Frequently Asked Questions: National Provider Identifier (NPI)
IMPORTANT NOTE: All claims electronically submitted without an NPI will be rejected.
General Information
Q: What is NPI?
A: The National Provider Identifier (NPI) is a 10-digit number required on all HIPAA standard electronic transactions. NPIs have replaced all separately issued identifiers, including Medicaid PINs, Medicare UPINs and health plan-assigned identifiers, on HIPAA standard electronic transactions. The NPI was put in place so that each provider has one unique, government-issued identifier to be used in transactions with all health plans with which the provider conducts business.
Q: Is the NPI required for all healthcare providers?
A: Yes. Magellan expects all providers submitting claims electronically to obtain and use an NPI. The NPI is required for all healthcare providers covered under HIPAA, including but not limited to Magellan individual practitioners, group members, and organizations.
Please note: some public sector plans include providers classified as “atypical,” who do not provide healthcare (e.g., transportation providers or non-licensed case management providers), as defined under HIPAA in Federal regulations at 45 CFR section 160.103; these providers are not eligible to receive NPIs.
Q: Does my NPI replace my Taxpayer Identification Number (TIN)?
A: No. Your NPI does not replace your TIN. TINs are required on all claims – paper and electronic. The NPI is for identification purposes, while the TIN is for tax purposes. Important – claims that do not include a TIN will reject.
Q: Where can I find more information about the NPI and CMS' guidance on compliance with the HIPAA NPI Rule?
A: You can find more about the NPI, including compliance guidance and answers to frequently asked questions, by visiting the Centers for Medicare & Medicaid Services (CMS) website.
Magellan-Specific NPI Information
Q: Does Magellan require NPIs on all HIPAA standard electronic transactions?
A: Yes. Magellan requires the NPI on HIPAA standard electronic transactions. All electronic claims submitted without an NPI are rejected.
Q: Should I include my Magellan MIS number on HIPAA standard electronic transactions?
A: No. Any HIPAA standard electronic transaction sent with a Magellan MIS number will be rejected.
The Magellan MIS number continues to be used (in most cases) as a provider's username when signing in to the Magellan website. If you do not know your Magellan MIS number, contact the Provider Services Line at 1-800-788-4005 to obtain it.
Q: I only provide EAP services and file for reimbursement using the EASI form. Do I need to obtain or use an NPI?
A: EAP services do not require an NPI.
Q: Does Magellan require NPIs on paper claim forms (CMS-1500 and UB-04)?
A: Magellan accepts – and strongly encourages you to submit – NPIs on both the CMS-1500 and the UB-04 forms. Several of our customer plans require NPIs on paper claims.
Applying for NPIs and Submitting NPIs to Magellan
Q: How do I apply for my NPI?
A: If you have not yet applied for an NPI, you should do so as soon as possible in one of three ways:
- For the most efficient application processing and the fastest receipt of an NPI, use the web-based NPI application process. Log on to the National Plan and Provider Enumeration System (NPPES) and apply online at https://nppes.cms.hhs.gov/NPPES/Welcome.do.
- You can agree to have an electronic file interchange organization (EFIO) submit application data on your behalf (i.e., through a bulk enumeration process) if an EFIO requests your permission to do so.
- You may wish to obtain a copy of the paper NPI Application/Update Form (CMS-10114) by contacting the Enumerator:
By phone: 1-800-465-3203 or TTY 1-800-692-2326
By email: [email protected]
By mail:
NPI Enumerator
P.O. Box 6059
Fargo, ND 58108-6059
Q: How do I submit my NPI to Magellan?
A: You can submit your NPI online by signing in with your secure username and password on this website (www.MagellanProvider.com), selecting Display/Edit Practice Information, and completing the NPI request field.
You can also submit your NPI by mail or fax, by sending us a copy of your NPI notification letter or email from NPPES:
Magellan Healthcare
Attn: Data Management
14100 Magellan Plaza
Maryland Heights, MO 63043
Fax number: 1-888-656-3804
Q: What if I no longer have a copy of my NPI notification letter or email?
