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Helpful Guide - National Provider Identification (NPI)

The NPI is a 10-digit unique identification number for covered health care providers. Covered health care providers and all health plans and health care clearinghouses will use the NPIs in the administrative and financial transactions adopted under HIPAA.

HIPAA currently mandates that all providers who submit claims to insurance for reimbursement possess an NPI number.

If you have questions regarding NPI, please view the NPPES NPI Registry, or call the NPI hotline at (800)465-3203, which is a government organization that assigns the NPI numbers.

Disclaimer:
MacPractice cannot be held responsible for any claim rejections you receive as the result of our recommendations and suggestions. It is your responsibility to be aware of the exact requirements for each of your insurance carriers and to set the software up accordingly. It is advisable to contact your carriers before you make any of the changes recommended in this documentation.

Facility NPI Number

The Facility NPI Number is entered in the Facility Reference. To enter this information, go to the References ability > Facility node in the sidebar. Click the triangle to the left of this to expand the node, then select the facility record. The National Provider ID (NPI) field is located at the bottom of the record.

An NPI number will need to be entered for each of your facilities. As with the other NPI fields, MacPractice will validate the format of the NPI number. If it does not match the NPI number scheme, you will see an "Invalid NPI Number" warning, and MacPractice will not let you save the record. This feature does not check to confirm this is the correct NPI for the facility, simply that it is a legitimate NPI number.

The Facility NPI number will appear in Box 32a on the CMS 1500 Claim Forms.

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Referral NPI Number

The Referral NPI can be entered in the Referrers Reference. Go to the References ability, select and click on the triangle to the left of the Referrers node to view your referrals. Select the referral, and the NPI field will be in the top portion of the window in the second row.

Note: In older builds of MacPractice, click the Provider IDs tab. The NPI field is at the bottom of the first column of fields.

As with the other NPI fields, MacPractice will validate the format of the NPI number. If it does not match the NPI number scheme, you will see an "Invalid NPI Number" warning, and MacPractice will not let you save the record. This feature does not check to confirm this is the correct NPI for the provider, simply that it is a legitimate NPI number.

The Referring Provider NPI number will appear in Box 17b on the CMS 1500 Claim Forms.

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Individual NPI Number

There are two types of NPI numbers: Type 1, which are used for individuals; and type 2, which are used for groups. Which number you use will depend on whether you have credentialed as an individual or a group with your insurance payers. MacPractice Support will not have this information.

The Individual NPI number will be entered in the Users Reference. Go to the References ability > Select the Users node in the sidebar on the left, then expand this node to view the list of Users. Select the Provider user, and go to the Provider tab > Claim Credentials sub-tab. Enter the NPI number into the National Provider ID (NPI) field.

MacPractice will validate the format of the NPI number. If it does not match the NPI number scheme, you will see an "Invalid" warning, and MacPractice will not let you save the record. This feature does not check to confirm this is the correct NPI for the provider, simply that it is a legitimate NPI number.

The Individual NPI will appear in Box 24j and Box 33a on the CMS 1500 Claim Forms.

The Individual NPI will also appear in Box 49 and Box 54 on the ADA Claim Form.

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Group NPI Number

Generally, the Group NPI number will be entered in the Offices Reference. Go to the References ability > Select Offices in the sidebar, then expand this node to view your office record. The Group National Provider ID Number field is located in the lower right corner.

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If you have multiple groups within your office, this group NPI can be overridden on a per-provider basis. In the provider's User Reference under the Provider tab > Claim Credentials sub-tab, the Group National Provider ID (NPI) field below the individual field.

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As with other NPI field on the user reference, MacPractice will validate the format of the NPI number. If it does not match the NPI number scheme, you will see an "Invalid NPI Number" warning, and MacPractice will not let you save the record. This feature does not check to confirm this is the correct NPI for the group, simply that it is a legitimate NPI number.

The Group NPI will appear in Box 33a on the CMS 1500 Claim Forms.

The Group NPI will also appear in Box 49 on the ADA Claim Form.

Medicare and Other Insurance Requirements

Medicare Requirements

As of May 23rd, 2008, Medicare began requiring NPI only transmission on all paper and electronic claims. While all insurance carriers most likely will conform to Medicare's new requirements, it is possible that an insurance carrier, or multiple carriers, will not accept NPI Only claims. Some carriers also might still be requiring both the NPI and Legacy Numbers. MacPractice has released three versions of the CMS-1500 claim form in order to address these three possible scenarios:

  • CMS-1500 (XX/XX) NPI and Legacy: Prints both NPI and Legacy Numbers if they are filled in; use this form only if requested.
  • CMS-1500 (XX/XX) Only Legacy: Prints Legacy Numbers only and leaves all NPI numbers blank; use only if insurance company requests it.
  • CMS-1500 (XX/XX) Only NPI: Prints NPI Numbers only and leaves legacy numbers blank; use this form unless requested to use a different form

If you have many carriers now accept NPI Only claims, you can set the CMS-1500 (02/12) NPI Only form as the Default Insurance Claim Form by going to the Forms Preference.

Other Insurance Requirements

Different insurance carriers may have different requirements. To prevent claim rejections, it is advisable to contact your carriers to determine what their specific requirements are and to then make the corresponding changes in MacPractice.

Example:
You receive notification from an insurance carrier, or multiple carriers, informing you that both the Legacy Numbers and NPI on the claim form are required. For the time being, you will want to set the CMS-1500 (02/12) NPI and Legacy form as the Default Claim form for that carrier(s).

This can be done through the Insurance Companies Reference Claims tab, then update the Default Form drop down menu to the required claim form.

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Doing this will ensure that the correct Default Form is selected when you go to print a claim for this company. However, you will want to verify that the correct Default Form is selected for the first few claims you print after making this change.

Two important notes regarding the Default Claim form:

  • The Default Claim Form overrides the Default Insurance Form specified through Preferences and Forms in the sidebar.
  • The Default Claim Form is ignored when a default eClaim template is set. Claims will default to the eClaim template unless the default eClaims template is set to "None."
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