Contents

General

Purpose

Applicability

Basic Concepts

Definitions

Detail

Receiver Requirements

Sender Requirements

Use Cases

Implementation

History

Appendix A – NPI Use Case Billing Scenarios

Use Case I

Use Case 2

Use Case 3

Use Case 4

Use Case 5

 

General

Purpose

The purpose of this Standard is to inform providers of NPI and Atypical Provider ID requirements and appropriate usage for these IDs within electronic transactions.

Applicability

This Standard applies to all providers and payers sending electronic transactions. Health care providers (as defined by 45 CFR 160.103) are required to send and receive the NPI.

Basic Concepts

The National Provider Identifier (NPI) is a Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification Standard. The NPI is a unique identification number for covered health care providers. Covered health care providers, all health plans, and health care clearinghouses must use the NPIs in the administrative and financial transactions adopted under HIPAA. See the CMS website for additional details about the NPI.

Some organizations may be reimbursed for their services through medical insurance plans, but do not qualify to receive an NPI through NPPES. These organizations are usually termed “Atypical providers.” As Atypical providers are not required/able to obtain NPIs, their electronic transactions must use an alternate Provider Identifier. Concept 1

Definitions

• Atypical Identifiers: Atypical identifiers are payer-assigned billing numbers for individuals/entities not required or eligible to obtain an NPI.
• NPPES: The entity contracted by the federal government to process applications for and assign National Provider Identifiers.
• Primary Identifier Fields: The location in the electronic transaction where the first iteration of the primary provider identifier is found.
• Receivers: Entities that receive HIPAA transactions. For purposes of this Standard, the reference applies to payers.
• Secondary Identifier Fields: The location in an electronic transaction where a number other than the primary identifier (such as a Federal Tax ID) is found. This is used to assist the payer in identifying the provider.
• Senders: Entities that send HIPAA transactions. For purposes of this Standard, the reference applies to providers.

Detail

Receiver Requirements

1. Utah payers may reject transactions containing an NPI or Atypical Identifier that does not match the setup in the payer’s system.
2. Payers will continue to enumerate Atypical providers through their normal provider enrollment/contracting process.
3. Payers will return the NPI or Atypical Identifier in all applicable outbound transactions.

Sender Requirements

1. Providers will submit the NPI to the payer during the enrollment or contracting process, as required by the payer.
2. When a payer requires enrollment, only the identifiers known to the payer may be used in transactions. Any number(s) used in a transaction not known to the payer may be rejected or denied.
3. Providers required to obtain an NPI must do so before sending EDI transactions.
4. Providers must notify the payers of applicable organization and/or individual NPIs as required.
5. Provider to provider communication: Providers may be listed in other providers’ claims as the referring, ordering, and/or prescribing provider for a common patient. In these cases, the NPI of the referring/ordering/prescribing provider should be shared with other providers billing for the same patient. Providers should consider placing their NPI on appropriate forms – such as the prescription pad or referrals – as a means of communicating the NPI to other providers.

Use Cases

UHIN payers and providers have addressed possible billing scenarios and have determined that there are specific data elements required for a payer to correctly adjudicate claims.  These use cases can be found in Appendix A.

Implementation

1. Providers are required to use the web portal to apply for their NPI. The web address is: https://nppes.cms.hhs.gov/. Providers should keep their contact and specialty information updated in their NPPES online profile.
2. Providers and payers must train their staff on the use of the NPI.
3. If the provider is not an Atypical provider, the claim transaction must contain the NPI and the Tax Identifier in the Billing Provider Loop.
4. An Atypical provider should coordinate with the payer for billing instructions.
5. Although NPIs and Atypical Provider IDs are used to identify the provider in the payer’s systems, credentialing and enrollment information is utilized in adjudication of the claim.
6. The Billing Provider Loop (2010AA) should not contain billing agency or clearinghouse information.

 

 

History

	V2	V2.1	V3
ORIGINATION DATE	4/27/2005	4/11/2007	6/29/2010
APPROVAL DATE	6/08/2006	8/01/2007	11/03/2010
EFFECTIVE DATE	7/08/2006	9/01/2007	12/03/2010

 

	V3.1
ORIGINATION DATE	05/08/2019
APPROVAL DATE	08/07/2019
EFFECTIVE DATE	09/07/2019

 

 

Appendix A – NPI Use Case Billing Scenarios

 

The use cases below give examples of circumstances requiring different combinations of Provider Identifiers. This information should be provided to Practice Management/EHR vendors, Payers, and any other parties required to send or process an electronic medical claim. These use cases are examples and are not intended to be all-inclusive.

