NPI and Billing

What is an NPI?
Let's first discover what exactly an NPI is, then explore the details.  NPI is simply an acronym that stands for National Provider Identifier number.  An NPI is a 10 digit number assigned by the Centers for Medicare and Medicaid (CMS) to health care providers, organizations and group practices.  Prior to the use of the National Provider Identifier (NPI) number, health care providers used a Unique Physician Identifier Number, commonly called the (UPIN).  This number was also supplied by the Centers for Medicare and Medicaid Services (CMS).  Unlike the NPI, the UPIN is a six digit alpha numeric Unique Physician Identifier Number (UPIN) that was created specifically for health care providers accepting Medicare insurance.  In an effort to establish national standards for electronic health care transactions and national identifiers for providers, health plans, and employers the Health Insurance Portability and Accountability Act (HIPAA) of 1996 was enacted.  As part of the mandated Administrative Simplification provision, the Unique Physician Identifier Number (UPIN) was transitioned to the National Provider Identifier (NPI) number effective May 23, 2007.   However, the UPIN has not been completely phased out.  By May 23, 2008the Centers for Medicare and Medicaid Services (CMS) began imposing a penalty to all health care providers, organizations, and group practices that were not in compliance using the new mandated NPI set forth by the Administrative Simplification provision found in the Health Insurance Portability and Accountability Act (HIPAA) of 1996.

Where do you get an NPI or information about an NPI?
An NPI can be obtained by application through the National Plan and Provider Enumeration System (NPPES)  Once an NPI is assigned it becomes permanent and will remain with the provider regardless of job or change of practice location.

Is there a difference between an individual NPI and a group NPI?
Yes.  There is a difference between an individual and group NPI.  Each health care provider is required to obtain an NPI, and if the provider is associated with a health care group, then that health care group should have an NPI.  A health care provider is described as any entity that provides health care services, whether they are an individual, group practice, or facility. Every group practice organization or facility will have its own NPI, whether it has one or one hundred physicians associated with it.  Each of those practicing physicians associated with the group will also have their own individual NPI.  This is because all parties involved are considered health care providers.   If you participate in an individual or group practice organization, your individual NPI number will be referenced as the individual rendering provider on claims, and the individual or group practice NPI will be referenced as the billing provider on the claim.

When is NPI required?
The NPI is required on all claims whether they are submitted electronically or by paper.  It is also required when requesting medical referral and prior authorization of services or procedures, as well as patient policy, eligibility, and claims inquiries from HIPAA compliant insurers.

How important is an NPI and is it necessary for billing?
The NPI number is extremely important for billing and receiving payment from the payers. All HIPAA covered health providers, organizations, and group practices are required to have an NPI in order to complete billing transactions, even if a billing service prepares the claim(s) for submission.

Is the NPI number confidential?  Who should you give your NPI number to?
No.  But it is proprietary information and should only be shared with other providers with whom you do business, and with health plans that request the NPIs.  All health care providers who conduct standard transactions as adopted under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) are covered health care providers. These providers must share their NPIs with other providers, health plans, clearinghouses, and any entity that may need those NPIs for use in standard transactions.  Providers should also consider letting health plans or institutions for which they work, share their NPIs for them.
CMS strongly encourages providers to share their NPIs with other health care providers to whom they refer patients; pharmacies that fill their prescriptions; health plans in which they are enrolled and to whom they submit claims; and organizations where they have staff privileges.
How do I find an individual provider or organization NPI?  Is there a special website that contains a list of NPI numbers?
You can search for a provider or organizational NPI through the online NPI Registry using the link provided. 
https://nppes.cms.hhs.gov/NPPES/NPIRegistryHome.do 
Upon entering the NPI registry website, to search for an individual provider select the Individual Provider link in blue on the web page.
This will bring you to a search screen where you can search for a provider using various demographics.  The registry also accepts a wild card search in the provider first name, last name and city address fields.  To use this feature, simply select the first few alpha characters and add an asterisk.  You can also add an asterisk at the beginning and end.  For instance, if you typed “*sm*” as your first name search criteria, the system would find any providers who have a first name which contains the letters “sm” in the midst of it.   If you're searching for an organizational NPI, then you'll want to select the Organizational Provider link.  The searchable fields on this screen are NPI, Organization Name, Doing Business As, City, State, and Zip.
Alternatively, you could use the straightforward method and go right to the source and call the referring provider directly so they can provide you with the NPI after you have adequately identified yourself as a rendering provider.

