Provider Notice issued 09/05/08

Referring and Ordering Practitioner NPI  – Delayed Implementation

On June 24, 2008, the department posted a notification on its Web site at regarding a delay in the implementation date for the reporting of NPIs for Referring or Ordering Practitioner IDs.  Providers who did not receive an electronic notification of this posting are encouraged to go to http://www.hfs.illinois.gov/provrel/ to register for e-mail notification.  The Referring Practitioner as referenced in this notification has no association with the Illinois Health Connect PCP Referral System.

The purpose of this notice is to advise providers that the implementation date for reporting the NPI for Referring or Ordering Practitioner IDs will be October 1, 2008.  Until then, providers should continue to bill as they have previously. This requirement has been delayed and applies to claims submitted via the 837I, 837P, Direct Data Entry (DDE) and paper claim formats. 

Effective with claims received on or after October 1, 2008, the NPI will be required to identify the Referring or Ordering Practitioner.  Claims submitted with a Referring or Ordering Practitioner Name must contain the Referring or Ordering Practitioner NPI.  Claims will be rejected if the NPI is not reported.  The following provides instructions for reporting the referring or ordering practitioner’s NPI. 

Paper Claim Forms

• HFS 1443 - The NPI of the Referring Practitioner must be reported in Box 21, Ref Prac No., in conjunction with the Referring Practitioner’s Name in Box 10.

• HFS 2360 - The NPI of the Referring Practitioner must be reported in Box 19, Referring Practitioner Number, in conjunction with the Referring Practitioner's Name.

• HFS 2210 - The NPI of the Ordering Practitioner must be reported, in the Ord. Prac. No. field, in conjunction with the Ordering Practitioner’s Name. 

• HFS 2211 - The NPI of the Referring Practitioner must be reported in Box 13, Ref Prac No., in conjunction with the Referring Practitioner's Name in Box 12.

• HFS 2212 - The NPI of the Referring Practitioner must be reported in Box 13, Ref Prac No, in conjunction with the Referring Practitioner's Name in Box 12.

• HFS 3797 - The NPI of the Referring Practitioner must be reported in Box 26, Identification Number of Referring Physician, in conjunction with the Referring Physician's Name in Box 25.

• Optical Prescription Order Form – The NPI of the provider must be reported in Box 2.

Direct Data Entry (DDE)

• All DDE submittals must conform to the requirements as defined for paper claims above.

837P Electronic Claim Format

• The NPI of the Referring Physician must be reported at the claim level, Loop 2310A (Referring Provider Name), NM109 or at the service line level, Loop 2420F (Referring Provider Name), NM109. The NPI of the Ordering Provider must be reported at the service line level, Loop 2420E (Ordering Provider Name), NM109.

• The REF segments (Secondary Identification) of these Loops are no longer required with the implementation of the NPI.

837I Electronic Claim Format

• For Home Health services billed electronically, the Referring Practitioner NPI is reported at the claim level, Loop 2310C (Other Provider), NM109 or at the service line level, Loop 2420C (Other Provider), NM109.

Your participation in our programs is greatly appreciated.  Questions regarding this notice may be directed to the Bureau of Comprehensive Health Services at 1-877-782-5565.

Your participation in our programs is greatly appreciated.  Questions regarding this notice may be directed to the Bureau of Comprehensive Health Services at 1-877-782-5565.

Theresa Eagleson, Administrator

Division of Medical Programs