|National Provider Identifier (NPI) FAQs
What is a National Provider Identifier (NPI)?
An NPI is a unique 10-digit numeric identifier assigned to health care providers and organizations defined as covered entities under HIPAA. The NPI will be a permanent identifier assigned for life.
What steps has Aetna taken to ensure transactions are compliant with the NPI regulations?
We implemented full support for NPIs in HIPAA transactions prior to the compliance date. We continue to communicate with providers to emphasize the importance of meeting their obligations to process transactions in accordance with the requirement of the HIPAA regulations.
What is the difference between a covered entity and a noncovered entity?
Health care providers who transmit standard electronic transactions (for example, claims submissions, referrals, etc.) are covered entities and are required by the HIPAA NPI regulations to apply for and receive an NPI. Acquiring an NPI is optional for noncovered entities (providers who do not submit standard electronic transactions).
What will an NPI do?
- Replace all other provider identifiers previously used by health care providers (for example, UPIN, Medicare/Medicaid numbers, etc.).
- Establish a national standard and unique identifier for all health care providers.
- Simplify health care system administration and encourage the electronic transmission of health care information.
What will an NPI not do?
It will not:
- Replace the tax identification number (TIN), which is an IRS requirement.
- Convey information about the provider (for example, provider type, service location, etc.).
- Guarantee reimbursement by health plans.
- Enroll providers in health plans.
Where can additional information about HIPAA NPI regulations be found?
- See the CMS website:
- CMS has also consulted with the Workgroup for Electronic Data Interchange (WEDI) in the development of standards and for comments on data dissemination and other issues. WEDI has formed several workgroups consisting of representatives from all areas of the health care industry. See published "white papers" on various topics and other information on the WEDI website:
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Getting an NPI
Who should apply for an NPI?
- Individual health care providers, such as physicians, dentists and pharmacists.
- Organizational health care providers, such as hospitals, pharmacies, group practices, laboratories, ambulatory care facilities and nursing homes.
How can a health care provider apply for an NPI?
The Centers for Medicare & Medicaid Services (CMS) has contracted with a vendor to administer the assignment of NPIs and deal with health plans and providers on issues concerning unique identification.
There are only three ways a health care provider can apply for an NPI:
- Complete the application online at http://www.cms.gov/NationalProvIdentStand/. It takes about 20 minutes to complete the NPI application.
- Call 1-800-465-3203 to request a paper application.
- With the provider's permission, an organization may submit the application in an electronic file on behalf of the provider.
Will nonparticipating provider NPIs be collected by Aetna?
Yes, we encourage all providers to obtain, share and use their NPI, regardless of their participation status or transaction submission method.
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Sharing your NPI with us
Please send us your NPI for our files through our:
Secure website: You can submit your NPI to us through the "Update Personal Info" section of our secure website at www.aetnadental.com. Not registered for our secure website? Go to www.aetnadental.com, and select "Register Now!"
National Dentist Line: Call 1-800-451-7715 to submit your NPI to us.
Network fax line for participating dentists: Fax your NPI to us at 1-860-754-1602.
Submit your NPI information:
Nonparticipating dentists: Fax your NPI information to: 1-859-455-8650
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Using your NPI in HIPAA standard electronic transactions
How do I use my NPI?
Dentists must use their NPIs on electronic transactions adopted by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Additionally, dentists need an NPI so they can be identified on electronic transactions performed by other entities.
Also, dentists need the NPIs of referring dentists to submit their own claims electronically. We strongly urge dentists to share their NPIs with these other entities.
If you are not using your NPI in electronic transactions, contact your EDI vendor to find out the steps you need to take to begin including NPIs in your transactions. If you use a Web-based solution, refer to that website for information.
If you submit electronic transactions using computer software, contact your computer system vendor support area for assistance.
What HIPAA standard electronic transactions have been revised to include the NPI?
- Claim Encounter
- Claim Status Inquiry (CSI)
- Electronic Remittance Advice (ERA)
- Interactive Voice Response (IVR)
- Real-time Eligibility (RTE)
Will NPI change the way Aetna pays claims and to whom?
NPI will not cause any changes to claim adjudication. Aetna currently uses the tax identification number and provider name and address information. The NPI will now also be used to identify the appropriate provider.