Which NPIs are needed to submit a claim?
There are potentially four types of NPI numbers that could be included on an electronic or paper claim form CMS-1500.  Let’s examine each of those four in greater detail using the paper claim as an example.
1. Referring physician's NPI number
Box17b:

Health care specialists receive their patient base from referring physicians, therefore the referring provider or other source field box17bmust be completed with the referring physician's NPI number.

2. Rendering Provider NPI number
Box24J:   

The rendering provider NPI number must be present in this field.

3. Service Facility Location NPI
Box32a:  

Box32ais reserved for the Service Facility Location NPI.  This is the Service Facilities NPI.  Whether you render services at an outpatient hospital, a freestanding radiation oncology center, skilled nursing home, or ambulatory surgery center, you will include the NPI for the service facility location in box32a.

4. Billing Provider NPI
Box33a:

The billing provider refers to the practice or organization the provider belongs to. If the rendering provider is part of a group practice organization, then use the group practice organization NPI in box33a. If the rendering provider is not part of a group practice organization use the physician’s individual NPI.

It is good practice to check with your local carrier for claim completion specific guidelines required in your area.
A list of examples is provided to be used as reference.  The graphic below can be used as a guide for the examples.

    

Example 1
In this example, Dr. Green is a single physician who is working in an outpatient hospital setting.  He is only billing the Professional Component. 
Referring Provider NPI
Here, the NPI of the referring provider is used.
Rendering Provider Individual NPI
Dr. Green will use his personal NPI in this box since he is the rendering provider.
Service Facility NPI
Because Dr. Green is rendering the services in the outpatient center, the NPI of this hospital facility is used here.
Billing Provider NPI
Dr. Green is not a member of a group practice and has not registered his own.  So he will use his own individual NPI here.
Example 2
Dr. Green has decided to leave the outpatient facility and join an existing practice called, “We Fix You Medicine”.  We Fix You Medicine has 15 different physicians working for it and it operates in a freestanding center. 
Referring Provider NPI
Dr. Green continues to use the NPI of the referring provider here.
Rendering Provider Individual NPI
Dr. Green will continue to use his personal NPI in this box since he is the rendering provider.
Service Facility NPI
Because Dr. Green is rendering the services in the freestanding center, he will use the NPI of the free standing center which is the same NPI as the organizational NPI for We Fix You Medicine.
Billing Provider NPI
Since Dr. Green is now working for We Fix You Medicine, he will use the NPI of We Fix You Medicine as the billing provider.  We Fix You Medicine has it’s own tax id and thus it’s own NPI number.

Example 3
Dr. Green is fed up with working at We Fix You Medicine.  He doesn’t like how the business is being run.  So Dr. Green has decided to go out on his own and open his own single physician practice.  Coincidentally, Dr. Green’s son just got accepted to medical school.  So, he calls his practice Green Family Medicine. 
Referring Provider NPI
Dr. Green continues to use the NPI of the referring provider here.
Rendering Provider Individual NPI
Dr. Green will continue to use his personal NPI in this box since he is the rendering provider.
Service Facility NPI
Because Dr. Green is registering his business as a sole proprietorship he will be using his own tax id as the group’s tax id.  Thus, he will not have to obtain a separate NPI for his organization.  Therefore, Dr. Green uses his own personal NPI as the service facility NPI.
Billing Provider NPI
Because Dr. Green is registering his business as a sole proprietorship he will be using his own tax id as the group’s tax id.  Thus, he will not have to obtain a separate NPI for his organization.  Therefore, Dr. Green uses his own personal NPI as the Billing Provider NPI.

Example 4
Dr. Green’s son finally graduated from medical school and completed his residency.  Fortunately, his son also met his new wife there who also just completed her residency.  Both his son and his son’s wife have decided to join the Green Family Medicine practice.  They opened up a new and larger facility that will house all of them and have room to expand.
Referring Provider NPI
Dr. Green continues to use the NPI of the referring provider here.
Rendering Provider Individual NPI
Dr. Green will continue to use his personal NPI in this box since he is the rendering provider.
Service Facility NPI
Because Dr. Green now has a multi-physician practice, he finally registered his practice as a corporation and obtained a separate tax id for his business.  Consequentially, he also had to obtain a separate NPI for his organization.  That NPI is also affiliated with his new facility, which is owned by the business and therefore used when submitting the Service Facility NPI.
Billing Provider NPI
Because Dr. Green now has a multi-physician practice, he finally registered his practice as a corporation and obtained a separate tax id for his business.  Consequentially, he also had to obtain a separate NPI for his organization.  That NPI is now used as the Billing Provider NPI.