 

1. PROFESSIONAL OR DENTAL CLAIM - SINGLE PROVIDER NOT ASSOCIATED WITH A GROUP
2. PROFESSIONAL CLAIM - SINGLE PROVIDER NOT ASSOCIATED WITH A GROUP, SENDING REFERRING/ORDERING PROVIDER INFORMATION
3. PROFESSONAL CLAIM - ORGANIZATION AS THE BILLING ENTITY SENDING WITH A RENDERING PROVIDER
4. PROFESSIONAL CLAIM - NON-MEDICAL PROVIDER SUBMITTING AS AN ATYPICAL PROVIDER
5. INSTITUTIONAL CLAIM - HOSPITAL WITH SUBPART

 

 

Use Case I

PROFESSIONAL OR DENTAL CLAIM - SINGLE PROVIDER NOT ASSOCIATED WITH A GROUP

Claims for medical services should be sent without a rendering provider when the provider is submitting as an individual with only a Type 1 NPI. The rendering provider loop is not expected in this scenario.

If the billing provider does not have an NPI, see Use Case 4.

 

Billing Provider

Purpose: Identifies the payee (single provider).

DESCRIPTION	LOOP	SEGMENT	ELEMENTS
Billing Provider Name & Primary ID	2010AA	NM1	01 – Entity identifier code 02 – Entity type qualifier 03 – Last name or org. name 08 – ID code qualifier 09 – ID (NPI)
Billing Provider Street Address	2010AA	N3	01 – Address information
Billing Provider City/State/ZIP	2010AA	N4	01 – City name 02 – State code 03 – Postal Code
Billing Provider Tax Identification	2010AA	REF	01 – ID qualifier 02 – ID (Tax ID)

 

Other

Information payers may need to pay correctly:

DESCRIPTION	LOOP	SEGMENT	ELEMENTS
Billing Provider Specialty (Taxonomy)	2000A	PRV	01 – Provider code 02 – ID qualifier 03 – ID (taxonomy code)

 

Special Instructions for Providers

Not all payers use or require Provider Specialty information (Taxonomy Code). Contact your payer for detailed instructions.

 

Back to the top of Appendix A

Use Case 2

PROFESSIONAL CLAIM - SINGLE PROVIDER NOT ASSOCIATED WITH A GROUP, SENDING REFERRING/ORDERING PROVIDER INFORMATION

Claims for medical services may be required to include the name and NPI of the provider who referred the patient or ordered the service.

Billing Provider

Purpose: Identifies the payee (single provider).

DESCRIPTION	LOOP	SEGMENT	ELEMENTS
Billing Provider Name & Primary ID	2010AA	NM1	01 – Entity identifier code 02 – Entity type qualifier 03 – Last name or org. name 08 – ID code qualifier 09 – ID (NPI)
Billing Provider Street Address	2010AA	N3	01 – Address information
Billing Provider City/State/ZIP	2010AA	N4	01 – City name 02 – State code 03 – Postal Code
Billing Provider Tax Identification	2010AA	REF	01 – ID qualifier 02 – ID (Tax ID)

 

Referring Provider

Purpose: Identifies the provider who referred the patient to the billing provider.

DESCRIPTION	LOOP	SEGMENT	ELEMENTS
Referring Provider Name & Primary ID	2310A	NM1	01 – Entity identifier code 02 – Entity type qualifier 03 – Last name or org. name 08 – ID code qualifier 09 – ID (NPI)

 

If the referring NPI is NOT available:

DESCRIPTION	LOOP	SEGMENT	ELEMENTS
Referring Provider Name	2310A	NM1	01 – Entity identifier code 02 – Entity type qualifier 03 – Last name or org. name
Referring Provider Secondary ID	2310A	REF	01 – ID qualifier 02 – ID

 

 

 

Ordering Provider

Purpose: Identifies the provider who ordered the service.

DESCRIPTION	LOOP	SEGMENT	ELEMENTS
Ordering Provider Name & Primary ID	2420E	NM1	01 – Entity identifier code 02 – Entity type qualifier 03 – Last name or org. name 08 – ID code qualifier 09 – ID (NPI)

 

If the ordering NPI is NOT available:

DESCRIPTION	LOOP	SEGMENT	ELEMENTS
Ordering Provider Name	2420E	NM1	01 – Entity identifier code 02 – Entity type qualifier 03 – Last name or org. name
Ordering Provider Secondary ID	2420E	REF	01 – ID qualifier 02 – ID

 

Special Instructions for Providers

When sending Referring/Ordering Provider Information, submitters should always send the individual’s referring/ordering name and NPI. The billing provider may need to get this information from the referring/ordering provider. If the referring/ordering NPI is not freely provided, the billing provider can find it by searching on the NPPES NPI Registry.

