When, If Ever, Do You Get a New NPI Number and Other NPI Questions
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What is a NPI again?
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 and all health plans and health care clearinghouses must use the NPIs in the administrative and financial transactions adopted under HIPAA. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number). This means that the numbers do not carry other information about healthcare providers, such as the state in which they live or their medical specialty. The NPI must be used in lieu of legacy provider identifiers in the HIPAA standards transactions.
As outlined in the Federal Regulation, The Health Insurance Portability and Accountability Act of 1996 (HIPAA), covered providers must also share their NPI with other providers, health plans, clearinghouses, and any entity that may need it for billing purposes.
When should you get a new NPI?
The National Provider Identifier (NPI) is meant to be a lasting identifier, and is expected to remain unchanged even if a health care provider changes his or her name, address, provider taxonomy, or other information that was furnished as part of the original NPI application process. There are some situations, however, in which an NPI may change such as when health care provider organizations determine they may need a new NPI due to, for example, certain changes of ownership, the conditions of a purchase, or a new owner’s subpart strategies. There also may be situations where a new NPI is necessary because the current NPI was used for fraudulent purposes.
A health care provider (or the trustee/legal representative of a health care provider) should deactivate its NPI in certain situations, such as retirement or death of an individual, disbandment of an organization, or fraudulent use of the NPI. To deactivate an NPI, a health care provider (or the trustee/legal representative of a health care provider) must complete a CMS-10114 and mail it to the NPI Enumerator.
Does the NPI replace the tax ID number?
The billing provider’s tax ID number and NPI are always required on claims. Any other providers identified on the claim, such as rendering provider or service facility, must be identified with their NPI only. Their tax ID number should not be included.
For eligibility, claim status inquiry, referral and precertification, only the NPI (no tax ID number) is used.
How does a rendering physician report their National Provider Identifier (NPI) on a claim that includes Physician Quality Reporting Initiative (PQRI) or Electronic Prescribing Incentive Program (eRx) quality-data codes (QDCs)? What if he/she is part of a group and the group NPI is used on the claim?
Your individual National Provider Identifier (NPI) must be included on the claim line items for the quality-data codes (QDCs) you submit as well as the line items for the services to which the QDC is applicable. The PQRI/eRx QDC must be included on the same claim that is submitted for payment at the time the claim is initially submitted in order to be included in PQRI analysis.
If a group NPI is used at the claim level, the individual rendering physician’s NPI must be placed on each line item, including all allowed-charge and quality-data line items. See the PQRI Implementation Guide for a sample CMS-1500 claim. This is available as a download from the Measures/Codes section of the CMS PQRI website. For eRx, see the Claims-Based Reporting Principles for eRx, available on the CMS eRx website.
If a health care provider with a National Provider Identifier (NPI) moves to a new location, must the health care provider notify the National Plan and Provider Enumeration System (NPPES) of its new address?
Yes. A covered health care provider must notify the NPPES of the address change within 30 days of the effective date of the change. We encourage health care providers who have been assigned NPIs, but who are not covered entities, to do the same. A health care provider may submit the change to NPPES via the web or by paper. If paper is preferred, the health care provider may download the NPI Application/Update Form (CMS-10114) from the Centers for Medicare & Medicaid Services’ forms page or may call the NPI Enumerator (1-800-465-3203) and request a form.
What happens when you join a group?
In Section 4B of the CMS-855I, the NPI of the Group should be entered if it has been issued to the Group. If you are joining a group, the group is responsible for providing you with their current Provider Identification Number (PIN) and the NPI, if they have been issued.
If you are a solo physician with an incorporated practice, how many NPIs should you have?
An individual is eligible for only one NPI. In the above example, there are two health care providers: the physician and the corporation. The physician would obtain an NPI (Entity Type Code 1, Individual). The corporation would obtain an NPI (Entity Type Code 2, Organization). Generally, the corporation’s NPI would represent the Billing and Pay-to Providers and the physician’s NPI would represent the Rendering, Referring/Ordering, Attending, Operating and/or Other Providers. These physicians should ensure that their enrollment records with the health plans to whom they will be sending claims are up to date, that those health plans are aware of the assigned NPIs, and that the NPIs are used in a way that is compatible with their enrollment.
