Dr. Brimhall's Health Puzzle Piece

May 5, 2008

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May 23rd is Do or Die for all Medicare Claims!


Docs, I hate to talk about insurance or Medicare in our Puzzle Pieces, but as Brandy spoke to our doctors at the last seminar about the new changes effective May 23, everyone looked blank.  As she explained the consequences of improper or non compliance, my eyes glazed over, panic set in and I asked her to please condense this down for our immediate understanding.  This represents many hours of work from our billing, collection, coding and insurance expert Brandy Beeson.  The doctors that have done an in-office evaluation with her all want her to work for or marry them so she never goes home. Sorry, neither is an option.


Industry-Wide Enforcement of the National Provider Identifier (NPI) Compliance Date

On and after May 23, 2008, providers MUST begin using only their NPI (National Provider Identifier) on all HIPAA electronic transactions and paper claims submitted.  All claims submitted after this deadline that have both NPI numbers and Legacy numbers or Legacy numbers only will be rejected.  CMS (Centers for Medicare and Medicaid Services) is now requesting that providers begin to submit test claims without legacy/PIN numbers as currently used to begin to test claims and processing systems with NPI numbers only.  After providers have first submitted claims containing both NPI number(s) and legacy identifiers and those claims have been processed correctly, Medicare urges you to next send a small batch of claims with only the NPI in the primary provider fields.  Submission of incorrect claims will affect cash flow 

Instructions for test submission include:

Step 1   

Bill with the Medicare legacy ID number and NPI. Once claims are successfully processed, move to Step 2.

Step 2

Bill with the NPI only. Start with a small batch of claims. When the results are positive, begin sending a greater volume and move to Step 3.

Step 3

Test the NPI only on other Health Insurance Portability and Accountability Act (HIPAA) transactions.  Providers should begin testing the use of the NPI on these transactions in small quantities prior to May 23 to ensure a smooth transition.

As outlined in the Federal Regulation, The Health Insurance Portability and Accountability Act of 1996 (HIPAA), covered providers must also share their NPI with other providers, health plans, clearinghouses, and any entity that may need it for billing purposes.  The NPI website is as follows:


New ABN (Advanced Beneficiary Notice of Non-Coverage) Form (CMS-R-131) has been implemented as of March 3, 2008.  This form replaces the general ABN (Advanced Beneficiary Notice) form (CMS-R-131-G) that has been used previously. 
CMS will allow a six month transition period from the date of implementation for the use of the revised ABN form.  All providers must begin to use the new ABN Form by September 1, 2008.  The new ABN form and instructions for use is posted on the following web page:\bni.  Once web page has been located, select ‘FFS ABN-G and ABN-L’ link and then select ‘Revised ABN CMS-R-131 Form & Instructions’ under the ‘downloads’ heading.

Important features of the new ABN Form Include:

  • New title ‘Advance Beneficiary Notice of Non-coverage’

  • Can be used for voluntary notifications, in place of the Notice of Exclusion from Medicare Benefits (NEMB) Form.

  • Contains a mandatory field for cost estimates of items or services being rendered.

  • Includes a beneficiary option in which an individual may choose to receive items or services and pay for these out-of-pocket, rather than having claim(s) submitted to Medicare.

It is the responsibility of the provider to know his/her requirements for all patient intake, documentation and proper claims submission detail.  Providers should closely monitor current CMS (Centers for Medicare and Medicaid Services) guidelines.  Fee schedules along with other guidelines and requirements are regularly updated (at least once per year).  To learn the requirements and fee schedules for your state or locality, log onto your local Medicare Carrier website and view your 2008 fee schedule.  Documents called LCD’s (Local Coverage Determinations) are posted as well which contain all documentation requirements, covered CPT and ICD-9 diagnosis codes and much more for each state and locality. 

For help obtaining your local Medicare fee schedule, LCD or with questions regarding such, please contact Brandy Beeson at (303) 242-8901 or via e-mail at

This is a little longer than we like to do for a Puzzle Piece, but I bet not one of you knew all of this. It is a very information dense, stripped down version of many more regulations and options.  This is one more of the articles that I have asked Brandy to do on Increasing Your Bottom Line.

The best to you and yours on this journey to wellness!

John W Brimhall, DC and the Wellness Team.





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The above statements have not been evaluated by the FDA. The nutritional information, suggestions, and research provided are not intended to diagnose, treat, cure, or prevent disease and should not be used as a substitute for sound medical advice. Please see your health care professional in all matters pertaining to your physical health.