Provider Notice issued 10/14/08

​National Provider Identifier (NPI) Implementation for the Pay-To Provider (Payee)

Effective with claims received on or after March 1, 2009, the department will begin requiring the NPI to be reported to designate the Pay-To Provider (Payee). This will replace the department’s current requirement of reporting the one-digit payee code to designate the appropriate Pay-To Provider (Payee). Claims received on or after March 1, 2009 that do not contain a registered Payee NPI will be denied. This applies only to claims submitted via the 837 and Direct Data Entry (DDE) formats. It does not apply to paper claims.

Reporting NPI Information to HFS

Payees and providers should immediately start registering their NPI information with HFS for each designated payee. Please reference the following MEDI Web site to report your NPI information:

 www.myhfs.illinois.gov

Payees need to share their NPI information with the providers, for the purpose of billing services to HFS. Once the NPI information is registered with HFS, the Payee NPI can be reported in the 837 and DDE transactions immediately.

Providers/Payees will not be required to report their NPI again to the department if there is only one active payee and that payee is the same as the Billing Provider. The department will default to the one active payee on the provider database if the Pay-To Provider NPI is not submitted in Loop 2010AB, NM109.

For providers or payees who do not have access to the Internet, the Provider or Pay-To Provider (Payee) National Plan/Provider Enumeration System (NPPES) approval letter with a contact name and phone number should be faxed to 217- 557-8800 or mailed to:

Illinois Department of Healthcare & Family Services
Provider Participation Unit
P.O. Box 19114
Springfield, IL 62794-9114

Updating Payee Information on File with HFS

The department allows providers the opportunity to designate alternate payees. HFS will require that an NPI be obtained for each unique 16-digit payee number. The 16-digit payee number can be identified on your Provider Information Sheet that is generated by HFS. The 16-digit payee number consists of the nine-digit FEIN for the designated payee, the five-digit zip code, and a two-digit vendor ID number. Providers do have the option of consolidating all active 16-digit payee numbers into one single 16-digit payee number. If the decision is made to consolidate all payees into one 16-digit payee number, all remittance advices and warrants will be mailed to that one payee. Providers who would like to consolidate their payees should contact the department's Provider Participation Unit at 217-782-0538.

Provider Billing Information

The following billing policies will be enforced with the implementation of the Pay-To Provider (Payee) NPI:

• If a provider is not the same as the payee for the claim, the provider would bill their NPI as the Billing Provider, Loop 2010AA, NM109 and the payee NPI in the Pay-To, Loop 2010AB, NM109 of the 837 transactions. In this situation, the payee(s) will be the Organization/Group NPI and the provider will be the sole proprietor/individual NPI.
• If a provider is also the payee for the claim, the NPI must be reported in Loop 2010AA, NM109. Loop 2010AB will not be required in this situation.
• Atypical providers are normally their own payees. They are NOT required to have an NPI because they are defined as providers who DO NOT furnish healthcare, i.e. non-emergency transportation. Atypical providers will still be REQUIRED to report the one-digit payee code to designate their payee in the “Pay-To”, Loop 2010AB of the 837 transactions.

Paper Claim Forms

Providers will still be required to report their one-digit payee code to designate their payee on the paper claim forms. The paper claim forms do not accommodate an NPI for the Pay-To Provider (Payee).

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

Theresa A. Eagleson, Administrator
Division of Medical Programs