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A constant EIN and variable Billing NPI

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A practitioner and sole proprietor uses a different billing NPI depending on the insurance. With certain insurance she has me place her NPI 1 (rendering NPI) in box 33a while other insurance require her NPI 2 (billing NPI) in box 33a. Her billing has become this endless nightmare of one moment waiting for a claim to deny the next moment rushing to submit a corrected claim before timely filing.

After reading the relevant posts I see it is not appropriate to be a sole proprietor and have an NPI 2. Being inappropriate carries about as much weight as being politically incorrect. Besides offering to do the work myself in updating her information with insurance how can I convince this woman to do away with her NPI 2? Something with life in prison without the possibility of parole would be grand.

We actually have a provider with a similar situation.  He is a sole proprietor but he obtained a type II NPI when they first came out.  He has an EIN & DBA so he thought he had to.  Medicare won't enroll him under his type II, but all commercial carriers did.  So we have to file his Medicare under his individual NPI but with the EIN, while filing all other claims under the group NPI.  Luckily our software allows us to set this up properly so it's not a huge deal.

He won't fix it because he's going to retire soon.  :)  (7 years later.........)

Sorry I didn't actually answer your question.  I am still so riled up over that other post about the biller blaming the provider for not telling her she only had 90 days.  :)

Anyway, it should be fixed.  The commercial carriers should be notified to change back to the individual NPI so that you can file all claims the same way.  Good luck convincing them.  You will most likely have to do the work.  Most people figure "if it aint broke, don't fix it" and from their end it aint broke!

As Michelle states, there was a bit of confusion on the part of Medicare itself when the NPI Numbers were first issued.  We also had several clients who were bitten by that confusion.  They are sole practitioner's and had created corporations through which they did business (which requires a Type 2 NPI Number).  We acquired that Type 2 NPI Number as required, and began using it in Box 33a.  Whereupon Medicare began rejecting all of our claims.  Investigation yielded the answer that the Type 1 Number was supposed to be in Box 33a.  So we re-sent the billing, and future billing, with the Type 1 NPI Number in Box 33a.  Whereupon Medicare begin rejecting all of these claims.  Investigation yielded the contradictory answer that the Type 2 NPI Number was supposed to be in Box 33a.  It took us a significant amount of time to get this straightened out - simply because Medicare had to get their message straight internally.

By way of review - here's a bit more detail for others who may be passing by:

NPI Number Type 1 = Who did the work?
NPI Number Type 2 = Who gets paid?

An "organization" is an entity created by the state.  It can be a corporation, partnership, LLC, etc.  An organization must have a Type 2 NPI Number - to distinguish it from the flesh-and-blood person who owns the organization.

A sole proprietor is an individual provider who has not created a corporation through which to do business.  Therefore, a sole proprietor has no need to distinguish the person from the organization that s/he owns, and so needs no Type 2 NPI Number - and in fact may not have one.

Organizations can never "do the work".  The work is always done by a flesh-and-blood person.
Organizations can get paid.  Just as can flesh-and-blood persons.
An organization can be a billing entity, just as a flesh-and-blood person can be.

So - a Type 1 NPI Number can go in both Box 24J and Box 33a.
A Type 2 NPI Number can only go in Box 33a; never in Box 24J.

ste - if your client created an organization (by filling out paperwork and submitting it to the appropriate authorities), then your client would need to have a Type 2 NPI Number for that organization.  If your client has not created an organization, than your client has no situation that requires a Type 2 NPI Number - and in fact may not have one.

Note that the Type 2 NPI Number would be issued to the name of the organization that was included on the application for the Type 2 NPI Number.  While mistakes can be made in any bureaucracy, it is not likely that your client would have obtained a Type 2 NPI Number unless they in fact have created an organization - and have place that organization's name on their application for a Type 2 NPI Number.

Finally, a Type 1 NPI Number should never go into Box 33a - unless the billing entity (your client) is truely a sole proprietor and does not own a legal entity (corporation, partnership, LLC, etc.)

See the top of Page 5 at this link:

We actually have seen where Medicare approved the type II NPI, then upon revalidation realized their mistake and then made the provider re-enroll properly.  Big mess.


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