Example 5
As it turns out, Dr. Green’s son and particularly his son’s wife are brilliant physicians and consequentially have helped make the business and Dr. Green himself extremely wealthy.  Dr. Green is getting older now, but he still loves to practice medicine.  So he has decided to do something to make himself feel good.  He decided to work part time at a rural clinic that is in dire need of help.  Technically, he will still be working for Green Family Medicine, he just isn’t physically working in the office.  The clinic is owned by a charity group which waives all technical charges.  The clinic also has a special agreement with any doctors who work there, in which the doctors commit to billing the patients’ professional charges at a specially reduced rate. 
Referring Provider NPI
Dr. Green continues to use the NPI of the referring provider here if there is one.
Rendering Provider Individual NPI
Dr. Green will continue to use his personal NPI in this box since he is the rendering provider.
Service Facility NPI
Because Dr. Green is rendering services at the rural clinic he must use the rural clinic’s NPI as the Service Facility NPI.
Billing Provider NPI
Dr. Green may only be billing for professional services now and at a very reduced rate, but he is still billing.  The billing is still performed through Green Family Medicine and therefore he continues to use the Green Family Medicine practice NPI as the Billing Provider NPI.
In all of the examples below, it is important to note that the practice relationship and how you intend to bill will drive the use of the appropriate NPI.

What should I do if I change practice locations or have become part of multiple practice locations?
If you should change practice locations or become a part of an additional practice location, you must notify the NPPES of the address addition and/or change within 30 days of the effective date of the change. If notification of this change has not been made, you will experience claim submission errors and denials.  Provider NPI information must match insurer enrollment information, in order for claims to process cleanly.
To submit a change to NPPES via the internet or by paper, select the link provided.
https://nppes.cms.hhs.gov/NPPES/StaticForward.do?forward=static.npistart
If you prefer to submit a change by paper, download the NPIApplication/Update Form (CMS-10114), complete the application/update form, sign it, and mail it in to the address found at the bottom of page 3.  This form can also be obtained from the Centers for Medicare & Medicaid Services' forms page at www.cms.hhs.gov/cmsforms or you can call the NPIEnumerator at 1-800-465-3203 and request a form.

What if my individual NPI number is assigned to an outpatient hospital, but now, I wish to deactivate that assignment to begin billing under my individual or practice NPI number?
Sometimes rendering providers will allow an outpatient hospital to assign their individual NPI number to the outpatient hospital as a rendering provider who is part of that group.  In turn the outpatient hospital will assume billing the technical and professional component, and the rendering provider is paid a salary by the outpatient hospital.  If you find that you are a part of this type of group, but are planning to make a change where you will assume billing the professional component, then you will need to request that the outpatient hospital group contact the NPPES to deactivate your NPI number as part of that group.  The outpatient hospital administration will need to complete the update/change form just as any other provider would, either by paper or online. Make sure that you request confirmation of this update/change with an effective date for your records.  It is imperative that you update your information with the NPPES as soon as possible.  Therefore, you will need to complete an enrollment form with the NPPES.  This scenario can get complicated and may require contacting the NPPES directly by phone to ensure that proper procedures are followed.  Begin this process immediately to prevent your claims payments from inadvertently being sent to the outpatient hospital.  You could find it difficult to get insurer payment from the outpatient hospital once payments had been received by them.

If I wish to enroll as a contracted rendering provider with an insurer, will I be required to provide an NPI number?
Yes.  As a matter of fact, if you do not have an individual NPI number or organizational NPI number if applicable, you will not be able to enroll with an insurer as a contracting rendering provider.  Obtaining an individual, as well as, organizational NPI is one of the first few steps you should take as part of the credentialing process.  Request an NPI number after you have obtained a Tax ID number for your organization.  If you will be using your social security number in lieu of a Tax ID number, then you will not need to wait to apply for an individual NPI number.  If you are enrolling a practice and the associated rendering providers in the practice, it's very important to be sure to ask the insurer to link the rendering provider NPI numbers to the organizational practice NPI number.  Doing so will allow a smooth claim processing transaction for the insurer and alleviate any enrollment headaches down the road.

Understanding an EOB and Your Bill

An Explanation of Benefits (EOB) is the document that health insurance companies send to communicate their decisions to members regarding payment for services. Every insurance company EOB is different, and many of them are difficult to understand. An EOB is not a bill, but it usually will have enough information for the member to review what the physician will eventually be billing them. Unfortunately, EOB’s are not standardized and can be very confusing to decipher, but it is usually a matter of semantics. Understanding health insurance language is very helpful in reading the communications between your doctor, your insurance company, and yourself.
In the health insurance world, the doctor or hospital is known as the “provider” because they provide services to you, the “member.” Insurance companies group multitudes of people with identical insurance plans into a “group.” The insurance “benefits” are the services that are payable according to the plan you are signed up with. For instance, some plans have maternity benefits, and others do not.
There are many different versions of an EOB.  While the information displayed is usually identical, each payer has the option to convey the information in their own format.  The most common format style used is the Standard Paper Remittance format.  This format is most commonly used by Medicare.  An example of that format is displayed below.