I do not submit healthcare claims to Medicare; do I need a National Provider Identifier (NPI)?
Where can you look up NPIs?
Posted in: Medicare & Reimbursement
Leave a Comment (51) ↓
I am one of two providers in a small practice. We currently have a total of three NPI numbers (each provider and the practice).
For tax and accounting reasons, we have been advised to change our corporate structure in a manner that will require a new Federal Tax ID (closing down the old practice entity and creating a new practice entity).
It appears the two providers will not need a new NPI (and should not apply for one), but rather, update their exisitng NPI information via the web to show the new Federal Tax ID when it is in place.
It further appears that the NPI of the previous practice will be terminated and a new NPI should be sought for the new legal entity.
Does this sound correct?
Hi William,
Yes, this sounds perfectly correct! Good advice.
Best wishes,
Mary Pat
Currently have 5 locations all owed by same provider. Other providers work for him. We have NPI’s for each location and each provider. Do now have one for the group. Currently bill from a different address from any of the above. Do I need an NPI for the Billing address and one for the Group?
Hi Linda,
You do not need one for the group based on this information from CMS:
What types of business structures are considered organization health care providers and thus eligible for organization NPIs? What types are not?
The NPI final rule defines “organization health care providers” as providers who are not individuals (persons). These are classified as Entity Type 2 providers. Examples are hospitals, home health agencies, clinics, nursing homes, residential treatment centers, laboratories, ambulance companies, group practices, health maintenance organizations, suppliers of durable medical equipment or pharmacies, among others.
A sole proprietorship is a form of business in which one person owns all of the assets of the business and is solely liable for all debts on an individual basis. Sole proprietors are individuals, and they must apply for their NPIs as Individuals (Entity Type I). The subpart concept does not apply to a sole proprietorship, even one with multiple locations, because the sole proprietorship is not an organization as defined in the Final NPI Rule (69FR3434).
State laws enable the creation of many other different types of businesses. While we cannot address every possible type of business structure, we apply the following broad principle to determine whether a business is eligible for an organization NPI: Any organization that is recognized by the State as separate and distinct from the individual is eligible for an organization NPI. The law in each State will govern how different business types are recognized by the State.
Your billing address does not need an NPI.
Best wishes,
Mary Pat
I am a psychologist who just formed a PLLC, where I am the only practitioner. Prior to that, I was just a sole practitioner. I have obtained a new tax ID number for the PLLC and was planning on just using my existing NPI. Since I am the only practitioner (member) of the PLLC, I don’t think I need a new NPI for the PLLC. Is that correct?
Hi Josh,
You are absolutely correct! Organizational NPIs are not needed for solo owners.
Best wishes,
Mary Pat
We are billing for a solo incorporated provider that travels to two rural communities once a month. He recently acquired an additional tax id for the rural areas for billing purposes.
He already has an organizational NPI for his non-rural tax id. For this additional rural tax id, he has formed a new corporation but is still a solo inc provider. Based on what I am reading, we do not need an additional organizational NPI for the rural tax id as he is a solo inc provider. However, because he already has an NPI with his non-rural tax id corp, do I need to acquire a new organizational NPI with his rural corp to be consistent?
Thanks!
Hi Margi,
I don’t see any reason for you to get an additional NPI. It only complicates things unnecessarily.
Best wishes,
Mary Pat
I have the same question as Josh above. The Q&A from CMS below seems to contradict your guidance. What do you think? Thanks.
Does an incorporated individual (e.g., a physician who has formed a corporation) whose corporation employs only one person (i.e., the physician who formed the corporation) need to apply for two National Provider Identifiers (NPIs)?
An individual is eligible for only one NPI. In the above example, there are two health care providers: the physician and the corporation. The physician would obtain an NPI (Entity Type Code 1, Individual). The corporation would obtain an NPI (Entity Type Code 2, Organization). Generally, the corporation’s NPI would represent the Billing and Pay-to Providers and the physician’s NPI would represent the Rendering, Referring/Ordering, Attending, Operating and/or Other Providers. These physicians should ensure that their enrollment records with the health plans to whom they will be sending claims are up to date, that those health plans are aware of the assigned NPIs, and that the NPIs are used in a way that is compatible with their enrollment.
