Correcting Medicare Crosswalk Errors

Date:   10/30/2008

Prior to May 23, 2008

Claims processing guidelines ensured verification of necessary patient eligibility information and correct claim submission requirements. Validation of the tax ID number associated with the PTAN or the provider's address was not mandated prior to May 23, 2008. All initial provider profile information was on file but never affected claims processing.

After May 23, 2008

Once NPI was fully implemented, Medicare claims began to edit in a different way:

• A three-way match must occur for all claims processed on or after May 23, 2008.
• The provider's enrollment profile is verified to the NPI database on the CMS Web site (National Plan and Provider Enumeration System (NPPES)), and both profiles must match the information that is submitted on the claims.
• This verification must be a one-to-one match in order for the PTAN number to link to the NPI number listed on the claim.

As a result, crosswalk rejections now occur that did not occur before NPI. Claim rejections and/or delays are due to information on the claim not matching either the enrollment profile and/or the NPI database. Qreport messages such as "SSN or EIN not on crosswalk" or "NPI not on crosswalk" may appear.

If a claim is rejected (i.e., SSN/EIN or billing provider/rendering provider is not on the crosswalk), please follow the steps below.

Step 1 - Verify Claim Was Properly Billed With NPI and Appropriate SSN or EIN

If the claim was billed correctly, proceed to step 2.

Step 2 - Verify and/or Modify NPPES

Verify the provider information on NPPES. For help, see provider alert dated 10/31/08 "How Do I Update or Modify National Provider Identifier Information?" on http://www.Infinedi.net

• You can access NPPES Web site at https://nppes.cms.hhs.gov/NPPES/Welcome.do.
• Update the appropriate information. Contact NPPES Customer Service at (800) 692-2326 for assistance.
• If NPPES information is correct, proceed to step 3 in getting a one-to-one PTAN/NPI Match.

Note: Please remember that NPPES and the Provider Enrollment profile must contain the same information; therefore, pay special attention to Step 3.

Step 3 - If Provider Enrollment Records Need to Be Updated

If the claim rejection issues cannot be resolved by correcting NPPES data or claim submission errors, please contact local Medicare contractor Provider Enrollment department to verify Enrollment profile information.

Verify enrollment profile information matches NPPES and the claims being submitted. You may need to update this information with Infinedi to make sure claim information matches NPPES & Medicare Enrollment Profile.

If you have to update Enrollment Profile with Medicare, you may have to complete a new CMS-855. For more information or help on this topic, see provider alert dated 10/31/08 "How Do I Update or Modify National Provider Identifier Information?" on http://www.Infinedi.net

Provider Action:

No action required by provider.