Feds change how providers apply identification number on insurance claims
June 17, 2013
By Kelly Soderlund, ADA News staff
The federal government has made some changes in how dentists and other health care providers must apply an identification number they typically use on claim submissions.
The National Provider Identifier is a unique, government-issued, standard identification number for individual health care providers and provider organizations such as clinics, hospitals, schools and group practices. NPIs that specify an individual, such as a solo practice dentist, are classified as Entity Type 1 (Individuals) NPIs. NPIs that specify a dental practice organization are classified as Entity Type 2 (Organizational) NPIs.
Any health care provider that uses electronic transactions—such as claims or eligibility verifications—is considered a covered entity under the Health Insurance Portability and Accountability Act standard and is required under federal law to include an NPI on electronic transactions.
As of Jan. 1, all Medicare Part D prescription claims must contain the prescriber's Type 1 individual NPI.
Even a dentist who does not need a Type 1 individual NPI to bill for his or her services directly needs this identifier to prescribe drugs for patients who have Medicare Part D prescription drug benefits. As of May 6, a Type 2 Organizational NPI that identifies a dental practice organization is no longer sufficient to allow patient prescriptions to be billed to third-party insurance carriers.
Only the Type 1 individual NPI is now valid for specifying the prescribing doctor on an insurance claim. For more information on this, visit the website, scroll down to the “Downloads” heading, and click on the resource “NPI Requirement for Prescribers.”
Even dentists who are not HIPAA-covered entities because they use only mail, voice and fax to transmit claims may be required to use NPIs.
For example, most dental plans require dentists to include NPIs on paper claim submissions, and, since 2006, all versions of the ADA claim form support the use of NPIs. Noncovered dentists are now also required to use a Type 1 NPI on prescriptions for Medicare Part D beneficiaries.
In addition, a specialist may request a referring doctor's Type 1 individual NPI to complete a claim, regardless of how it is transmitted to the plan. A drug plan may require pharmacists to include prescribing doctors' Type 1 NPIs on prescription claims for certain drugs.
Applying for an NPI is free and easy. To apply through a secure, Web-based process, visit the National Plan and Provider Enumeration System website.
Those with valid applications will receive their NPI via email within one to five business days. The emails may end up in a spam folder so it's important to check regularly to ensure you receive the message.
Dentists who prefer to submit paper applications should contact the NPPES customer service hotline at 1-800-465-3203. The paper application process should take between four and six weeks.
Questions about the status of an NPI application can be emailed to customerservice@NPIEnumerator.com. For more information, visit the website.