This document is cryptic looking and intimidating on first glance.  Be assured that it isn't as complicated as it looks.  To make things clearer we are going to examine the most important pieces of the EOB.  Let's take a closer look now at each section.

  

The header of the document contains three items of note.  On the top left is the name, address and phone number of the insurance company that the EOB is being sent from.  Directly below this is the  name and contact information of the provider where medical services were rendered.  On the right hand side,
the date and check number are displayed.  This information provides important tracking data.
After the header there are one or more sections of very detailed data.  An example of one of these sections is displayed below.

  

Each one of these sections represents a claim.  A claim is made of one or more charges which are usually from a similar date range and which represent treatment for one or a few similar medical diagnosis. Depending on the type of medical treatment you are undergoing, the billing for that medical condition might be comprised of many claims over a period of time. When an EOB is sent to a patient it usually only contains a single claim such as in our example.  The claim identifies the member, the individual charges and how or if the insurance company paid each charge.  Let’s examine the claim in detail.

  

At the top of the claim the patient or member is identified.  The patient name is displayed here.  There are several numbers appearing on the EOB which all pertain to the provider and insurance company identification and references.  The “HIC” number is the member’s personal identification number that the insurance company uses to identify them. The “ACCT” number is a blend of the patient’s account number from the physician’s records and an assigned number from the insurance company.  The internal control number or “ICN” is the number assigned by the insurance company that identifies the claim. The ICN will be asked for anytime you communicate with your insurance company about a processed claim.  “ASG” shows a Y or N, indicating whether or not the provider accepted the assignment of the claim, which includes allowed amounts and acceptance of their decisions and any payments. The Medicare outpatient adjudication remarks codes under “MOA” refers to a list that summarizes the decisions made for that particular service.  Details about these codes are available at the bottom of the EOB in the glossary.
The most important data for a patient to understand on an EOB is pertaining to the services rendered. The headers for each are at the top of the claim.  Both the header and the data have been labeled in these examples.

  

The “service date” or a range of dates is when the provider claims you received services. In some instances, such as a treatment that requires a great deal of planning, the patient may not necessarily have been present during the rendering of the service, such as in radiation therapy planning. The “POS” or place of service is the code showing where you received services.  For example, this EOB indicates the service was provided in an office/outpatient setting, represented by an ‘11’. The term “NOS” is the quantity of times you received each service.  This is usually one, but there are times when a procedure is repeated during the same visit.  When this occurs, it is billed for the number of times it was rendered. Also, keep in mind that often a service can actually refer to a range of similar treatments.  When you visit the doctor, you may receive many different services, such as an office visit and lab work. Each different service is identified by a code and represented by an individual line in the EOB.  These codes are referred to as procedure codes and identified in the “PROC” column.  These codes are standardized and designed by the American Medical Association.  They are used by all physicians to describe the services you received. These numbers have very specific definitions such as “office visit – 30 min. or less” or “Set radiation therapy field.” There may be a modifier labeled as “MODS” .  Modifiers are used to describe an additional detail about how the service was performed or how it is being billed.  “BILLED” is the doctor’s charge to the insurance company.
If you have received services from a ‘preferred’ or ‘in-network’ provider, that means the doctor has a contract with your insurance company to accept the amount the insurance company is willing to pay for services. The amount the company is willing to pay is known as the “allowed amount”.
  In this example, the preferred provider who bills $431.00 for a complex office visit is allowed only $193.15 as a payable amount, and therefore would “write off” the remaining $237.85. This is one of the most complicated issues in medical billing.  In order to understand it, you need to realize that the provider almost always bills more than is expected to be paid.  So, even though $431.00 was billed, the provider is technically only able to bill $193.15.  The difference is written off and neither the insurance company nor the patient is expected to be responsible for this amount.  The provider must adjust it off.  The write off/adjustment process must take place every time the provider sends a bill out.  Patient responsibility such as deductibles and co-insurance are calculated from the allowed amount, not the original charge amount.  Often, invoices are sent directly to the patient before this process takes place.  When the patient receives the original bill before the write off process, the cost can seem overwhelming.  That is why it is important that the patient understands the EOB and waits for the write-off process to occur before paying the bill.
Once the allowed amount is determined, the insurance company applies the insurance policy’s patient responsibilities. Many insurance plans have a “deductible,” or a set amount that the patient is responsible for each year. If your plan has a $200 deductible, then starting January 1^st each year, your responsibility of $200 begins again and the insurance company will not pay anything to your physician until you have paid the $200. However, as noted above, the provider’s charges still must be adjusted down based on the policy’s allowed amount.  The allowed amount is the only amount the patient can be responsible for.   “Coinsurance” is a percentage of the allowed amount. This can be a confusing aspect of a patient’s benefits because the insurance company may have different coinsurance percentages on different types of services. For example, laboratory coinsurance can be 20% while an office visit is only 10%. Because of the allowed amounts, the insurance company has to process the physician “claim” or charges before patients will know the actual amounts they are responsible for.  Again, it is easy to be deceived by an initial bill received from a provider which was sent before the write-off or adjustment process took place.
When you see “Disallow” or “RC-AMT” on an EOB, this is the portion of the billed charge that the insurance company will not pay.  This is inclusive of the write-off amount based on the allowed amount .  This can simply be the write-off as per the contract between the insurance company and the physician, or it can be a full denial of the services being billed. Either way, there will be a “denial code” somewhere on that line being billed. The write off or denial code will be short, such as in this case, CO-45 .  This code stands for Contractual Obligations, meaning that this amount was written off, or adjusted based on the contract agreement with the provider.
The next item of interest is the “PROV PD” or more succinctly, the amount the insurance company paid.  In this case, the insurance company paid $154.52.  Remember this is based on the allowed amount of $193.15.  That implies that only $38.63 is outstanding.  Notice that the amount $38.63 is referenced next to the title “PT RESP” .  This stands for Patient Responsibility or the amount that the patient must pay the provider.  If you have secondary insurance, make sure you have given all of your information to your physician, because the next bill to go out will be to that insurance company. Generally, a secondary insurance company will only pay the amount the patient is responsible for. An EOB from a secondary insurance company will show if the patient has any responsibility to the physician.
This summarizes the most important aspects of the claim section of the EOB.  The rest of the data fields shown represent the totals of the claim. There are also some fields that allow for when unusual circumstances occur such as interest payments.  There is one more important area on the EOB. The “GLOSSARY” reference at the bottom of the EOB will give a short explanation of each code referenced in the EOB.

