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Provider Agreement Healthcare

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					     Minnesota HIPAA
       Collaborative
What We Know About Atypical Providers

           Ann Wandersee
    MN Department of Human Services


                                        1
        Who is eligible for an NPI?
• NPI regulation published 1-23-04
  – Covered healthcare providers must obtain an NPI by
    compliance date and must use the NPI in covered
    transactions
  – A covered health care provider is a healthcare
    provider that meets the definition in paragraph (3) of
    the definition of covered entity at 45 CFR 160.103



                                                             2
             Who is eligible for an NPI?

• All healthcare providers are eligible to obtain an NPI
• Healthcare providers
   – Hospital, critical access hospital, skilled nursing facility,
     CORF, hospice, home health agency
• Healthcare services
   – Physician services, hospital services, drugs, psychologist
     services, home dialysis services, DME and medical supplies,
     ambulance diagnostic services, eyeglasses, PT, OT, ST etc.


                                                                     3
          What is an “atypical provider”?
• From the preamble of the Final Rule
   – Individual or organization that provides nontraditional
     services that are indirectly healthcare related
   – Must determine if the individual or organization
     provides any services that fall within definition of
     healthcare
   – If no, and does not provide other services or supplies
     that bring it within the definition of “healthcare
     provider” then not a healthcare provider under
     HIPAA and not eligible for an NPI

                                                               4
        Atypical Service Examples
• Non-emergency transportation
• Physical alterations to living quarters for the
  purpose of accommodating disabilities
• Vehicle modifications
• Some Medicaid Home and Community Based
  Services
• Habilitation
• Respite services
                                                    5
          How to Determine if you are an
             Atypical Provider
• Must evaluate the service as well as the entity providing
  the service
• Consider the definition of a healthcare provider
• Does the organization provide or bill healthcare services
  as defined in law in the normal course of business?
• If the service is not a healthcare service and the
  provider does not meet the definition of a healthcare
  provider then an NPI will not be assigned

                                                              6
            WEDI SNIP White Papers

• WEDI and NMEH created a list of entities that
  are considered to be atypical, including:
   –   Custodial care facilities
   –   Adult day care provider
   –   Assisted living facility
   –   Massage therapist



                                                  7
             Purpose of the WEDI SNIP
                   White Paper
• Education
• Document types of atypical providers
• Gain industry consensus and agreement on certain
  types of providers and the need for an NPI
• Includes list of provider examples
• Describes the services they render
• Review alternative approaches to enumeration


                                                     8
        Atypical Providers Today


• Health plans assign legacy provider identification
  numbers for all providers including atypical
  providers
• Some atypical providers are currently paid
  through an organization
• MN DHS assigns provider numbers for atypical
  providers contracted by Medicaid MCOs
                                                       9
       How will atypical providers be
              enumerated?

• Some may obtain an NPI
• Continue to use legacy numbers
• Enumerate on a national, regional or health plan
  level




                                                     10
         Atypical Provider Enumeration

• In the absence of a regional or national enumerator,
  atypical providers:
   – Face diverse enumeration rules and regulations for each
     payer
   – Variances in definition of atypical vs. covered healthcare
   – Different billing rules for organizations providing both non-
     medical services and covered healthcare services
   – Billing requirements for border providers will be non-standard


                                                                      11
             Atypical Provider Enumeration

• Impact on Coordination of Benefits
   –   Lack of standardization
   –   Impact on crossover processes
   –   Costly for provider and health plan
   –   Difficulty determining duplicate billings




                                                   12
                DHS Approach to Atypical
                    Providers
• DHS has determined which providers are atypical based on the
  WEDI white paper
• Create a 10-digit number with a leading alpha character based
  on the current 9-digit provider identification number
• Put edits in place so an atypical provider can not submit an NPI
  to DHS
• 10-digit number will be communicated to atypical providers
• DHS will not support the “WEDI Dual Use Strategy” for atypical
  providers


                                                                     13
               Regional Approach
• DHS would enumerate all atypical providers in MN
• DHS 10-digit number could be used by all MN payers
• Each payer would still require enrollment in their
  program
• MN payers are reviewing the proposal
   – Difficulty in consistent nomenclature and defining provider
     types
   – Difficulty matching providers from one payer to another


                                                                   14
          Regional Enumeration
• Discussions have been limited to payers in the
  MN HIPAA Collaborative
• Other payers need to be included in the
  discussions
• Payer impact analysis needs to be completed
• Payer systems would need to be modified
• Communication plans need to be developed
• Is there enough time?
                                                   15
           National Enumeration
• National enumeration
  – Unique number
  – Provides administrative savings
  – Facilitates COB
  – Provides consistent definition of atypical providers
    and non-traditional services
  – Provides a database of numbers
  – Database is maintained

                                                           16
            Alternate Solutions
• National enumeration is the best option
• Best meets provider and payer needs
• Providers and payers need time for systems
  modifications
• Payers need contingency plans
• Timing is everything


                                               17
                   Resources

• MN HIPAA Collaborative
  – www.mnhippacollab.org
• Workgroup for Electronic Data Interchange
  – www.wedi.org
• Ann Wandersee
  – ann.wandersee@state.mn.us


                                              18

				
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Description: Provider Agreement Healthcare document sample