An NPI by any other name…

health Insurance Claim form

An NPI by any other name…

Providers and staff are often confused by the myriad amounts of information needed to simply identify their practice on a claim. It is of the highest importance that all identifying information on the claim be correct so that not only is payment issue to the right provider but benefits are allocated based on the provider’s contracting status.

First, the billing provider. This is the provider to whom payments will be issued and will be accounted for on tax notices at year’s end. If you are an individual dentist you will want to use your tax ID paired with your individual NPI. If you are incorporated or bill in the name of your practice you need to establish an organizational type 2 NPI for filings. Please keep track of your NPI numbers. Many carriers, like BCBS, will set you up in their system with the identification on your first filings and if subsequent filings deviate to other identifiers they will reject those claims.

Second, the rendering provider. This is the provider who has performed services. This is not the provider that will be paid, simply the one who administered treatment. Always put the correct billing provider, regardless of network participation, on your claims. Putting the identifier of another provider just to circumvent credentialing or contracting issues can be viewed as fraudulent submission under most state laws.

Third, the facility. If you are a doctor with hospital privileges or who performs surgeries in an outpatient clinic then you are familiar with having a third identifier on your claims. If you are performing services outside your own location it is imperative that you list the facility NPI you are using. Make sure you also code your service location appropriately since you will not be in an office. Use either hospital or outpatient codes as appropriate to your claim.

If you are filing Medicare claims please ensure that your PTAN number is listed in the appropriate place so that the Medicare contractor can easily reference your provider profile. Failure to supply your PTAN can result in incorrectly denied or rejected claims.

Pay close attention to your billing data. Even the smallest errors (individual vs. organizational NPI, transposed numbers, omitted identifiers) can delay a claim by at least 30 days if not more. Almost always you will have to refile the claim delaying you yet another 30 days. Do your best to send clean claims on the first opportunity to reduce turnaround time, follow up hours and maximize your reimbursement.

Dental Billing Tips and News for Pros; Edition #135

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