National Provider Identifier (NPI)
The NPI is a required element for all bill types. A provider can obtain the number by contacting the National Plan and Provider Enumeration System (NPPES). When a bill is input in the system for processing, a validation process is used. If you have been receiving denials due to an NPI issue, the following may be the reason:
- Rendering provider NPI missing – this means that the individual NPI for the actual service provider is missing from Box 24J of the CMS 1500 form;
- Rendering provider NPI incorrect – The NPI entered in Box 24J of the CMS 1500 form does not match the actual service provider submitted in the documentation. The NPI used must be that of the provider who has provided the service and signed the medical record;
- Practice Provider NPI missing or does not match – this NPI is required in Box 32a of the CMS 1500 form and must match or closely match the name that is registered on the NPPES website. Exception is if the Place of Service is 12 (home) in Box 24B;
- Billing Provider NPI is missing or does not match – this NPI is required in Box 33a of the CMS 1500 form and must match or closely match the name that is registered on the NPPES website;
- Attending Provider NPI missing or does not match – the attending provider NPI in Box 76 of the UB04 form is required for all services. This should be the NPI of the attending provider or the provider responsible for the care of the patient.
Please see the NPPES website for more information.