If the referring/ordering provider does not have an NPI, the billing provider will need to send the name in the Referring Provider Name Loop and send the referring/ordering UPIN, State License, or Provider Commercial number in the Referring Provider Secondary Identification Loop.

 

Back to the top of Appendix A

 

 

Use Case 3

PROFESSONAL CLAIM - ORGANIZATION AS THE BILLING ENTITY SENDING WITH A RENDERING PROVIDER

Claims for medical services may be required to include the name and NPI of the rendering provider (the provider who performed the service) when the rendering provider is different from the billing entity.

Billing Provider

Purpose: Identifies the payee (organization).

DESCRIPTION	LOOP	SEGMENT	ELEMENTS
Billing Provider Name & Primary ID	2010AA	NM1	01 – Entity identifier code 02 – Entity type qualifier 03 – Last name or org. name 08 – ID code qualifier 09 – ID (NPI)
Billing Provider Street Address	2010AA	N3	01 – Address information
Billing Provider City/State/ZIP	2010AA	N4	01 – City name 02 – State code 03 – Postal Code
Billing Provider Tax Identification	2010AA	REF	01 – ID qualifier 02 – ID (Tax ID)

 

Rendering (Servicing) Provider

Purpose: Identifies the individual who provided the service.

DESCRIPTION	LOOP	SEGMENT	ELEMENTS
Rendering Provider Name & Primary ID	2310A	NM1	01 – Entity identifier code 02 – Entity type qualifier 03 – Last name or org. name 08 – ID code qualifier 09 – ID (NPI)

 

Special Instructions for Providers

Not all payers use or require Provider Specialty information (Taxonomy Code). Contact your payer for detailed instructions.

 

Back to the top of Appendix A

 

 

 

Use Case 4

PROFESSIONAL CLAIM - NON-MEDICAL PROVIDER SUBMITTING AS AN ATYPICAL PROVIDER

Non-medical providers who are unable to obtain an NPI are considered “Atypical” providers, and in some cases may send claims to medical insurers.

Billing Provider

Purpose: Identifies the payee (non-medical provider).

DESCRIPTION	LOOP	SEGMENT	ELEMENTS
Billing Provider Name & Primary ID	2010AA	NM1	01 – Entity identifier code 02 – Entity type qualifier 03 – Last name or org. name 08 – ID code qualifier 09 – ID (NPI)
Billing Provider Street Address	2010AA	N3	01 – Address information
Billing Provider City/State/ZIP	2010AA	N4	01 – City name 02 – State code 03 – Postal Code
Billing Provider Tax Identification	2010AA	REF	01 – ID qualifier 02 – ID (Tax ID)
Billing Provider Secondary ID	2010BB	REF	01 – ID qualifier 02 – ID (assigned by payer)

 

Special Instructions for Providers

Not all payers use or require Provider Specialty information (Taxonomy Code). Contact your payer for detailed instructions.

 

Back to the top of Appendix A

 

 

Use Case 5

INSTITUTIONAL CLAIM - HOSPITAL WITH SUBPART

When a subpart of a hospital is identified separately from the main organization, the NPI must be representative of the subpart.[1]

Billing Provider

Purpose: Identifies the payee (hospital) and the subpart.

DESCRIPTION	LOOP	SEGMENT	ELEMENTS
Subpart Name & Primary ID	2010AA	NM1	01 – Entity identifier code 02 – Entity type qualifier 03 – Last name or org. name 08 – ID code qualifier 09 – ID (NPI)
Billing Provider Street Address	2010AA	N3	01 – Address information
Billing Provider City/State/ZIP	2010AA	N4	01 – City name 02 – State code 03 – Postal Code
Billing Provider Tax Identification	2010AA	REF	01 – ID qualifier 02 – ID (Tax ID)

 

Subpart Information

Purpose: Identifies additional details for the subpart of the hospital.

DESCRIPTION	LOOP	SEGMENT	ELEMENTS
Attending Provider Name & Primary ID	2310A	NM1	01 – Entity identifier code 02 – Entity type qualifier 03 – Last name or org. name 08 – ID code qualifier 09 – ID (NPI)
Attending Provider Specialty	2310A	PRV	01 – Provider code 02 – ID qualifier 03 – ID (taxonomy code)
Service Facility Location	2310E	NM1	01 – Entity identifier code 02 – Entity type qualifier 03 – Last name or org. name
Service Facility Location Street Address	2310E	N3	01 – Address information
Service Facility Location City/State/ZIP	2310E	N4	01 – City name 02 – State code 03 – Postal Code

 

Special Instructions for Providers

Not all payers use or require Provider Specialty information (Taxonomy Code). Contact your payer for detailed instructions.

Back to the top of Appendix A

 

[1] Refer to the 5010 837 Institutional Implementation Guide (TR3) for additional information.

 

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