Hi Cornelia,
You are right! The Q & A now states that two NPIs are appropriate. Why they changed this language is unclear, but they definitely have changed the language. I’m not clear on their statement that the corporation’s NPI would represent the Billing and Pay-to Providers – why would a solo provider needs a separate number to delineate which entity is billing and should be paid? Unless they’ve decided that as a corporate entity, payers should not be paying his individual NPI and thereby by his social security number instead of his EIN.
Maybe there is a CPA who can clarify – anyone?
Thanks for bringing this up, Cornelia!
Best wishes,
Mary Pat
Hello,
my doctor currently has 2 npi one for the practice and one for him. He just advised that he is moving, changing the practice name, and has a new NPI. Called NPPES and was told that i would still have the same npi number.
When I called and spoke to WPS Medicare to update my info they advised me that I needed to obtain NEW NPI numbers and that i could not use my old ones. That I would need to have the doctor reapply/enroll. why would I have to do this.
Thank you
chris
Hi Chris,
There seems to be a lot of confusion surrounding NPI numbers – you are not the first one who has gotten conflicting information!
There is a much heavier focus on fraud, and NPI numbers are the root of billing Medicare.
Sorry I don’t have an explanation for you.
Best wishes,
Mary Pat
I am a PA changing jobs and taking a new position in a neighboring state. Does my NPI follow me or does it change?
Hi,
Your NPI does go with you. You need to update your NPI with your new information, then update your Medicare information (if you have a Medicare number) in PECOS.
Good luck in your new position!
Mary Pat
I am a prosthetic and orthotic boutique and am opening a second location. Do I need a new NPI number before I fill out the CMS-855S form for Medicare? Thank you
Hi Nancy,
As long as you are operating under a single tax ID number, you will not need a second NPI.
Best wishes,
Mary Pat
Hi Mary,
I am an employee of an organization that bills medicaid and medicare. As an unlicensed individual and employee, is it required that I have an NPI?
Hi Leilani,
The only people who need to have NPIs are physicians or other providers who provide or order services or goods for Medicare patients.
Best wishes,
Mary Pat
Mary,
I have an individual NPI and I am in a Professional corporation with a partner that has his own NPI. Can I start a new business in addition to my current corporation using my same individual NPI number ? Is that even possible? What if I get a new tax ID for the new business?
Joy M.
Hi Joy,
Yes, you will need to get a new tax ID for your new corporation, and you will have to add your new corporation information to your existing NPI, so payers can see that you work for more than one corporation.
Best wishes,
Mary Pat
Hi Mary,
I work at small rural hospital and we are in the process of a change of ownership from a non-profit foundation (one tax ID) to a newly formed hospital authority (new tax ID). Each business unit under the foundation (hospital, clinic, etc.) has an NPI set up as “foundation dba hospital”, etc. When we become “authority dba hospital” will we need a new NPI? I called the enumerator and was given one answer, put on hold, then given another answer and referred to CMS.
Also, what happens since we have already received an initial payment on the EHR incentive program under the old tax ID/NPI?
Thanks for any insight you can provide!
Connie
Hi Connie,
Thanks to my friend David Zetter of Zetter Healthcare Management Consultants who answered your question – I was sure he would have great advice for you!
MPW
Good Morning Connie-
Mary Pat forwarded your question on to me.
If you have changed your tax ID, then YES, you will need to obtain a new NPI for the new tax ID since Type II NPIs are tied to the tax ID of the entity. The old NPI may be collapsed by contacting the enumerator after the entity feels the NPI is no longer useful. I suggest the NPI be collapsed once all claims have been filed and adjudicated.
As far as the EHR incentive goes – you get paid directly to either a tax ID or social security number. Once you have the new Tax ID in place with the new Type II and reassignments (855Bs) have been completed on the providers, then you may log into each EHR registration/attestation for each provider and link any future reimbursements to the new tax ID. If this is not done, then the reimbursement will be made to the previous tax ID if it is still valid. The old tax ID should be discontinued and communicated to the IRS once the tax returns have been completed for that year and any subsequent business conducted using the old tax ID.
You will want to collapse all the PTANs associated with the old tax ID and you will need to obtain new ones from your local MAC. Do this very carefully. Any errors will definitely have an effect on your reimbursement and cash flow.
