,2,3 and 4. |
Segment
REF (Billing/Pay-To Provider Secondary Identification) is missing.
Either EIN or SSN of Provider must be carried in this REF segment when
NM108 is 'XX'. |
For
Professional and Facility Claims only – If the NPI is sent in the
NM1 loop for the Billing (2010AA)/Pay-to Provider (2010AB), then either
the Employer’s Identification Number (IEN) or the Social Security
Number (SSN) must be sent in the REF segment of the same loop. |
Register Your NPI with Health Plans
Providers must ensure they have correctly registered their NPI with any
applicable health plans prior to including them on any health care
transactions. Availity is not responsible for registering individual
NPI numbers or verifying the accuracy of the NPI registered for a given
provider. Additionally, it is also imperative to include the XX
qualifier in any transactions which require the NPI.
Atypical Providers
Availity will continue to
accept the existing legacy identifier as the primary identifier for
atypical providers. Atypical providers are non-health care providers
who are not eligible to obtain an NPI, such as taxi and construction
companies. Such providers will need to register their identifiers with
Availity. Availity will maintain a database of registered identifiers
and refer to it to determine if an NPI is required for the submitting
provider.
- WEB -
Atypical providers submitting via the web must complete the ID tab
within the Maintain Provider function by selecting the option
indicating that they are not required to have an NPI and completing the ID field for their primary identifier. This functionality is currently available.
- Non-WEB (EDI/B2B)
- Transactions submitted by or on behalf of atypical providers without
an NPI will be rejected unless they are registered as an atypical
provider with Availity. You may contact Client Services for assistance
in registering atypical providers. If you wish to contact Availity on
behalf of your atypical providers, we request that you send a list of
atypical providers and their primary identifiers to npiquestions@availity.com
ahead of time. This will ensure a smooth transition for the atypical
providers, and avoid rejections and possible claim delays.
This registration allows
Availity to relax the NPI requirement in order to properly pass the
transaction to the payer. Availity has no way of knowing every impacted
payer, and therefore cannot notify payers of a provider’s atypical status.
Atypical providers should notify applicable payers of their status so
that transactions are not rejected by the payer for a missing NPI.
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