In accordance with the Health Insurance Portability and Accountability Act (HIPAA), beginning May 23, 2008, claims submitted to WellCare, and/or designees of WellCare, must comply with the requirement to use only the National Provider Identifier (NPI) on standard transactions.

This notice serves as a modification to the WellCare provider manual specifications on claims submissions. 

NPI Claim / Encounter Submission Requirements(excludes atypical providers who are not eligible to receive NPIs)

• Electronic, direct data entry (DDE), paper health care claims
  and encounters submissions must include an NPI in the
  primary and secondary provider fields.
   
• Claims / encounters are considered non-compliant and will be rejected
  if either of the following conditions exist for the primary and/or secondary
  provider fields:
   
  • Lack of NPI when required per Implementation Guides and CMS requirements
    
  • Contain an invalid NPI

Important Claim Submission Instructions

As of May 23, 2008, the way providers file claims with WellCare must comply with HIPAA's NPI requirement. Please click the links below for updated instructions on the various methods of claim submission:

Electronic Data Exchange (EDI)             CMS 1500                    UB-04

Steps Providers Must Take to Prepare for NPI Implementation

1. Submit your NPI (and taxonomy information where necessary) to WellCare immediately, if you have not already done so.
    
2. Test billing systems and processes prior to the compliance date
   of May 23, 2008, to allow for resolution of any problems encountered.
   WellCare is transacting with NPI and taxonomy information on
   electronic and paper claims.
    
3. For electronic claim submissions, consult the Electronic Data Interchange Transaction Set Implementation Guides adopted as HIPAA standards for requirements for compliant completion of transactions or refer to the enclosed abbreviated guidelines.  For paper claim submissions, utilize the new paper claims forms.

If You Have Not Submitted Your NPI to WellCare

To submit your NPI:

1. Complete the appropriate NPI Submission form, Type 1 and Type 2 or spreadsheet listing.

Type 1 form: To record the NPI of the individual member who renders health care either independently or as part of a group

Type 2 form: To record the NPI assigned to the entity receiving payment as well as an organization that renders health care or its subpart

Spreadsheet : To record NPIs on multiple providers within a medical group on a spreadsheet, include the respective names of the rendering and pay-to providers, NPI, address, WellCare ID, Tax ID, taxonomy, social security number and date of birth for each provider listed

Providers Should Always Remember:

• The NPI is yours. It doesn't belong to a health plan or the employer you work for. And it is assigned to you for life.
• The NPI is unique. It identifies you uniquely across the country and with one single ID, regardless of where you practice or the type of practice you have.
• The NPI will be your only identifier. It will be the only permitted identifier used in HIPAA transactions to identify providers.
• You must share your NPI. Other entities will need to know your NPI in order to conduct business with you.
• You must use your NPI. It is required in all HIPAA transactions, including claims, claim payment, coordination of benefits, eligibility, referrals and claim status.
• You must use your NPI with all health plans. Medicare, Medicaid and all private health plans are required by HIPAA to receive/submit the NPI as the only provider identifier in electronic transactions.
• You must protect your NPI. Only in rare circumstances like fraudulent use will the NPI be able to be replaced.
• You must take care of your NPI. Changes to any of the required information furnished during the NPI application need to be reported to the NPI Enumerator within 30 days of the change.
• You must still report your Tax ID to health plans. This will allow them to properly report payment information to the IRS on form 1099-MISC.

Information Resources

• CMS Main NPI Web site - http://www.cms.hhs.gov/NationalProvIdentStand/
  Contains NPI Final Rule, FAQs, Fact Sheets, Tip Sheets, NPI Viewlet, Medicare MedLearn Articles, Enumeration Statistics.
• NPI Enumerator Web site - https://nppes.cms.hhs.gov/NPPES/Welcome.do
  Main site to enter an NPI application.
• WEDI NPI White Papers - http://www.wedi.org/snip/
  Industry NPI papers, including "NPI Impact on Providers"; "NPI Dual Use Strategy"; "NPI and Subparts"; and others.
• WEDI NPI Outreach Initiative - http://www.wedi.org/npioi/index.shtml
  NPI Resource Center with information resources, web links, Industry readiness assessment survey, other.