The tips below are intended to help providers ensure successful claim processing and appropriate reminbursement for claims submitted using the National Provider Identifier (NPI). For more guidance on billing with an NPI, view the NPI Registration Errors and Discrepancies List.

Valid, Registered NPIs Are Critical

Medi-Cal Claims
Claims submitted with an NPI that is not registered with Medi-Cal will be denied. Updates to NPI registrations must now be submitted through the Department of Health Care Services (DHCS) Provider Enrollment Division (PED), using the Medi-Cal Supplemental Changes form (DHCS 6209). It is recommended that this form be submitted with a cover letter that details the specific update that is being requested. Providers must verify the NPI update before submitting claims. The National Provider Identifier Collection (NPIC) tool is available for initial NPI registrations. Providers who have not already registered an NPI with any Medi-Cal provider number may still complete NPI registration through NPIC without contacting PED.

CHDP Claims
Claims submitted on the Confidential Screening/Billing Report (PM 160) with an NPI that is not registered with the CHDP program in your county will be denied even if you already registered your NPI with Medi-Cal. Updates to NPI registrations must be submitted through the local CHDP program in addition to Medi-Cal. Providers can identify the local CHDP program in their county by refering to the CHDP County Offices directory.

Verify Registration
The following is a five-step process providers can follow to verify that their NPI is registered with Medi-Cal:

1. Select the “Register/Update/Inquire NPIs” link in the left column.
2. Click the "Continue Register/Update/Inquire NPIs" button at the bottom of the page.
3. Enter the 9-digit Medi-Cal provider number.
4. Enter one of the following three numbers to access National Provider Identifier Collection (NPIC):
• Provider Identification Number (PIN)
• The last four digits of the Social Security Number (SSN)
• The last four digits of the Tax Identification Number (TIN).
5. Click the “Login” button. Registration information will be available for a provider number if the NPI is already registered.

Organizations that obtained a separate NPI for each of its Medi-Cal provider numbers should do the following:

• Verify which NPI subpart corresponds to which existing Medi-Cal provider numbers.
• Review the billing policies applicable to the existing Medi-Cal numbers, and apply the same rules to the new subpart NPI.

Organizations that obtained one NPI to replace multiple Medi-Cal provider numbers should do the following:

• Verify specific business processes. If a provider obtained one NPI to replace multiple Medi-Cal provider numbers, the various “pay-to” addresses, electronic funds transfer (EFT) accounts, and PINs will be transferred to this NPI record. The “pay-to” addresses, EFT account and PIN information on the first Medi-Cal or Child Health and Disability Prevention (CHDP) Program number, entered during registration or designated on the hardcopy form, will be transferred to the new NPI.

Note:

If a provider currently has a different TIN for each provider number, the system will transfer only the TIN from the first Medi-Cal/CHDP provider number registered to the one NPI record, resulting in Medi-Cal providing the provider with only one 1099 tax form.

Verify Correct Usage
Incorrect use of NPIs can result in claim processing delays or denials. To ensure successful and timely reimbursement of claims, providers need to verify the following correct usage of NPIs as applied to either Medi-Cal or CHDP claims:

• The NPI is registered with Medi-Cal and CHDP.
• A valid 10-digit NPI is entered in the billing provider field on the paper claim form or electronic claim submission.
• The ID qualifier is not included in the NPI.
• The NPI belongs to the correct provider. (A rendering provider cannot use the group’s NPI and vice versa. Providers who render services in a facility cannot use the facility’s NPI, and vice versa. An individual provider cannot use another individual provider’s NPI).
• The NPI is the correct NPI for the subpart (component of a healthcare organization). A claim for an outpatient service submitted with an NPI registered for an inpatient Medi-Cal provider number will be denied.
• A valid NPI is entered in the attending, admitting, or operating provider ID field. If the NPI is not available, providers should enter the 9-digit Medi-Cal provider number or license number.
• A valid NPI is entered in the referring provider field. If an NPI for the referring provider is not available, providers should enter the 9-digit Medi-Cal provider number or license number.
• A valid NPI is entered in the rendering provider field. If an NPI for the rendering provider is not available, providers should enter the existing 9-digit Medi-Cal provider number. The group’s NPI must be entered in the billing provider field.
• The complete 9-digit ZIP code for the billing provider address must be entered on claims. ZIP codes entered on claims must match the ZIP code on file with Medi-Cal, or inaccurate payment of services may result.
• The data should be properly aligned and inside the boxes on paper claim forms. Providers should use 10-point font size (not to exceed the area of the field).
• A valid NPI of the inpatient facility where services were rendered is entered in the service facility NPI field.

Additional Important Reminders for Providers and Submitters
Providers should be mindful of the following:

• Providers must use the “proprietary” forms that were updated to accommodate the 10-digit NPI. These forms include Treatment Authorization Requests (TARs), Payment Request for Long Term Care (25-1) forms, Pharmacy claim forms, Claim Inquiry Forms (CIFs), Appeal forms and CHDP forms.
• Submitters must check the registration status of providers. If any of the providers for whom the claims are submitted is not registered, those provider's claim submissions will be rejected from the batch.
• Providers must contact their Medicare contractor and confirm the inclusion of the NPI on Medicare claims in order for crossover claims to be processed. NPIs are required on crossover claims.
• The NPI must be entered in the designated field on TARs.
• All department forms have been revised to allow for use of the NPI. Effective March 17, 2008, the revised forms must be used and submitted with a valid NPI. Forms submitted that have a revision date prior to December 7, 2007 and without an NPI will be denied and returned.
• When a claim is submitted with an NPI (including dual-use claims) the associated Medi-Cal provider number(s) will be end-dated effective for dates of service beyond the date of NPI claim submission. Using only the associated Medi-Cal provider number(s) following an NPI claim submission will result in claim denials for subsequent dates of service.
• For providers who chose to replace multiple Medi-Cal/CHDP provider numbers with one NPI, the “pay-to” addresses, EFT account and PIN information on the first Medi-Cal or CHDP provider number entered in the online registration tool (or designated on the hard copy registration form) will be applied to the new NPI record. If the first Medi-Cal or CHDP provider number registered did not have an EFT account and the other provider numbers did, none of the EFT accounts will be transferred and instead will be cancelled.

Checkwrite Information
Organizations that obtained a separate NPI for each of its Medi-Cal provider numbers must use the appropriate NPI registered for each of its Medi-Cal provider numbers when checking for payment information. In addition, organizations that obtained one NPI to replace multiple Medi-Cal provider numbers will receive checkwrite information for each of the Medi-Cal provider numbers that the NPI was assigned to.