Provider Numbers

Although patients will identify providers by their given name, the way that a medical provider is identified by a health insurance carrier, and even the state they practice in, will be by one of the various provider numbers that will be assigned to them.

A medical provider is assigned numerous different provider numbers by their state, government as well as insurance carriers.

Examples:

1.      The state assigns each new doctor a license number as proof that he passed all of the necessary requirements to practice medicine in the state where the license was issued.

2.      A commercial insurance carrier will assign all new participating providers a unique provider number.

3.      A new doctor will also be assigned a Tax ID number. This number is used to identify the provider of service and is also used for tax reporting.

4.      CMS now assigns each doctor an NPI number, replacing the old UPIN number.

5.      Durable medical suppliers may be assigned a taxonomy number.

Out of all of these numbers, the NPI number is most critical to billing. This number is required on every claim that is billed.

The Centers for Medicare and Medicaid Services (CMS) began issuing NPI numbers in 2007 as part of HIPAA. HIPAA's primary role is to protect patient information and to simplify and standardize the health insurance process.

The NPI number:

1.        Identifies who is billing a claim. 

2.        Helps providers identify each other.

3.        Helps clearinghouses standardize the way they create and transmit data.

4.        Helps to identify who the treating provider is with regard to in-patient medical records.   

This unique 10 digit number is used by all provider types and is permanent. Some of the providers that are required to have an NPI number include:

  • Midwives
  • Nurse Practitioners
  • Dentists
  • Chiropractors
  • Pharmacy Technicians
  • Doctors
  • Physician's Assistants
  • Hospitals
  • Medical Device Companies
  • Physical and Occupational Therapists 
  • Nursing Homes
  • Laboratories    

Depending on the health carrier’s specific requirements, the NPI number may be used on some or all of these various places on the CMS 1500 form, including:

  • 17 B requiring a referring provider NPI number.                                       
  • 24J on the claim form requiring a rendering provider NPI number.
  • 32A and/or B requiring a service facility location NPI number.
  • 33A and/or B requiring a billing provider’s name, address and NPI number.

Providers are required to have and use this number when billing, even if they use an outside billing agency to bill claims. A medical biller is not required to have a NPI number. The NPI number of the provider that rendered the service will always be used instead.

Not only is this number critical to the billing process, it is also the number that you will be asked to provide when you call the carrier to verify benefits, eligibility or to check patient status.

The NPI number is also the number that is on all correspondence from the health plan; from checks and EOB’s to requests for additional information and claim denials.

Source Wikipedia.org /NPI


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