Provider Notice issued 09/08/08

Delay in Implementation of the Edits Regarding the Reporting of the Prescriber’s National Provider Identifier (NPI)

The Department of Healthcare and Family Services, in accordance with National Provider Identifier (NPI) regulations under the Health Insurance Portability and Accountability Act (HIPAA) of 1996, will, in the future, require the prescriber’s NPI in the Prescriber ID field (411-DB) of pharmacy claims.  The department had planned to implement a point-of-sale edit, effective August 1, 2008, to reject claims containing non-NPI prescriber identifiers, and recently announced a delay in implementation of this requirement.  The purpose of the delay is to allow pharmacies additional time to obtain NPIs of prescribers.  

Over the past several months, the department has experienced a significant increase in the number of pharmacy claims that contain prescriber NPI.  Currently, about 74 percent of pharmacy claims submitted to the department contain the prescriber’s NPI.  The remainder contain the prescriber’s DEA, state license number, or legacy provider number.  The department expects the percentage of claims containing the prescriber’s NPI to continue to increase.  The vast majority of prescribers should have an NPI.  Pharmacies are expected to use diligence in obtaining a prescriber’s NPI for all prescriptions billed to HFS.  If a pharmacy has exhausted all efforts to obtain a prescriber’s NPI, including searching the National Plan and Provider Enumeration System (NPPES) NPI registry, the pharmacy may submit the claim using the prescriber’s DEA, state license number, or legacy provider number.  It should be a rare exception that a pharmacy needs to submit a claim with a non-NPI prescriber identifier. 

Further, when a client is in the Recipient Restriction Program (RRP) and is restricted to a primary care provider, pharmacies must populate the Primary Care Provider ID field (421-DL) and the Primary Care Provider ID Qualifier field (468-2E).  If the pharmacy populates the Primary Care Provider ID field, it should contain the Primary Care Provider’s NPI.  Again, pharmacies must use diligence in obtaining a primary care provider’s NPI when it is required for the claim.

Effective with claims submitted on August 6, 2008, the department will return an informational message for claims that contain an identifier other than an NPI for a prescriber or a primary care provider.  These informational messages will be returned both electronically, as well as on the Remittance Advice.   The informational messages will read as follows:

Prescriber NPI Required

Primary Care Provider NPI Required

The department has been reaching out to pharmacies that continue to submit a significant number of claims with a non-NPI prescriber ID.  The department will continue to monitor these pharmacies and expects to see an increase in the number of claims submitted with the prescriber’s NPI. 

The department encourages you to continue to work diligently towards 100 percent compliance.  It is the department’s policy that pharmacies provide the prescriber’s/primary care provider’s NPI on pharmacy claims, except when the pharmacy has exhausted all efforts to obtain the NPI and has been unable to do so.  Failure to exercise due diligence in obtaining prescriber/provider NPIs may result in audit findings.

If you have any questions regarding this notice, please contact the Bureau of Pharmacy Services toll-free at 1-877-782-5565, Option 7.

Theresa A. Eagleson, Administrator

Division of Medical Programs

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