I hope this was helpful.
Best regards,
DJZ
David J. Zetter, PHR, CHCC, CHCO, CPC, CPC-H, PCS, FCS, CHBC
Zetter Healthcare Management Consultants
161 Old Schoolhouse Lane, Suite 3 | Mechanicsburg, PA 17055
Tel: 717-691-7100 | Cell: 717-979-5037 | Fax: 717-691-6855
Hi,
I am a chiropractor with an npi that I have had for roughly 10 years. I have since gone back to school and earned my Family Nurse Practitioner credentials and I have been hired by a major retail health clinic.(to work as an FNP, not a chiropractor).
Of course when they tried to get register me for an npi, they saw that I have one already. Is there some distinction that I can make between the two licenses that I now have? Will there be billing problems as an FNP if my npi is also established as a chiropractor?
Thank you,
Mary
Hi Mary,
It is my understanding that the NPI application/form has room for three taxonomies, so you should be able to add your FNP taxonomy in addition to your chiropractor taxonomy.
Best wishes,
Mary Pat
We own as Ambulatory Surgery Center and bill under a group NPI; we also have a subpart NPI for the ASC. We are selling the ASC to a hospital. Does the subpart NPI stay with the ASC when it’s sold to hospital? Does the hospital need to apply for a new NPI for the ASC we are selling them? Is there anything we need to do to “unlink” our connection with the NPI currently associated with the ASC?
Hello Barbara-
Mary Pat forwarded your question on to me.
Type II NPIs which you have for your group entity and the ASC are tied to tax ID numbers. Type I NPIs are tied to social security numbers. If you are selling off the ASC and it has an NPI, the NPI currently tied to it is also tied to your group NPI. Whoever purchases the ASC will need to obtain a new NPI for the ASC since they will not be purchasing the entity, but most likely be purchasing the assets. You should contact NPPES (Fox Systems, the enumerator) to terminate the NPI associated with the ASC, BUT do not do this until all claims have been adjudicated.
You will also want to collapsed any PTANs associated with the ASC through Medicare (via PECOS or paper applications) and contact your state Medicaid program and any commercial payers that you currently are contracted with at the ASC.
I hope this information is helpful.
Best regards,
David J. Zetter, PHR, CHCC, CHCO, CPC, CPC-H, PCS, FCS, CHBC
Website
Tel: 717-691-7100 | Cell: 717-979-5037 | Fax: 717-691-6855
Hi Mary!
There is a confusion on my side what entity is suppose to get NPI number, all entities have to have an NPI or a physician with 100% ownership of a new corporation can use his own NPI for billing? Can a biller apply for a new NPI or the doctor has to do that? If the entity (owned 100% by the Dr.) has been using only the physicians NPI for billing for a longer period, can we still apply for one for the entity?
Please reply!
Thank you in advance!
Hello Melanie-
Mary Pat as forwarded this to me to answer for you.
There are two types of NPIs. Type I which is tied to the provider’s social security number and a Type II which is tied to a Tax ID of an entity. If the provider intends to show revenue through their practice entity (Tax ID) then they should bill for services through a Type II NPI which needs to be obtained on behalf of the entity. Anyone can apply for the NPI on behalf of the provider or the entity as long as they have the permission of the provider or the owner(s). I would suggest obtaining this permission in writing.
If you have been utilizing the physician’s NPI and billing through that and now decide that you want to bill using an NPI for the entity, I would suggest you wait until the beginning of the calendar or fiscal year. It makes no sense to confuse the process. Additionally, in many cases the payers will require you to complete full contracting and/or credentialing to recognize a new payee with Tax ID and the new Type II NPI.
Having a Tax ID and Type II NPI would also be important if the provider/owner wants to employ other providers or bring on other owners. Be very careful, you do not want to disrupt your cash flow by making any mistakes.
Best regards,
DJZ
djzetter@zetter.com
__________________________________________________________________________________________________
David J. Zetter, PHR, CHCC, CHCO, CPC, CPC-H, PCS, FCS, CHBC
161 Old Schoolhouse Lane, Suite 3 | Mechanicsburg, PA 17055
Tel: 717-691-7100 | Cell: 717-979-5037 | Fax: 717-691-6855
Please help! We are a small LLC with my husband being the owner/dentist. We have not had an NPI for the business so far. However, we are hiring a new dentist, just graduating with no NPI, and we will remain an LLC. He will not become a partner just yet. In order for the payment to come to the practice, we will need a group NPI number, correct? And, the rendering dentist section will have the NPI of the new dentist?
