How Does a Nurse Practitioner Obtain a Medicare/Medicaid Number for Billing Purposes?

Carolyn Buppert, NP, JD

September 14, 2006

Question

How does a nurse practitioner get a Medicare/Medicaid number for billing purposes? Will this same number be applicable for durable medical equipment?

Paula Ivey

Response from the Expert

Carolyn Buppert, NP, JD 
Attorney, Private Practice, Annapolis, Maryland

 

To become enrolled as a Medicare provider, you must fill out a Center for Medicare and Medicaid Services (CMS) Form 855I. The form asks for:

  • your name and former names;

  • your date of birth;

  • year of graduation;

  • contact information;

  • name of collaborating or supervising physician;

  • any adverse legal actions imposed against you (felony or misdemeanor conviction, revocation or suspension of license, and/or suspension from a Federal or State health care program);

  • whether you have any outstanding Medicare overpayments;

  • the location of your practice;

  • the address where payments should be sent;

  • the name and address of the organization that manages the day-to day operations for your practice;

  • the name, address, and any adverse legal history of the managing employee;

  • the name and address of the billing agency;

  • the location of your patients' medical records;

  • information about your contract with the billing agency;

  • information about any company you use for electronic claims transmissions; and

  • if you are employed with a company which staffs healthcare organizations, information about that company.

The applicant must agree to abide by Medicare's regulations. For more information on Medicare provider enrollment, visit www.cms.hhs.gov/MedicareProviderSupEnroll/. To download Form 855I, visit www.cms.hhs.gov/CMSForms/CMSForms/itemdetail.asp?filterType=none&filterByDID=-99&sortByDID=1&sortOrder=ascending&itemID=CMS019477.

To become a Medicaid provider, contact the agency that administers Medicaid in your state and ask for a provider enrollment form. Each state's form is slightly different.

The CMS Web site advises new providers to get a National Provider Identifier (NPI) before filling out the provider enrollment applications. The NPI is a new 10-digit number, unique to each individual, which will replace the Medicare Provider Identification Number (PIN), the Unique Physician Identification Number (UPIN), the Medicaid provider number, and any current identification system used by commercial health plans.

There are 2 types of NPIs: individual and organizational. If an NP works for a practice, organization, or facility, then the employer will bill the NP's services under the entity's organizational NPI. The NP's individual number must be supplied on the organization's claim form as "rendering provider."

However, the new NPI numbers will not be officially accepted for transactions until October 2, 2006. On that date, Medicare will begin accepting the new NPIs but will continue to accept Medicare PINs until May 22, 2007. After May 23, 2007, Medicare will accept only the NPI on its claim forms, and as of that date all health plans, except small health plans, must use the NPI. Small health plans have until May 23, 2008 to start using the NPI. Depending upon the date when your enrollment becomes active, Medicare and Medicaid will tell you whether to use your new NPI or whether they will issue you a PIN.

Switching from current provider numbers to the NPI was mandated by Congress in the Health Insurance Portability and Accountability Act (HIPAA) of 1996. The legislative intent was to simplify electronic transactions, including claims, electronic remittance advice, eligibility, and claim status, thus saving money in the long run, and to streamline the coordination of benefits among insurers. The NPI, however, does not guarantee reimbursement, enroll providers in health plans, or require providers to conduct electronic transactions.

All nurse practitioners who use electronic transactions to bill for their services (and all others who use electronic transactions to bill for the NP's services) are required by law to get NPIs by May 23, 2007. If an NP's services are free, if a practice is completely cash-based, or if no electronic transactions are used, an NP may, but is not required to, get an NPI. However, because the NPI will replace the UPIN, and the UPIN is required on requisition for laboratory tests and on referrals for consultation, even NPs whose services are not billed will need an NPI.

For now, nurse practitioners and other providers authorized to order durable medical equipment should continue to use their Medicare PINs and UPINs or their Medicaid provider numbers. In the future, the NPI will be used on these orders.

To apply online for an NPI, visit https://nppes.cms.hhs.gov. A paper application form is also available at that site. To apply, you must enter your name, address, telephone number, date of birth, provider type, state and country of birth, contact person's name and telephone number, Social Security number, professional license number, credentials, current Medicare PIN, UPIN, and current Medicaid numbers, if you have those numbers. The NPI arrives by email in about 5 days.

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