Has the requirement for reporting the NPI been relaxed? HIR 569 specifically indicates that the NPI is required now that the NPI is mandated for use. However, the 5010 TR3 note for the NM1 segment states that the NPI must be passed in NM109, but until that ID is "available", the Federal TIN or another id must be sent. What does "available" mean? If the employer group does not have access to (or chooses not to go to the effort to access) the NPI, then the NPI is "not available", and consequently not required. Moreover, the Situational Rule given in NM108 clearly states that any one of 4 possible qualifiers may be used (34, FI, SV or XX), but only if the provider has received an NPI. So it seems that once the provider has received an NPI, the sender is no longer obligated to send it. Instead, the submitter is now free to send the provider's SSN or TIN or a payer-assigned id. Since most medical providers now have NPI's, no NPI's need ever be sent. Could you please clarify the intent of the workgroup?
The WG has separated the answers for each question identified.
1) Has the requirement for reporting the NPI been relaxed? WG Response: No
2) What does "available" mean? WG Response: Available means when the NPI mandate has been implemented.
3) If the employer group does not have access to (or chooses not to go to the effort to access) the NPI, then the NPI is "not available", and consequently not required. Instead, the submitter is now free to send the provider's SSN or TIN or a payer-assigned id. Since most medical providers now have NPI's, no NPI's need ever be sent. WG Response: This is an incorrect interpretation.
4) Could you please clarify the intent of the workgroup?WG Response: The "XX" qualifier is the only permissable ID that can be submitted to identify a provider with an NPI.
If the NPI is unable to be sent, then per the guide notes, "the Provider's Name must be passed using elements NM103 through NM107 as outlined in segment note 2."