Thank you!
Regina
Hello Regina-
Mary Pat forwarded your question on to me to answer.
If you currently do not have an NPI, you should. All healthcare providers were to obtain an NPI quite some time ago, 2005. I would suggest you obtain one sooner than later, for each billing provider in your practice AND the LLC, given that you will be employing another provider/dentist. Ensure the new dentist has an NPI already or obtain one for him.
National Provider Identifier Standard (NPI)
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 and all health plans and health care clearinghouses must use the NPIs in the administrative and financial transactions adopted under HIPAA. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number). This means that the numbers do not carry other information about healthcare providers, such as the state in which they live or their medical specialty. The NPI must be used in lieu of legacy provider identifiers in the HIPAA standards transactions.
As outlined in the Federal Regulation, The Health Insurance Portability and Accountability Act of 1996 (HIPAA), covered providers must also share their NPI with other providers, health plans, clearinghouses, and any entity that may need it for billing purposes.
est regards,
DJZ
djzetter@zetter.com
__________________________________________________________________________________________________
David J. Zetter, PHR, CHCC, CHCO, CPC, CPC-H, PCS, FCS, CHBC
161 Old Schoolhouse Lane, Suite 3 | Mechanicsburg, PA 17055
Tel: 717-691-7100 | Cell: 717-979-5037 | Fax: 717-691-6855
I am currently part of a corporate Hospitalist group with my own individual NPI. I am now venturing into a IC contract with a practice that is ran by nurse practioners. They have a Tax ID but need my NPI number for billing of rendered services. Do I need to apply for a new number so that my current job and the new IC job do not conflict ( keep in mind I do not have any ownership in either group).
Thx
Hello Dr. Panoussi-
Mary Pat forwards these type of questions on to me because of my expertise with Medicare, NPPES and PECOS.
You only need one NPI that is tied to your social security number. The Tax ID that the NPs have for their group has a Type II NPI tied to their Tax ID. They would bill using your NPI as the rendering provider in Box 24J of the 1500 claim form and use their NPI in box 33 as the billing provider. If you are an independent contractor, they will want to get you credentialed with all of their insurance companies that they participate with and then they can bill for your services and they will get reimbursed for them. If you and they participate with Medicare, you will want to complete a reassignment of benefits to their Tax ID/Medicare PTAN so that they can collect for your services, assuming you will be paid by the practice and they take the collections.
I hope this is helpful. If you have further questions, please do not hesitate to contact me.
Best regards,
DJZ
djzetter@zetter.com
__________________________________________________________________________________________________
David J. Zetter, PHR, CHCC, CHCO, CPC, CPC-H, PCS, FCS, CHBC
161 Old Schoolhouse Lane, Suite 3 | Mechanicsburg, PA 17055
Tel: 717-691-7100 | Cell: 717-979-5037 | Fax: 717-691-6855
I am an optometrist with an individual NPI (Type 1). I will be practicing as an independent OD seeing patients at different offices, but I will be billing insurances for services through my home (base) office. I set myself up as a sole member LLC, and will be using sole proprietorship for tax purposes. I also obtained an EIN although not required to. Since an LLC can be taxed two different ways (sole proprietorship or corporation), I’m not sure how to enroll on to insurance panels, specifically Medicare and Medicaid. My initial thought was to obtain a type 2 NPI and enroll as an organization, but the sole proprietorship taxation setting of an LLC makes me wonder if I should be enrolling as an individual.
Thank you in advance for any advice,
Jenny
Hello Jenny-
Mary Pat forwards these questions to me because of my expertise and close working relationship with CMS, PECOS, NPPES, etc.
As a sole member LLC and sole proprietorship for tax purposes, and the fact that you will not be billing for services from any other provider, Medicare wants you to bill using your Type I NPI attached to your SS#. There is no reason to enumerate your Tax ID and obtain a Type II NPI. If you never have plans to employ any other providers and bill/collect for their services, there is no reason to contract or credential as anything other than a sole proprietor since you intend to be a sole proprietor. You would complete a paper 855I form or enroll through PECOS (online enrollment) and enroll just yourself and place the name of the location as the LLC, but you will bill under your SS#. If you intend to bill using the tax ID, then you will need a Type II NPI.
