Beaverlog Tips:  Volume 42 - July 3, 2008

Insurance Claim Provider IDs

On May 23, providers were required to include their NPI on insurance claims, according to both printed and electronic claim standards. The use of secondary ID numbers is more ambiguous and, as everyone should be aware, payers love ambiguity. They use it to their advantage by creating nit-picking claim submission rules that let them reject your claims without violating the letter of the law. This article will try to give you some help in navigating through the morass of rules so that you can get your claims accepted and get paid sooner.

If you are using a claims clearinghouse, they are doing the hard work of making sure that the information is complete and in the right places. If you are one of those fortunate ones, this article, though superfluous, might still be interesting.

HIPAA Standard Electronic Claims

If you have The THERAPIST EZ, you can skip this section and jump right to CMS-1500 Printed Claims unless you need something to help you sleep.

There is both good news and bad news about generating and submitting the X12 standard electronic claims required by HIPAA. The bad news is that the standard is big (over 850 pages) and complex (about 2500 unique data fields of which about half are actually used). The good news is that the standard is codified in federal law and payers can get into big trouble (i.e. expensive fines) if they violate the standard.

First a little background on claim files themselves. The data in a claim file is organized into loops, segments, and elements. A loop has no physical or even electronic reality, it is only a label given to a group of lower level loops and data segments. Loops are recognized only by the identity of the particular segment that begins the loop. Segments, unlike loops, are collections of actual related data elements. They start with a particular two or three-character identifier followed by one or more data elements. Each piece of information in a claim file is separated from the next by a separator or terminator character. These separators are usually uncommon characters such as the asterisk (*), tilde (~), or carat (^). The first segment of the claim file defines the which separator characters are used. The actual data in the file cannot contain any of the separators. The data in claims is made up of normal text characters though you might find that hard to believe it you were trying to read a claim file in a text editor or word processor.

On May 23, 2008, all claims were required to contain a provider NPI wherever a provider is identified. There are lots of places in the file where this happens and all of them indicate that the NPI should be placed in an NM1 segment (remember, each segment begins with a two or three-character segment identifier and this one is NM1). This segment includes the provider name and, as of May 23, the NPI. Following the NM1 segments is a series of REF segments that list secondary identification numbers for the provider. Unfortunately (and nobody caught it when the standards were being developed), one of the rules for the REF segment is that, if the NPI is used in the NM1 segment, one of the REF segments must contain the provider's tax ID number, either a social security number (SSN) or an employer ID number (EIN). The very next page says that, if the payer is Medicare, the SSN is not allowed. Aha! Here's the dreaded ambiguity. Many providers don't have an EIN and thus must include the SSN except they are not allowed to use the SSN for Medicare claims.

True to form, payers, even (or perhaps especially) Medicare payers are taking that ambiguity and running with it. Many of them are requiring the SSN in the REF segment and one Medicare payer—who shall remain nameless—claimed that they were given a waiver of the prohibition against including the SSN. When we contacted CMS, they were vehement that no waivers were or would be given. Despite the current administration's penchant for ignoring laws it doesn't like, CMS didn't feel compelled to flout this one.

We can be as stubborn as anybody when we think we are in the right but we didn't want our customer to suffer so we added a new X12 Generator Option that lets you tell the program to go ahead and include the SSN, if present, on Medicare claims.

But wait, there's more! Another rule for the REF segment says "If the reason the number is being used in this REF can be met by the NPI, carried in the NM108/09 of this loop, then this REF is not used." I don't know about you but I find this ambiguous and so do many payers. It implies that an NPI in the NM1 segment (which now must be there) should cause none of the secondary ID REF segments to be generated. Once again, there are payer requirements on both sides of the arguement so we added yet another generator option to control whether REFs for secondary IDs other than SSN and EIN will be generated.

Both of the new options are on the Overrides tab (also new) of the X12 generator's Generator Options screen. The first is a check box labeled "Allow provider SSN in REF for Medicare" and the second is also a check box and is labeled "Allow other provider IDs in REF." Both of these follow the previously available option labeled "Ignore provider NPI if present." Although this should probably be unchecked now that the NPI is mandated, we left it in in case some crazy payer somewhere had a rule that needed it.

CMS-1500 Printed Claims

Like the X12 claim standards mentioned above, there is both good news and bad news about the CMS-1500 standard. The good news is that it is relatively simple (130 unique data elements versus about 1300 for X12). The bad news is that the standard is not really a standard and there are no laws mandating how it is to be used. Payers are still free to require any information in any place on the form and there is little the poor provider's can do about it.

A little more good news is that The THERAPIST Pro and EZ have so far been able to jump over almost any hurdle payer's have placed in front of them. The biggest concern as of May 23, is whether to fill the secondary provider IDs (boxes 24j and 33b) when the associated NPI is present. By using the carrier-provider overrides, you can put any ID (even blank) in either box for a particular carrier. Box 17a, the referring provider's secondary ID, is still ambiguous regarding whether to fill it when the NPI is present so we added a Carrier option that lets you blank 17a if 17b (the NPI) is filled. This new option also affects the electronic versions of the form even though clearinghouses are the only ones you can send electronic CMS-1500s to and they can fill 17a or blank it themselves as needed.


Generating and submitting claims isn't getting any easier but Beaver Creek Software is doing its best to give you the flexibility to handle whatever barriers that are placed in your path. Claim standards were supposed to make your life easier but it doesn't look like that prediction has been realized.

Here are a couple of other predictions that didn't quite pan out: PCs were going to usher in the paperless office. Yeah, right. Bill Gates predicted that nobody would ever need more than 640 kilobytes of RAM. My computer has 2 gigabytes (more than 3,000 times as much) and I wish I nad more.


Tip: Changing Tabs Using the Keyboard

The screens in The THERAPIST have been designed to be friendly to those of us who prefer to keep our hands on the keyboard and move to the mouse as seldom as possible. To help make this possible, the program has several shortcuts and one of those often overlooked is the keyboard shortcuts for switching tabs. There are lots of tabbed screens in The THERAPIST, many of them data entry screens you use often, so being able to select the next or previous tab with the keyboard rather than the mouse can save a few seconds every time you have to do it.

To move to the lext tab to the right, hold down the Alt key and press the Right Arrow key. From the rightmost tab, Alt+Right Arrow takes you back to the first tab. To go in the other direction hold down Alt and press the Left Arrow.


Technical Support Ended

Ok, don't panic. We haven't shut down technical support and never will. However, we don't support all versions of a product forever. Our policy is to support a version for four years after the next higher version comes out. The THERAPIST for Windows 2.0 came out in September 2002 amd we stopped supporting version 1.0 in September 2006. Version 2.5 came out in June 2004 and support for version 2.0 came to an end on June 1, 2008. If you have version 1.0 or 2.0, we strongly encourage you to upgrade to either The THERAPIST Pro or The THERAPIST EZ, both version 2.5.