Single Member LLC- NPI Type Question

[James]

Hi everyone,

I have been reading quite a bit online about LLC's and NPI types and I just can't seem to figure out what to do for my situation. I was hoping someone could shed some light for me.

-I am a psychologist starting a private practice that will be out of pocket only (clients can submit to their insurance companies via a superbly).
-I have a single member LLC and an individual NPI number.
-I have read that I also need a type 2 NPI number but I am not sure if this is just for providers that accept insurance.
-I tried to go through the process of getting a type 2 NPI but was unsure what to put as the taxonomy as the only thing that resembled what I do is "Clinic/Center- Adult Mental Health" -I am not a clinic or center- I am an individual in private practice, so I am not sure if this is correct. Anyone have any idea?

Thanks for any help anyone can provide.

Best,

James

[RichardP]

This is a question best answered by a healthcare attorney.

Having said that, here are some things to consider:

What follows in italics is the last paragraph of my first post at this link:

https://www.medicalbillinglive.com/members/index.php?topic=8882.msg29813#msg29813

The thing that trips people up is the distinction between sole proprietor (doing business in your own name, using your own SSN, having created no organization) and a sole practitioner or solo practitioner (having obtained an EIN, and doing business in the name of your organization).

After that paragraph, I provided a link - and that link no longer works.  I suggest you read through the thread I linked to above - several times if necessary - until you understand the general gist of what is being said.  And then read through the following two links.  They say the important parts of what the link-that-no-longer-works said.

Come back with questions as they develop.  But the primary take-away is that you only need 1 NPI number if your Taxpayer ID Number is your Social Security Number.  If your Taxpayer ID Number is the EIN of your LLC, then you must get a Type II NPI Number for your LLC, using the EIN of your LLC.

https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/NationalProvIdentStand/Downloads/NPI_FactSheet_Sole_Prop_web.pdf

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/NPI-What-You-Need-To-KnowText-Only.pdf

[RichardP]

A slightly different way of looking at the answer to your question is to pose a question that gets used quite often around here:

Who is the billing entity?

If the billing entity bills using its Social Security Number / reports its business tax using its Social Security Number, then they only need the Type 1 NPI Number.

If the billing entity bills using its Employer ID Number (EIN) / reports its business tax using its EIN, then they need a Type 2 NPI Number to go with their EIN.

[Michele]

Richard gave some great information and based on what you are describing, if your patients will be submitting claims to their insurance, a type II NPI would be required for your LLC.

As for the taxonomy, you would pick "single specialty group" and then the appropriate taxonomy for psychologist.  Since there is only one practitioner (you) and you are a psychologist, you would select that for the group taxonomy.

[James]

I really can't thank you all enough. I am so happy that I posted in this forum. You have answered my questions! I feel less frustrated now. Take care!

James

[Michele]

You are most welcome!   

[Jennifer]

HI,
I have a question on this same topic. I am a medical biller for mental health therapists. One of my LMFT's has several interns and is now wanting to become a group. She is getting things ready to switch to an LLC and get her group NPI. Regarding billing to insurance, she is both in and out of network. I will need to update her NPI with all her insurance companies, will this be my only change regarding updating her practice information and will it affect her in network status? I am thinking it should be basically an NPI update? Also, will I only be billing with the NPI 2?

Thank you, Jennifer

[kristin]

Insurance companies contract with individual providers in the scenario you present. So I don't see that her forming a group practice under the LLC and getting an organizational NPI will effect her network status with insurances she is already contracted with.

As far as billing goes, the individual provider name/NPI will go into the rendering provider area, and the billing provider area will be populated by the group name/NPI on the CMS-1500, as the group practice will now get all the payments from insurance.

If any of the providers are contracted with Medicare, each provider will have to update their Medicare enrollment at PECOS to reassign benefits to the group practice, also.

[Michele]

In addition to what Kristin said, if she will be billing under an EIN then you may have to register the EIN with the insurance carriers that she wants to be in network with.  If she is billing under the group NPI and EIN then they may need to credential that EIN as well.

[Jennifer]

Thank you for this information. This provider is out of network with all insurance companies except Partnership (California). My plan was to update her group NPI and business name change with all insurance companies correct? At what point should I update my software? Right away I am thinking? I just do not want to update if this could cause a denial.

Thank you, Jennifer

[Michele]

If the provider is out of network you should not need to update with the insurance carriers.  I would update the software as soon as the provider wants the change to go into effect.