Again, there is no need to obtain a Type II NPI unless you intend to bill using it and intend to employ other providers that will need to reassign their benefits so that you can collect for their services, but you could do this via your own NPI and reassignment to that.
Best regards,
DJZ
djzetter@zetter.com
__________________________________________________________________________________________________
David J. Zetter, PHR, CHCC, CHCO, CPC, CPC-H, PCS, FCS, CHBC
161 Old Schoolhouse Lane, Suite 3 | Mechanicsburg, PA 17055
Tel: 717-691-7100 | Cell: 717-979-5037 | Fax: 717-691-6855
Mary- I am a sole member LLC for my psychotherapy practice. I already have a type I NPI. I am applying to become a provider on an insurance panel but they told me I have to get a type II NPI to join their panel. They admitted that they are one of the only insurance companies that requires this. I have no intention of hiring anyone ever in my LLC. Am I allowed to get a type II NPI? Will I still be able to use my type I with the other insurance companies that I am already credentialed with?
Thanks!
Hello Jeannie-
Mary Pat forwards these type of questions to me. The payer can dictate their policy on what you have to do to join their panel. If they say you need a Type II NPI, that is fine. You can obtain one, but the Type II NPI gets tied to your Tax ID number. If you bill using your Type II NPI and the payer sends payment there, then you will have income coming through that Tax ID and you will also have revenue flowing through your personal tax return via your social security number since your Type I NPI is tied to that.
It seems ridiculous that they require a Type II NPI, but you can obtain one. Just don’t register that Type II NPI with any other payer, if you do not want to.
Given that you are a psychotherapist, I am curious how you are dealing with the new mental health codes and having to use E/M codes now? We have a lot of clients that have requested education and coding reviews to ensure they are on the right track. Just curious.
Good luck.
Best regards,
DJZ
dzetter@zetter.com
David J. Zetter, PHR, CHCC, CHCO, CPC, CPC-H, PCS, FCS, CHBC
161 Old Schoolhouse Lane, Suite 3 | Mechanicsburg, PA 17055
Tel: 717-691-7100 | Cell: 717-979-5037 | Fax: 717-691-6855
I work for a dentist, his company has changed tax designation from Sole Proprietor to an LLC company being taxed as an S Corportaion. He remains the owner and considered a Single Member Owner. We have a new tax ID number, do we need to get a new NPI # or can we continue to use our current NPI #?
Thanks!
Hello Sandy-
Mary Pat forwards questions about Medicare, NPIs and other topics to me, so your question is in my hands.
A Type II NPI is tied to the tax ID of an entity just as the Type I NPI is tied to the social security number of an individual. You can never use an NPI from one tax ID and assign it to another tax ID. The original NPI would have to be deactivated and a NPI will have to be issued and tied to the new tax ID. Additionally, all your payers will need to be notified and you will most likely have to change credentialing and contracts since you have a new tax ID and NPI. If you attempt to bill for services with the existing NPI, the revenue will go to the old Tax ID and you will need to file tax returns based on all revenue received to that Tax ID. If you attempt to submit claims with the new NPI or tax ID and you did not inform your payers, then most likely all claims will be denied or some might be paid at out-of-network rates since they do not have any record of the new tax and what providers are associated with it.
Good luck.
Best regards,
DJZ
djzetter@zetter.com
David J. Zetter, PHR, CHCC, CHCO, CPC, CPC-H, PCS, FCS, CHBC
161 Old Schoolhouse Lane, Suite 3 | Mechanicsburg, PA 17055
Tel: 717-691-7100 | Cell: 717-979-5037 | Fax: 717-691-6855
I have a small speech pathology practice which i purchased from my retired unofficial partner. She was the sole owner of the PLLC although we worked together. Now I am the sole owner.Here is my delema: I am using our old existing tax id for the business (created by the previous “owner” of the PLLC).I have one NPI number that I use for billing which is under my name. I currently send claims with the original tax id since I was listed as a provider before I became the sole owner of the business. I have even added new insurance companies to be providers for since my ownership. All has been fine until recently I was informed by one insurance compnay that my name could not be found with the business name with the IRS.They sent my my 1099 with the business name and the original owners name on it. No other insurance has does that. I now have read that I should have a new Tax ID. Is this necessary and if so how is the best way to transition with all the insurance companies and third party payors. Also, will I need a new NPI as a sole owner of the PLLc? I will be hiring subcontractors and an employee.
