Be sure to enroll your billing location with DHS

We’re reaching out to all providers who care for GHP Family and GHP Kids (CHIP) members to reiterate some important information about Affordable Care Act (ACA) and Medical Assistance (MA) program requirements.

If you render and bill for services provided to GHP Family or GHP Kids members — or you’re included on claims as an ordering, referring or prescribing (ORP) provider — you’re likely aware of the state-mandated requirement to enroll all active and current service locations with the PA Department of Human Services (DHS). NPI, taxonomy code and zip code for each location are required to verify enrollment with the state.

However, we’ve noticed some group practices billing from a centralized billing location are not including the GroupNPI, taxonomy number and zip code for the billing location on claims for services rendered at another location that is enrolled. DHS mandates that group practices secure an NPI for the service location from which they do their billing and include that information on claims.

In accordance with DHS, we consider NPI, taxonomy code and zip code for the group practice billing location required elements on claims. Group practice billing entity information is required for claims to pay appropriately. Claims that do not include the NPI, taxonomy code and zip code for the group practice billing location for dates of service on or after Thursday, Aug. 1, will be denied.

Key points to remember to avoid GHP Family and GHP Kids claims denials

1. DHS enrollment and revalidation requirements

All rendering MA providers must comply with the state-mandated requirement to enroll with DHS and revalidate their PROMISe™ ID and all active and current service locations every five years. Providers who do not complete the revalidation process every five years may have their MA provider record disenrolled, their contract terminated and their claims denied.

If you have not done so already, register with DHS today so you can continue to care for your GHP Family and GHP Kids patients. If you are not registered with DHS, claims on which you are included as an ORP provider may be denied. All applications, requirements and the step-by-step instructions are available on the DHS website.

2. NPI on all claims

Your National Provider ID (NPI) is required on all claims. We must be able to crosswalk your NPI to a PROMISe™ ID indicating your registration with DHS. If we cannot crosswalk your NPI to a valid PROMISe™ ID, claims may be denied.

3. Taxonomy and zip codes

Taxonomy and zip codes are required on all claims. We use taxonomy and zip codes to accurately match NPI numbers on claims to valid corresponding PROMISe™ ID numbers on file with DHS. When a valid match cannot be found, claims may be denied.

Submit your taxonomy code and zip code — as registered with DHS for each location — in the appropriate 837 loop and segment as referenced in the ASC X12 Standards for EDI or in the appropriate box location as per paper claim billing standards.

4. ORP provider billing requirement

Providers furnishing services to MA and CHIP beneficiaries that require an order or prescription must obtain the order or prescription from a MA enrolled provider (a provider with a PROMISe™ ID). Claims will be rejected or denied:

• When submitted without the valid NPI for an ORP provider
• When submitted with the NPI of a GHP participating ORP provider that does not crosswalk to a valid PROMISe™ ID