A: You can log in to the NPI Enumerator page and print a copy of your NPI notification email from NPPES, or you can contact the NPI Enumerator to request a copy of your NPI notification letter or email.
By phone: 1-800-465-3203 or TTY 1-800-692-2326
By email: [email protected]
By mail:
NPI Enumerator
P.O. Box 6059
Fargo, ND 58108-6059
Q: If an electronic file interchange (EFI) organization obtained my NPI for me, how do I obtain a copy of the NPI notification?
A: You should contact the EFI organization that obtained the NPI for you.
Q: Does Magellan accept NPIs on paper claim forms (CMS-1500 and UB-04)?
A: Yes. Magellan accepts – and strongly encourages you to submit – NPIs on both the CMS-1500 and the UB-04 forms. Several of our customers require NPIs on paper claims as well.
Q: Where are the main NPI (Type 2) and rendering NPIs (Type 1) to be inserted on electronic transactions and on the paper claims forms?
A:
- For claims submitted via the ASC X12N 837 professional healthcare claim transaction, place the Type 2 NPI in the provider billing segment, loop 2010AA; and the Type 1 NPI in loop 2310B.
- On the CMS-1500 form, insert the main or billing Type 2 NPI in Box 33a. Insert the service facility Type 2 NPI (if different from main or billing NPI) in Box 32a. Insert Type 1 NPIs for rendering providers in Box 24J.
- On the UB-04 form, insert the main Type 2 NPI in Box 56; insert Type 1 NPIs for rendering providers in boxes 78-79.
Q: What is a Type 1 NPI and Type 2 NPI?
A: Type 1 – Healthcare providers who are individuals, including physicians, psychiatrists and all sole proprietors. An individual is eligible for only one NPI.
Type 2 – Healthcare providers that are organizations, including physician groups, hospitals, nursing homes, and the corporations formed when an individual incorporates him/herself.
NPI Instructions for Sole Providers, Group Members and LLCs
Q: I am a provider with a sole proprietorship. Do I receive two NPIs (one for myself and one for the sole proprietorship)?
A: No. You would only receive a Type 1 NPI. A sole proprietorship is a form of business in which one person owns all assets of the business and is solely liable for all the debts of the business in an individual capacity. Therefore, sole proprietorships are not considered organization healthcare providers for purposes of the NPI Final Rule and thus cannot obtain organization NPIs. In terms of NPI assignment, a sole proprietor would be an Entity Type 1 (Individual) and would be eligible for a single NPI. As an “Individual,” the sole proprietor cannot have a subpart and cannot designate subparts.
Q: I am a sole provider who is incorporated. Do I receive two NPIs (one for myself and one for the corporation)?
A: If you are an individual who is a healthcare provider and is incorporated, you need to obtain an NPI for yourself (Type 1) and an NPI for your corporation (Type 2).
Healthcare providers who are individuals are eligible for an Entity Type 1 (Individual) NPI. If these individuals incorporate themselves (i.e., if they form corporations) and the corporations are healthcare providers, the corporations are organization providers that are eligible for an Entity Type 2 (Organization) NPI. If either of these healthcare providers (the individual or the corporation) are covered providers (i.e., providers that send electronic transactions) under HIPAA, the NPI Final Rule requires them to obtain NPIs. Visit the CMS website for more information.
Q: I am a provider who has formed an LLC (Limited Liability Company). Do I receive two NPIs (one for myself and one for the LLC)?
A: It depends. Providers who have formed a single-member LLC (i.e., disregarded entities) would only be eligible for a Type 1 NPI. Providers classified as a partnership or corporation who have formed an LLC would be required to obtain both a Type 1 and Type 2 NPI. Please ensure that Magellan has a current copy of your Form W-9 and check the box at the top of the Form W-9 that is appropriate to your situation: Individual/Sole Proprietor, Corporation or Partnership. Also check the Limited Liability Company box and enter the appropriate tax classification for your situation.
Q: I am a provider who is affiliated with two different groups. