NPI Number Everything You Need to Know About NPI Numbers

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1 NPI Number Everything You Need to Know About NPI Numbers By Alice Scott and Michele Redmond What is an NPI number, who needs one, how do you get one, when do you need two NPI # s, what is a taxonomy code and how does it affect my NPI #, how do you get someone else s NPI number, and did I already get one are just a few of the questions that have arisen. The whole realm of NPI is confusing and since it just came into effect May 23, 2007 we re just beginning to see the challenges. We are all learning together about how the change will affect our offices. We are still obtaining NPI numbers for providers who call and haven t gotten one yet. We are also answering many questions on our Ask the Biller page on NPI numbers. Here s our best at answering all these questions. What is an NPI Number? Since May 23 rd it is required that any provider of medical services must obtain a National Provider Identification number. They are free and fairly easy to obtain. In order to be reimbursed by an insurance company the provider must now file all insurance claims on a new form that was designed to accommodate the NPI with the providers NPI number in the correct boxes on the claim form. There are two types of NPI numbers. A type I NPI is for any individual provider. A type II NPI is for any organization that renders health care services. 1

2 A little confusing? Not yet. It s coming. Keep reading. Who needs a NPI number? There is still some confusion over whether certain providers need to have an NPI. If you contact the NPI enumerator they can t even tell you. Nurse practitioners and physicians assistants need to have one as well as midwives. But RN s and LPN s do not. For example, there is not a specific taxonomy code (we will explain what a taxonomy code is later) for LMT s but they tell you to use the one that is under Other Taxonomy, then pick Specialist. If you are billing insurances then it is a good idea to have one. Bottom line, the NPI numbers are free, and it s better to be safe than sorry. If I were you I would get one. So if you don t bill insurance companies you shouldn t need a NPI number should you? Not necessarily. If you refer patients out to a specialist, your NPI number is required by the insurance company for that specialist to be reimbursed. Life has a way of changing. Maybe you ll be billing insurance companies in the future. 2

3 How do you get a NPI Number? The easiest way to get a NPI number is to hire us to get it for you for $ Michele has obtained so many now she can get through the website application in four minutes while you are on the phone with her. The assigned number has been coming back to us the same day in many cases. You can call Michele at The NPI number itself is free. You can fill out an application yourself at It takes about minutes for a first time user. You can also download a paper application to send by mail. When does an office need two NPI Numbers? If an office is a group practice, with a group name and tax ID number, then you would need a type II NPI for the group and a type I NPI for each provider within the group. For example, if you have a group named Smithtown Medical Group with 3 MD s and 2 NP s then you would need a type II NPI for the group Smithtown Medical Group, and 5 type I NPI numbers, 1 for each MD and NP. If you are a single physician but you use a group name & tax ID# then you may still need both types of NPI s. If the insurance carriers have you credentialed as a group or if you want to be reimbursed under the group name & tax ID, then you would need both. I had an insurance company provider representative tell me that basically, whatever the name is that is associated with the NPI number that is in box 33a of the CMS form is who the check will be made out to. 3

4 Does a physician who works at two offices need two NPI numbers? No. Each provider only needs 1 individual NPI number, no matter how many locations, or offices they work at. If you are a fee for service provider, why do you still need a NPI number? If you refer any patients out to a specialist that specialist needs your NPI number to be reimbursed by the insurance company. These providers will not be able to accept referrals from you without a NPI number for the billing. Why would a physician in a non-profit organization need a NPI number? Even if you are a physician who works for a non-profit organization you need to get an NPI number. You may not be billing any insurance claims, but if you need to refer a patient to a specialist who does bill insurance they have to have your NPI number, as the referring doctor, on the claim in order to get reimbursed. Why does an ambulatory surgery center need a group NPI? Ambulatory Surger Centers must have a type II NPI number in order to bill for the facility charges. Each physician who works at the Ambulatory Surgery Center also needs their own NPI. 4

5 What do you do if you think you have a NPI number, but you don t know what or where it is? You need to call the NPI enumerator and be prepared to furnish your SS#, date of birth, etc to get any information. You can reach them at They can tell you if you have already applied and send you a new if necessary. What is a taxonomy code and why does it affect my NPI number and my payments? Taxonomy Codes are an administrative code set for identifying the provider type and area of specialization for health care providers. They are alphanumeric and are ten characters in length. Taxonomy codes allow providers to identify their specialty. A provider can have more than one taxonomy code. Taxonomy Codes have 3 distinct levels. Level I is the provider type which is a major grouping of health care providers. For example: Dentists, Osteopathic Physicians, and Chiropractors. Level II is Classification or a more specific service or occupation related to the provider type. Level III is the Area of Specialization. This is a more specialized area of the classification in which a provider chooses to practice or make services available. This is usually based upon the sub-specialty certificate. Taxonomy Codes allow the provider to identify their specialty at the claim level so this can directly affect your reimbursement from insurance companies. If you have an inaccurate taxonomy code linked to your NPI number then your services may be paid at a lower reimbursement rate, or outright denied by an insurance company. 5

