Billing > Billing

weird Medicare denial?

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Michele:
We use OA too and ours go through ok.  Did you get it resolved?

RichardP:
Here is a bit more background for those who might be interested.


--- Quote from: Christy on June 23, 2014, 07:21:11 PM ---it's a sole provider with one type 1 NPI.
--- End quote ---

Edit:  I have deleted my comment here because I got it backwards and don't have time at the moment to craft a correct comment.  Basically, I was arguing that a CMS Form with the EIN box checked in Box 25 of the CMS 1500 should have a Type II NPI Number in Box 24J.  That is incorrect.  The Type I NPI Number (who did the work) goes in Box 24J.

But, for Christy's situation - if the CMS 1500 Form has an EIN on it, or if the EIN box in Box 25 is checked, there must be a Type II NPI Number in Box 33a and a Type I NPI Number in Box 24J.  Christy, regarding the CMS 1500 Form where the NPI Number(s) in Box 24J are disappearing, is there an EIN on that Form, or is the EIN box in Box 25 checked.  If the answer to either is yes, you must have a Type II NPI Number in Box 33a.

Our experience with our MAC has been that, if the sole provider is conducting his business with an Employer Identification Number (EIN), then he must have both a Type I (for his person) and a Type II (for his EIN) NPI Number.  Perhaps your Sole Provider has an EIN but only has a Type I NPI Number??

Christy:
thanks for the replies. I am still working on this, will post back.

Richard- a provider can have an EIN and only a type 1 NPI. At lease in NY, they can. I bill for sole proprietors with an EIN and just a type 1 NPI to Medicare with no problems.....

RichardP:

--- Quote from: Christy on July 08, 2014, 02:02:54 PM ---Richard- a provider can have an EIN and only a type 1 NPI. At lease in NY, they can.
--- End quote ---

Thanks for that.  We have been processed by the Palmetto MAC and have recently been required to switch over to the Noridian MAC.  Noridian rejects quite a bit of stuff that Palmetto accepted.  So - perhaps it depends on the MAC?

I just know that, when the NPI stuff first started, we had a sole provider with an EIN.  Based on info published at the time, we billed with his Type 1 and Type 2 NPI Numbers.  Billing was rejected, and we were told to only bill with the Type 1 NPI Number.  We did this, and got paid for a time.  Then, inexplicably, they started rejecting our billing.  Inquiries yielded the answer that we needed to bill with both the Type 1 and Type 2 NPI Numbers (which we had initially done and it was rejected).  So we switched back to using both - for our Sole Provider who has an EIN - and have had no problem with payment since.  We have other Sole Provider clients with EINs for whom we have been billing with both NPI Types since the beginning with no problem.  We long ago stopped looking for the logic behind any of this.  We just do what they tell us to do, until they tell us to do something different.

Michele:
We have providers in NY who use Tax IDs and only an individual NPI.  Our understanding is that if they have a Tax ID under their name (not a legal entity such as a professional assoc or a corporation) they do not need a group NPI.

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