Will Aetna continue to maintain old and generate new legacy numbers?
We plan to continue to maintain old and generate new legacy identifiers in our systems since they are needed for other processes not encompassed by the NPI regulation.
Will Aetna require the NPI on paper claims?
Regulations only require the use of NPIs on electronic transactions. However, we recommend that you send NPIs on paper claims.
Will Aetna send the legacy identifier, the NPI or both on paper Explanation of Benefits (EOBs)?
We do not plan to include NPIs on paper EOBs at this time.
Will the NPI from the claim be included on the payee's electronic remittance advice, or will Aetna derive the NPI from its internal database?
Only electronic remittance advices include NPIs at this time.
Attention dentists who receive Electronic Remittance advices (ERA):
We will only generate ERAs that are NPI-compliant. If you want to receive an ERA, you must include your NPI on paper claims. Otherwise, you will receive a paper or online Explanation of Benefits (EOB).
If an electronic remittance advice (ERA) can have a different NPI than submitted on the claim, how can I tell which claim the ERA is responding to?
The submitter's claim number (from CLM01 in an 837 EDI claim) is required to be returned in the CLP01 element in the 835, and this is not affected by the NPI regulations or related changes. The 835 ERA implementation guide states the following about the CLP01:
"This data element is the primary key for posting the remittance information into the provider's database. We also recommend that it be used for that purpose rather than matching by provider IDs."
Matching remittances to claims using the provider ID is normally not necessary.
When can providers submit a claim or other electronic transaction using only the NPI?
Aetna will always require the billing provider's TIN on claims. You should now include your NPI on claims as well.
For real-time transactions (eligibility and benefits inquiry, claim status inquiry, and claim & predetermination submissions), we must be informed of the provider's NPI and it has to be loaded into our provider database. Providers need to verify that any system vendors or clearinghouses they use are also ready to pass transactions with the NPI as well.
What should I do if I get an error message when I try to transmit my NPI in a real-time transaction?
If you get an error message when using your NPI in a real-time transaction, please contact Aetna to provide us with your NPI number.
Will providers still be able to send currently used IDs, such as PIN and TIN, in electronic transactions?
To be compliant with the regulations, covered entities must use the NPI of any health care provider (or subpart) that has been assigned an NPI to identify that health care provider in HIPAA standard transactions. The use of other IDs is only permitted to identify:
- An entity or individual "as a taxpayer" using the TIN — for example, Social Security number or employer identification number (EIN). This exception applies only to billing/pay for providers in claims and payees in remittance advices. An NPI must be used to identify covered health care providers "as providers" in these situations.
- Providers acting in a way that is not considered to be a "provider" role, such as information submitter or receiver or utilization management organization.
Another payer has notified me that in addition to my NPI, I must submit a different tax ID number on my claims. Should I make the same change in my Aetna claims submissions?
Some providers have multiple tax ID numbers, for example, SSN and EIN or multiple EINs. We are aware that other payers, such as Medicare, have asked some providers to submit claims with a different tax ID number than they used in the past. However, if you make changes to the tax ID number on your Aetna claims, it may affect our ability to process your claims in a timely manner.
If you want to change your tax ID number for Aetna, you can communicate this change as you do any other demographic update by doing one of the following:
- Faxing your information to: 1-859-455-8650
- Contacting the Dentist Contracting Hotline: 1-800-776-0537
- Faxing your information to the Network fax line: 1-860-754-1602 (for participating providers)
- Contacting your network account manager
My claim was rejected for missing "Billing Provider" NPI. What action do I need to take on these claims to have them processed?
For claims that reject for National Provider Identifier, please resubmit electronically with the Billing Provider NPI.
What error codes will I see if my claim submissions reject for no NPI?
Depending on the format of your vendor's claim status report, you may see codes as listed below and/or text similar to that below:
A3 — Acknowledgement/Returned as unprocessable claim: The claim/encounter has been rejected and has not been entered into the adjudication system.
562 — National Provider Identifier (NPI)
85 — Billing Provider
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Additional resources (for participating providers)
We continue to provide information on NPI through our dentist newsletter, Dental Dialog. We also provide information through direct outreach and communications, along with industry events. If you have questions, call our National Dentist Line at 1-800-451-7715.
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