Hello Sue,
Mary Pat forwards these type of questions and concerns to our firm as we are very familiar with these issues. Your question(s) and concern(s) are a little more in-depth than can be solely answered in an email and I would need to determine other information in order to assist. I would not suggest keeping the old Tax ID from the previous practice. You will run into many issues with this and already have, as you noted. More will crop up. It is best you resolve this prior to other issues coming up.
Would you be willing to give me a call or provide me your contact information to call you to discuss this further and how we might be able to assist you?
We are a practice management consulting firm that does credentialing and contracting on a national basis (happy clients coast to coast) and we also help providers set up practices and support them as they practice.
I look forward to speaking with you.
Best regards,
DJZ
djzetter@zetter.coe
David J. Zetter, PHR, CHCC, CHCO, CPC, CPC-H, PCS, FCS, CHBC
161 Old Schoolhouse Lane, Suite 3 | Mechanicsburg, PA 17055
Tel: 717-691-7100 | Cell: 717-979-5037 | Fax: 717-691-6855
I am helping a physicians practice open a dme, I beleive they should get an additional NPI, so filling out the application it would be considered a initial application not a change correct? Thanks
Hello Wendy-
Mary Pat sends these type of questions to me. There is no change in application because a DME has to be licensed, certified and approved by a different MAC, so it requires a different enrollment application (855S). Depending on how your DME is set up (just selling under your current practice with the same Tax ID), then you do not need another NPI, but you will need another PTAN just for the DME. The 855S needs to be filed with the appropriate MAC for your jurisdiction. There are 4 different MACs, Noridian, CIGNA, NHIC and NGS. Just because you may be in one for the practice does not mean that you will use that one. See the attached map I provided.
Here is the link to the NSC website: http://www.palmettogba.com/palmetto/providers.nsf/DocsCat/Providers~National%20Supplier%20Clearinghouse~Articles~General~7GMRY72460?open&navmenu=Articles||||
Here is the link to the 855S form: http://www.google.com/url?sa=t&rct=j&q=855s&source=web&cd=1&cad=rja&sqi=2&ved=0CC8QFjAA&url=http%3A%2F%2Fwww.cms.gov%2FMedicare%2FCMS-Forms%2FCMS-Forms%2Fdownloads%2Fcms855s.pdf&ei=wRVTUcTjDKrE4AOC-ICYDA&usg=AFQjCNHSrGDWG3ylhjOJDUJBACQw1U75Zw&bvm=bv.44342787,d.dmg
You could also (I highly recommend) using PECOS to file the 855S on behalf of the practice rather than using paper applications. It will be processed much quicker.
I hope this helps.
Best regards,
DJZ
djzetter@zetter.com
David J. Zetter, PHR, CHCC, CHCO, CPC, CPC-H, PCS, FCS, CHBC
161 Old Schoolhouse Lane, Suite 3 | Mechanicsburg, PA 17055
Tel: 717-691-7100 | Cell: 717-979-5037 | Fax: 717-691-6855
I am currently working for a group as an physician (MD) in California and have my own NPI number. The group also has their own. If I decide in the future to incorporate myself by forming an S corporation, open my own practice as a solo practictioner, do I need to apply for an office NPI?
Hi John,
Here is the answer from our resident NPI Expert, David Zetter:
If you ever intend to open your own solo practice and DO NOT intend to hire any other providers, you do not need a Type II NPI. You could bill using your Type I NPI (Tied to your SS#) and this would all flow through your 1040 tax return. If you ever intend to hire other licensed providers, it is best to bill through a Type II NPI and have the other providers “reassign” their benefits to the entity rather than you personally. This will also help to protect you give the “corporate veil” through the entity.
