Last Modified: 3/12/2024
Location: FL, PR, USVI
Business: Part B
If you’re a Part B provider with multiple billing PTANs linked to a single NPI for your Medicare claims, First Coast is implementing a new process January 1, 2024, to auto-plug in the claims processing system the most appropriate PTAN to your NPI. With this enhancement, we’ll no longer issue development letters requiring you to tell us in writing which PTAN to use for payment for a billing NPI or for a rendering provider NPI.
Please notify your billing and credentialing staff to prepare for this change and verify that your provider enrollment files are up to date with only the currently active PTANs linked to your NPI.
Medicare requires claims to contain NPIs to be accepted for adjudication. NPIs reported on the claims are cross- walked to the Medicare-assigned PTAN. Adjudication is based on a one-to-one relationship between the two. When a unique match cannot be made using the crosswalk, claim development, or rejections may occur.
To reduce provider burden, we’re implementing a new auto-plug process that will result in less claim development and delays. The claims processing system first strives to narrow down the universe of possible PTANs for an NPI based on a comparison of NPI to PTAN crosswalk. When the claim processing system cannot identify a unique PTAN to NPI combination for a billing or rendering NPI, it initiates the auto-plug option.
The lowest alphanumeric PTAN is selected and plugged into the claims for processing.
For example, NPI 888888888 is associated with PTANs 222222 and 111111. If a unique match cannot be identified, the claim will be processed under PTAN 111111.
The universe of possible PTAN matches for a billing NPI is narrowed down in the following order for Part B claims when more than one possible match is found:
• Contractor number
• Tax Identification Numbers (TIN)
• Taxonomy specialty codes
• Presence of a group NPI or group PTAN
• Exclude PTANs with an action reason code of 72
• PTAN termination dates
• Medicare effective dates
• Group/member relationships
• CLIA numbers
• Place of service/service facility location zip code
• Practice address zip codes
• Pay to address zip codes
The mapping process continues through each step until a one-to-one unique NPI/PTAN combination is found. The crosswalk process is similar with the rendering NPI.
First Coast recommends using a one-to-one match if your enrollment allows for it. While we understand the necessity of having more than one NPI, if your enrollment dynamics permit the use of one single NPI to one PTAN, then you will avoid possible claim rejections. This can be done for all practice locations under one single TIN.
Please review the CMS
locality and pricing information of each location before considering this setup. All locations would need to be in the same pricing locality.
Example of one-to-one match for a location to NPI association:
• Practice Location or facility 1, Group or facility PTAN #1 – NPI #1
• Practice Location or facility 2, Group or facility PTAN #2 – NPI #2
• Practice Location or facility 3, Group or facility PTAN #3 – NPI #3
While not required, this approach would reduce the need for further clarification. All claims for each location would pay to one single PTAN/NPI combination in the system.
If the PTAN auto plugged is inactive or terminated, your claim may be rejected or denied:
• A rejected claim will use claim adjustment reason code (CARC) 16 and remittance advice remark code (RARC) N257
• A denied claim could use one of several CARCs and RARCs. Claims should only deny if the PTAN used is terminated and the codes will reflect the reason for the termination (e.g., suspend military, retired, returned to residency)
• Keep enrollment records up to date with current billing and physical addresses for the location in which the PTAN is intended
• Ensure PTANs are end dated when they are no longer in use
• Ensure all locations where a provider renders services are listed on their 855I Medicare Enrollment Application for Physicians and Non-Physician Practitioners (including facility and hospital locations)
• Ensure the billing provider address on claim submissions matches the enrollment file associated with the desired PTAN
• Ensure a taxonomy code is listed on your Part B claim if the billing provider has multiple specialties
If your claims continue to reject or deny for provider information after following the tips above, please contact our Part B Provider Contact Center at:
• Florida and U.S. Virgin Islands: 888-454-9007
• Puerto Rico: 877-715-1921
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.