NPI or National Provider Identifier

NPI or National Provider Identifier numbers are important for claim payment.

NPI or National Provider Identifier numbers must be properly reported on your claims or there will be denials and possibly hold-ups on the processing of many claims submitted by your practice.  Basically there are two types of NPI numbers:

Type 1: The individual healthcare provider, in this case, dentist—is identified by this number

Type 2: The organization or billing entity, such as the dental practice, clinic, dental school or hospital

The individual dentist who is operating as a corporation must apply for and receive both types of NPIs.  One would be for the treating dentist and one for the practice or the billing organization.

If the dentist is operating as a sole proprietor, the NPI Type 1 may be reported for both the dentist and the billing entity.  Once the sole proprietor employs an associate dentist, many payers require that a Type 2 NPI number be obtained for the practice.  The payer needs to know the difference between the provider associate dentist and the owner of the practice.

Entering the NPI numbers in the correct box on the ADA 2012 claim form is very important.  Often claims are denied because of this and it has nothing to do with the treatment rendered.

Box 54 on the ADA 2012 form is for reporting Type 1 NPI

Box 49 on the ADA 2012 form is for reporting Type 2 NPI

The name that is registered as the owner of the NPI number must be the name reported on the claim.  If the providing dentist is the same as the billing entity, the names must match exactly.  Any variance in registered names can lead to a denial.   For instance, if the NPI number is registered to Stephen Z. Quigley, DDS but on the claim form the name is listed as Steve Quigley, DDS, it could be denied.

Having issues with claim denials?  Check the claims going out for proper NPI numbers.

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