4010 to 50104010 to 5010DMH DMH

NPI and Taxonomy EditsNPI and Taxonomy Edits

Providers and Service Providers and Service ScenariosScenarios

Kinds of ProvidersKinds of Providers County owned-and-operated facilities County owned-and-operated facilities County contracted providersCounty contracted providers

County contracted facilitiesCounty contracted facilities Fee-for-service providersFee-for-service providers

Service ScenariosService Scenarios Service provided Service provided outsideoutside of the of the

patient’s homepatient’s home In-home servicesIn-home services

5010 NPI Locations5010 NPI Locations

Pay-to Provider NPI has been Pay-to Provider NPI has been eliminatedeliminated

Billing Provider NPI Billing Provider NPI Service Facility Location NPIService Facility Location NPI Rendering/Attending Provider NPIRendering/Attending Provider NPI

Billing Provider NPIBilling Provider NPI

Report only Report only countycounty NPIs in Billing Provider NPIs in Billing Provider LoopLoop

Report the “most specific subpart” NPI of your Report the “most specific subpart” NPI of your county organization county organization relevant to the servicerelevant to the service

Do Do notnot report a county NPI in the Service report a county NPI in the Service Facility Location or Rendering Provider LoopsFacility Location or Rendering Provider Loops

Notify DMH of Notify DMH of allall county NPIs you will use county NPIs you will use when billing (for inclusion in the DMH when billing (for inclusion in the DMH Provider File)Provider File)

Service Facility LocationService Facility Location For a provider For a provider externalexternal to the county to the county

organizationorganization County-contracted FacilityCounty-contracted Facility

Report the facility’s “most specific subpart” NPIReport the facility’s “most specific subpart” NPI Notify DMH of Notify DMH of allall county-contracted NPIs used county-contracted NPIs used

for billing (for inclusion in the DMH Provider for billing (for inclusion in the DMH Provider File)File)

Fee-for-Service ProviderFee-for-Service Provider Report the location NPI if availableReport the location NPI if available

In-home servicesIn-home services Report the patient’s address* Report the patient’s address*

Rendering/Attending Rendering/Attending Provider NPIProvider NPI

Identifies the person rendering the serviceIdentifies the person rendering the service May May notnot be a subpart NPI of the county be a subpart NPI of the county

A county employee is not a “subpart”A county employee is not a “subpart” Taxonomy code will be used for the:Taxonomy code will be used for the:

Fee-for-service Provider EditFee-for-service Provider Edit Medi-Medi Dual Eligibility EditMedi-Medi Dual Eligibility Edit

No longer necessaryNo longer necessary to report a hospital to report a hospital taxonomy code to identify Mode 12 taxonomy code to identify Mode 12 servicesservices

In-home ServicesIn-home Services

Place of Service = “12”Place of Service = “12” Report patient’s home address in the Report patient’s home address in the

SFLSFL For For county-contracted facilitiescounty-contracted facilities report: report:

The facility’s NPI in the The facility’s NPI in the claim levelclaim level SFL SFL Patient’s home address in the Patient’s home address in the service-service-

levellevel SFL SFL Leave the service-level NPI blankLeave the service-level NPI blank

County Provider County Provider ValidationValidation

The DMH Provider File Lookup uses The DMH Provider File Lookup uses the:the: County codeCounty code County’s federal Employer Id Number County’s federal Employer Id Number

(EIN) (EIN) Revenue code (inpatient claims only)Revenue code (inpatient claims only) NPI in the NPI in the Billing ProviderBilling Provider loop loop Procedure code and modifiersProcedure code and modifiers Date of serviceDate of service

Contract Provider Contract Provider ValidationValidation

The DMH Provider File Lookup uses:The DMH Provider File Lookup uses: County codeCounty code County’s federal Employer Id Number County’s federal Employer Id Number

(EIN) (EIN) Revenue code (inpatient claims only)Revenue code (inpatient claims only) NPI in the NPI in the Service Facility LocationService Facility Location

looploop Procedure code and modifiersProcedure code and modifiers Date of serviceDate of service

Fee-for-Service Provider Fee-for-Service Provider ValidationValidation

Claim Note:Claim Note: “FFS”, “SED-FFS” or “FFS-SED” “FFS”, “SED-FFS” or “FFS-SED” Rendering Provider Taxonomy CodeRendering Provider Taxonomy Code

prefix:prefix: 103 - Psychologist103 - Psychologist 104 - Licensed Clinical Social Worker104 - Licensed Clinical Social Worker 106 - Marriage Family Therapist106 - Marriage Family Therapist 163 - Registered Nurse163 - Registered Nurse 193 - Mixed Specialty Practice* (will be phased 193 - Mixed Specialty Practice* (will be phased

out)out) 207 - Physician207 - Physician 208 - Psychiatrist208 - Psychiatrist 363 - Nurse Practitioner / Physician’s Assistant363 - Nurse Practitioner / Physician’s Assistant 364 - Nurse Specialist364 - Nurse Specialist

Quiz #1 Quiz #1 County Owned FacilityCounty Owned Facility

For services provided by a For services provided by a county county operatedoperated facility, what should be facility, what should be reported in:reported in: Billing Provider Loop?Billing Provider Loop? Service Facility Location Loop?Service Facility Location Loop? Rendering Provider Loop?Rendering Provider Loop?

Quiz #2Quiz #2County Contract FacilityCounty Contract Facility

For a service provided by a For a service provided by a county county contractcontract facility, what should be facility, what should be reported in the:reported in the: Billing Provider Loop?Billing Provider Loop? Service Facility Location Loop?Service Facility Location Loop? Rendering Provider Loop”?Rendering Provider Loop”?

Quiz #3Quiz #3Fee-for-Service ProviderFee-for-Service Provider

For a service provided by a For a service provided by a Fee-for-Fee-for-Service providerService provider, what should be , what should be reported in the:reported in the: Billing Provider Loop?Billing Provider Loop? Service Facility Location Loop?Service Facility Location Loop? Rendering Provider Loop”?Rendering Provider Loop”?

Medi-Medi Dual Medi-Medi Dual Eligibility EditEligibility Edit

Requires Medicare COB information for Requires Medicare COB information for most H2010 and H2015 services when most H2010 and H2015 services when the Rendering Provider Taxonomy Code the Rendering Provider Taxonomy Code begins with:begins with:

103103 PsychologistPsychologist 104104 Social WorkerSocial Worker 207207 PhysicianPhysician 208208 Physician Physician 363363 Nurse Practitioner/Physician’s Nurse Practitioner/Physician’s

AssistantAssistant 364364 Nurse SpecialistsNurse Specialists

Medi-Medi Dual Medi-Medi Dual Eligibility EditEligibility Edit

Requires Medicare COB information for Requires Medicare COB information for most H2010 and H2015 services when most H2010 and H2015 services when the Rendering Provider Taxonomy Code the Rendering Provider Taxonomy Code begins with:begins with:

103103 PsychologistPsychologist 104104 Social WorkerSocial Worker 207207 PhysicianPhysician 208208 Physician Physician 363363 Nurse Practitioner/Physician’s Nurse Practitioner/Physician’s

AssistantAssistant 364364 Nurse SpecialistsNurse Specialists

DMH DMH Provider NPI and Taxonomy Provider NPI and Taxonomy

EditsEdits Questions?Questions?