  

After the primary insurance and secondary insurance have processed the claims, finally, the physician will send a bill for any leftover patient responsibility to the patient. Some offices collect co-pays at the time of the visit because that amount is always due and can be counted upon as correct. Always read the communications from your insurance company and compare the dates, billed amounts, and patient responsibility amounts to your physician’s invoice.
Again, a patient who has insurance needs to make sure they wait until their insurer has processed the charges before they pay their portion. Patients may receive the initial unprocessed charges that show the provider has billed the insurance, and it may appear that the patient owes the amount being billed. It is important to understand that the provider is charging more than they expect to be paid, and the insurance company will likely reduce that amount again before applying patient responsibility.
Wait for an EOB from your insurance company before paying for services that appear on your physician’s invoice. If you have more than one insurance company, wait for all EOB’s showing each determination. Remember, the “billed amount” minus the “adjustment” or write-off equals “allowed amount.” Patient responsibilities are based on this “allowed amount” and subtracted from it before the physician gets a payment. The physician will bill the amount marked “Patient Responsibility” on the EOB.  All this information should be conveyed in the patient bill.  Let’s look how this would appear based on the example EOB above.

  

Here, you can see how it all breaks down.  In this example, the initial billed amount is $431.00.  Next, $237.85 represents primary payer’s (MEDICARE), disallowed amount, which was adjusted off the account by the provider.  The primary payer also made a payment of $154.52.  This corresponds exactly to the original EOB we looked at above.  Next, it is shown that the secondary payer also made a payment of $28.63.  Finally, that all adds up to a remaining patient responsibility   of $10.00.  This is the amount billed to the patient.
In some cases, physicians will set up a payment plan with their patients in the case of ongoing therapies or lengthy illness. The monthly bill should reflect this agreed upon amount due in a ‘Minimum Amount Due’ category, even if the total balance is larger. This is shown in the example below.  You can see that while the current account balance  is very large, the minimum payment required reflects the fact this patient is on a $100.00 a month payment plan.

  

If you ever have questions or suspect any errors in your patient bill, don’t hesitate to ask for assistance.   As you can tell, this is a complex process and miscommunication is common.  Consider calling both your insurance company and physician to verify that the explanations are in sync.  Always take notes, and if possible, retrieve a case number for these calls in case you need to dispute a bill. Communication with all parties is important for your understanding, and if you find a mistake, it is always correctible.