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Medicaid NPI Attestation

TX Medicaid Preferred Setup

If you have a group NPI for your practice and you have recently upgraded your Medisoft to version 16 or version 17, in the conversion all providers
are setup as individuals. Edit the Provider, go to the IDs tab, if there is a rule for the insurance company you are sending to, edit the rule and
make sure the rule has the Group option selected. Mark the claims ready to send and send them.

Traditional Medicaid

things to verify in the www.tmhp.com attestation data against what is in Medisoft.

  1. Zip Code, must be 9 digits of the Physical Address that is on file at TMHP

  2. Taxonomy Code

  3. NPI/TPI combination

     4.  Benefit Code, if there isn't one then make sure the Patient's Group Policy is blank in Medisoft, else try putting the Benefit Code there.

other things to look for at tmhp.com
see if they have any individual provider tpis not in the group attested to the group npi,
rule of thumb, if the TPI identifies a person then it shouldn't be attested to the group npi.
to fix the problem, attest the correct npi to the individual TPI, then make sure that provider has a different Taxonomy Code or Zip Code
be careful of TPIs with benefit codes such as EP1on providers that appear to not be in a group.
The EP1(TSTEPS) provider TPI identifies the practice but can be attested to the individual provider' NPI. This isn't what TMHP prefers. TMHP doesn't consider the TSTEPS provider TPI to be a Group TPI so in Medisoft the provider to insurance combination should not be setup as a group provider.

things to check for in Medisoft

  1. Case/Medicaid/EPSDT check box should be checked for THSteps claims, this causes our program to put the required EP1 in the Group Policy field. (Group Policy field must be blank or the program will send what is in the Group Policy field as an override).

  2. Case/Policy 1/Group Number, do not put anything (i e NONE) that is not a benefit code (i e EP1 or CSN) in the Group Number field. Benefit Codes for a specific TPI can be found in the Medicaid NPI Attestation Data on tmhp.com.
  3. Insurance/Options/Plan Name, do not put anything in here if you have NONE or anything that is not a Medicaid Benefit Code in the Patients Group Policy Number.

For THSteps claims, set up the Medisoft provider(s) with the Zip Code, Taxonomy Code and NPI/TPI combination of the TMHP attestation data, make sure you do not set up a group number or a Group NPI for the Medisoft provider. The claim should look like a sole proprietor claim.This may require you to put the Practice NPI in the National Provider ID field of the Medisoft provider. Look at the TMHP data.

In version, we added a switch to address TX Medicaid and TSTEPS claims. If you create two Insurance companies in Medisoft. One for TSTEPS and one for Acute claims. In the Acute Insurances make sure the Plan Name is blank. In the TSTEPS Insurance company, put EP1 in the Plan Name. Doing this will cause InterfaceEDI to put the provider's Taxonomy Code in the 2010AA loop. If the Taxonomy Code in the Medisoft provider is not the Taxonomy Code you want to send with your TSTEPS claims, you can place that Taxonomy Code in the Provider Class Description. Doing this will allow you to attest your practice NPI to the TSTEPS TPI and only have one Provider in Medisoft.

For CSHCN claims, it may be required to send the claims as a solo provider not in a group. Even though on TMHP the CSN provider is under the group.

If a provider is in a Group(s), and

If a provider sees patients in more than one location and has multiple TPIs for those locations, the provider must send the 9 digit zip code in the PIN Column of the Pins tab with an LU qualifier. But to make sure the group information is sent with the claim leave the group TPI in the group column or put the zip code and LU qualifier under the group columns too. The zip code must match the zip code from the TMHP attestation data for the individual provider TPI. Make sure the address information for each individual TPI is the address of the practice for that group.

Some practices use a P.O. Box in their pay to address. But Medicaid won't let you use a P.O. Box as the physical address. But the Zip code must match what is in Medisoft. To get around this limitation. Requires InterfaceEDI version or above,

for a group practice, you can be can enter in the Physical Address Zip Code in the Group Column of the Pins tab of Provider Information with an LU qualifier. This will cause the program to replace the Zip Code in the Billing Provider with the value from the Group Column.

for a sole proprieter practice, you can be can enter in the Physical Address Zip Code in the Pin Column of the Pins tab of Provider Information with an LU qualifier. This will cause the program to replace the Zip Code in the Billing Provider with the value from the Pin Column.

This only works for TX Medicaid (payer 86916) or if you are sending direct to TMHP and the value is 9 characters long.
2010-12-08 some issues may be corrected by removing the Case/Facility if the procedure(s) were done in the office. Removing the Case/Supervising Provider seems to help in some cases too. Not sure if it might be related to a common diagnosis (ex 729.5 Pain)

non traditional Medicaid

Amerigroup, Americaid, Parkland, Cook's Children and other small Medicaid programs have their own copy of attestation data. They should be contacted to compare with what is in Medisoft.

Some of these payers still require the legacy pin(s). Check www.availity.com NPI/NPI Readiness documents to find out which.