David can be reached here:
David J. Zetter, PHR, CHCC, CHCO, CPC, CPC-H, PCS, FCS, CHBC
161 Old Schoolhouse Lane, Suite 3 | Mechanicsburg, PA 17055
Tel: 717-691-7100 | Cell: 717-979-5037 | Fax: 717-691-6855
Email: djzetter@zetter.com
Best wishes,
Mary Pat
I have to add a new address to an NPI number. Where do I do this at ?
Go to https://nppes.cms.hhs.gov/NPPES/Welcome.do to make any needed changes.
Best wishes!
Mary Pat
I have a FNP who has just opened Up her own office as a PLLC and obtained an EIN # from the IRS. She is the sole owner of the practice. She does not want her revenue to be connected to her social security #, but to the EIN # for the PLLC. She also will be using a clearinghouse to submit her claims. Should be obtain a 2nd NPI for the PLLC to use for claims submission?
In summary: She is the sole owner and the rendering provider of this PLLC with a EIN # and she will use a clearing house to submit her claims.
Hello Jeannie-
Mary Pat forwarded your question to me.
If the FNP does not want her revenue to be connected to her SS#, then she can create a Type II NPI that is tied to her Tax ID/EIN of her entity, although her revenue and income will go directly to her 1040 if she is an LLC/PC and chose to be taxed as an S Corp. The clearinghouse will need to know her Type II NPI and all EDI paperwork will need to be set up to properly submit claims under that NPI.
Technically, this is NOT obtaining a 2nd NPI. It is obtaining a Type II NPI tied to the EIN. She would still have her NPI (Type I) tied to her SS# and would still use this number in Box 24J as the rendering provider.
I hope this helps.
Best regards,
DJZ
djzetter@zetter.com
_________________________________________________________________________________________________
David J. Zetter, PHR, CHCC, CHCO, CPC, CPC-H, PCS, FCS, CHBC
161 Old Schoolhouse Lane, Suite 3 | Mechanicsburg, PA 17055
Tel: 717-691-7100 | Cell: 717-979-5037 | Fax: 717-691-6855
I am a solo proprietor physician who hired a nurse practitioner. I have a type 1 NPI She has her own. most insurers say we bill under mine as practice because it is sole proprietorship not Corp. Only one insurer is saying that this makes us a group and need type 2 NPI. Is this really needed/ correct?
Hello Erin-
Each payer has the ability to inform you of what their policies, procedures and requirements are in billing for services. The issue may be that the payer does not allow a provider to bill under another provider’s NPI so they may require a “group” NPI (attached to an Employer Identification Number).
How can you be a sole proprietor when you have another provider? The definition of a sole proprietor is:
A sole proprietorship is a type of business entity that is owned and run by one individual and in which there is no legal distinction between the owner and the business.
If the physician employs another provider, such as a nurse practitioner, the provider should have a tax ID or EIN since they are NOT a sole proprietor anymore. This provides security and protection for the physician’s personal belongings which should not be at risk due to having employee providers. Anytime a provider things that they will employ other providers, we always recommend that they form an entity (LLC, PLLC, PA, PC, etc) in order to protect themselves and have the group be a separate entity unto itself.
In my opinion it is not good business or prudent to employ another provider and not create an entity for protection, let along issues that may arise with certain payers. In addition, there are provider contracts and group contracts. Many payers will not contract independently with an NP or PA and will require that the group have a contract and the mid-levels bill via the group ID (Box 33 on the claim form) yet reflect the mid-level as the servicing provider (box 24J on the claim form).
You become responsible for everything personally. Do you really want to be responsible for anything that may occur with the nurse practitioner? I would think not. You want protection from any clinical issues, etc. By setting up a different entity you separate your personal life from your business life (corporate veil). If your nurse practitioner had a malpractice case, the patient could sue you personally, because there is no entity to go after. They can always go after your malpractice as well, but they could take your house or anything else that you personally own. You should protect this to some extent.
I hope this helps.
Best regards,
DJZ
djzetter@zetter.com
http://www.zetter.com/
__________________________________________________________________________________________________
David J. Zetter, PHR, CHCC, CHCO, CPC, CPC-H, PCS, FCS, CHBC
161 Old Schoolhouse Lane, Suite 3 | Mechanicsburg, PA 17055
Tel: 717-691-7100 | Cell: 717-979-5037 | Fax: 717-691-6855