6 Example: If you are a Pediatric Surgeon and you pick a taxonomy code for just straight Pediatrics, your services may be denied. You would need to pick the more specific code of Pediatric Surgeon (at Level III) in order to ensure proper reimbursement for your services. In order for health care providers to receive reimbursement from insurance companies after May 23, 2007, they must apply for an NPI number and choose a taxonomy code. When applying for your NPI number it is extremely important that you pick the correct taxonomy code. It can affect your payments from insurance companies. The NPI number application has a list of the taxonomy codes available. Where do you put the NPI number on a claim form? On the new CMS 1500 form the NPI goes in box 24J, 32A & 33A. On the old HCFA 1500, there isn t a specific place on the form, but some insurance carriers are having providers put it in box 19. We re not supposed to be using the old HCFA 1500 forms after May 23 but we spoke to a provider rep who said they had many requests to use up older versions rather than throw them out. That company was going to accept them a little longer. We ve just finished writing an ebook How to Complete a CMS 1500 Completely and Correctly, Line By Line, Box By Box which will soon be available. We go through the new CMS 1500 form explaining what is required and what should be included. Our goal is to walk you through the form, line by line, box by box, so you will understand what the insurance carriers are looking for in each box and line so you can fill out the form correctly and your claims are not denied. You can order the ebook for $39.95 at alice-solutions@cnymail.com. How do you report your NPI number to the insurance companies? 6

7 Each insurance carrier seems to be handling it differently. Some insurance carriers are requesting that you sign into their website and enter your NPI. Some are asking for your NPI when you call for claim status. A few are calling offices and asking for them. Some are sending letters asking you to fax back the info. If you get a request from a company for the NPI to be submitted in a certain way, we suggest you do that. We applied for NPI numbers for all of the providers we work with and put them all on a spreadsheet. We then faxed the spreadsheet to all the major insurance carriers. A couple of companies have asked us to enter the NPI s on their website. When you file your insurance claims, make sure that you are submitting both the old legacy # and the NPI number. That will leave less room for error. Why do you need other providers NPI numbers? If a referral is made to a specialist and the referring doctor s name is to be included on the claim form, the referring doctor s NPI number must also be included. Some of the smaller insurance carriers are not requiring it, but Medicare does. They use to require the referring providers UPIN number, but now they are requiring their NPI number. So how do you get this doctor s NPI number? You must either call or fax that office and request it. Very recently we have been notified by two insurance companies that they are offering lists of the NPI numbers of participating providers. One company has a secure website you must enter to find them. The other company sent letters requesting permission to list the NPI number on an that was sent to providers. If more companies follow suit, this will help greatly. Some of the groups in our area sent out letters to all of their colleagues listing all of their providers NPI numbers and asking them to return the sheet listing their own NPI numbers. That was also very helpful. 7

8 Can a foreign doctor apply for a NPI number? Yes. A foreign Dr. can apply for a NPI number. The application will not be denied for a practice location with a foreign address. Will your NPI number ever change? No. Each provider gets one NPI number that goes with them wherever they practice. Is an NPI number required on workers comp and no fault claims? Even though most workers comp & no fault carriers are not requiring the use of the NPI number on claims by May 23, 2007, they will eventually be requiring the NPI number. So I would encourage you to begin using your NPI number on workers comp & no fault billings as soon as possible. Is the NPI number required on claims resubmitted after May 23, 2007 with dates of service in months previous to the May cutoff? Yes. Claim submissions after the May 23 cutoff date require the NPI number no matter the date of service. Are the insurance carriers really going to deny a claim if it doesn t have a NPI? Yes and no. Medicare announced they would start denying claims May 23, 2007 if they did not contain the NPI number. Smaller carriers have been granted an extension of up to a year. 8

9 The problem with the extension is that all carriers have different cut off dates for the required use of the NPI number so your safest bet is to begin using it as soon as you can. What challenges are arising as a result of the implementation of the NPI number? So far the biggest problem we ve seen arise was when we sent our first batch of electronic claims to the clearing house with the newly entered NPI numbers. Some of the insurance carriers receiving the claims were not yet ready for the change to the NPI numbers (they were granted the extra year to comply) and not yet ready to accept the NPI numbers. All their claims were kicked out of the system. When we called the support line to find out what happened, we found chaos. They were going crazy trying to fix all the glitches in the system. It s taking them a little longer to get back to you with support than it usually does. Why do I have to keep a hard copy of my NPI number? The official notification that you received from the NPI enumerator is required by many insurance carriers if you are applying to become participating or in-network, or if you are making a change to your provider file. The official notification is all that you have for proof of what your NPI number is. Why do I want to call it an NPI number instead of a NPI number? I don t know why, but every time I go to type a NPI number I want to type an NPI number. It s driving me crazy. 9

10 As you can see the whole NPI thing gets a little confusing. I hope we ve answered all your questions about NPI numbers. If we haven t, you can always ask us about the NPI or any other medical billing questions at Copyright June Solutions Medical Billing Inc. Disclaimer - This publication is offered only as information we have experienced in our work in medical insurance billing and is not meant as legal advice. We are not advising you of how you should use this information only offering our experiences with the hope that you find something useful here. Alice Scott Michele Redmond 10