Q I have had nothing but denials for Medicare claims submitted since the 1st of June. What is going on?
A More than a few offices have contacted me with this same question.One issue is that as of May 23, 2008, Medicare only accepts NPI as the provider identifier. If the claim contains any of the old legacy numbers (PIN, PTA, or UPIN), the claim is automatically rejected. (Note: The tax ID in block 25 is still required.) Also, the NPI for the group or individual should only be in block 33a and not in 32a. Block 32a is used only if the "facility" has its own NPI, which would be unusual in a chiropractic setting.
In addition, many offices that have incorporated (or become a group) also may have problems with NPI identification. (The group will have its own NPI, type 2, and the individual doctors in the group will have their own NPI, type 1.) The group NPI should be listed in 33a and the individual doctor who provided the service should list their NPI in block 24j on each line of service they provided.
What has happened is that many providers continued to bill as individuals to Medicare after becoming a group. Because Medicare still had the individual doctor's information and the numbers did not change, the billing continued to be processed. However, with the use of NPI, Medicare began to cross-reference the numbers. If you did not sign up as a group with Medicare and the group NPI is on the claim, they will not be able to identify the provider as a Medicare member and the claim will be rejected.
Unfortunately, the only way to correct this is for the provider to reapply to Medicare and complete a new enrollment form 855I, so Medicare can properly identify the group and the individual(s). If you note on the EOB from Medicare that there is missing or incomplete information, CO16 is the typical notation. If it further states that the provider cannot be indentified, I suggest you contact your local Medicare intermediary to begin the process of re-enrolling. Bear in mind that all reimbursement is halted during this period and it may take up to 60 days to process the new enrollment.
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