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How to understand the National Provider Identifier

Lisa Baker

We want to help you understand the process that uses the National Provider Identifier (NPI). Here are some guidelines and facts about the regulation and its requirements.

About the NPI

Each health care provider who transmits health information related to a standard transaction in electronic format must obtain an NPI. The Health Insurance Portability and Accountability Act (HIPPA) requires an NPI to conduct electronic transactions.

The NPIs are:

  • Unique 10-digit numbers for each provider or health care organization.
  • Random numbers that do not contain encoded information about the provider or organization.
  • Permanent identifiers that do not change or expire over time.
  • A replacement for other identifying numbers currently used in electronic transactions, such as Medicaid, Blue Cross and Blue Shield, UPIN, CHAMPUS, and other “legacy” numbers.
  • They are not a replacement for social security numbers, DEA numbers, tax identification numbers, taxonomy (special) numbers, or state professional license numbers.
  • Issued by the government through an independent group, the National Provider and Plans Enumeration System (NPPES), in charge of processing applications and assigning numbers.

All independent health care providers (including dentists) and health care organizations, such as clinics and joint practices, are eligible for an NPI.
 

Who Needs an NPI?

If you answer yes to the following questions, you are within what is considered a “covered entity” under the NPI standard and obtaining the NPI is required under federal law.

  • Do you submit claims in electronic format?
  • Do you use a clearinghouse?
  • Do you send attached documents with claims in electronic format?
  • Do you use the Internet to verify eligibility or monitor claims status?
     
How important it is to you and your practice
  • It is a simple identifier that saves you from having to preserve and match identification numbers with the appropriate insurers for transactions.
  • It allows you to relocate your practice or change specialties without having to request new identifiers from multiple insurers.
  • Helps you reduce costs and simplify healthcare transactions.
     
The application process
  1. Go to https://nppes.cms.hhs.gov
  2. Complete the application and follow the instructions to submit it online or by mail. Fax submissions are not accepted.
  3. After your application receipt confirmation arrives, you should receive your NPI by email within one to five business days if you submitted the application online. Processing of requests sent by post can take up to 20 days.
     
Report your NPI to Delta Dental
  • Check with your Delta Dental member company and ask how they prefer to receive it. (Simply submitting a claim will not guarantee entry into our system).
  • After you have notified your NPI, you can start using it in claims.
  • Please use the new claim forms as they have a specific space to include it. (This may require you to update your software).

If any information regarding your NPI changes (name, address, etc.), you are responsible for submitting an update to NPPES within 30 days of the change.


Type 1 or Type 2 NPI: Which is Right for You?

There are two types of NPI: Type 1 for individual healthcare providers, such as dentists and hygienists, and Type 2 for registered businesses, such as group offices and clinics.

  • Type 1 is for the provider. This is the only type of NPI you will need if you are receiving payments on your behalf or using your social security number as a self-employed professional. For multiple dentist offices, obtain a Type 1 NPI for each dentist.
  • Type 2 is for group offices , registered dental offices, or other business entities that receive payments on behalf of the company or business, or by virtue of the employer identification number (EIN).

In claims, the Type 2 NPI identifies the beneficiary and can be submitted along with a Type 1 NPI to identify the dentist who provided the treatment. For example, on a standard ADA (# J400) dental claim form, the consulted dentist’s NPI is entered in field 54 and the billing entity’s NPI is entered in field 49.

Do you need a Type 1, Type 2, or both?
Practice typeNPI type
Freelance professionalOnly type 1, if the claims are transmitted in the name of the dentist and with a social security number.
Freelance dentist in one officeType 1 for the dentist and Type 2 for the office, if claims are submitted on behalf of the office and with a tax identification number (TIN).
Multiple dentists, one officeType 1 for each dentist and Type 2 for the office, if claims are submitted on behalf of the office and with a TIN.
Several dentists, several officesType 1 for each dentist and Type 2 for each office with a separate TIN.

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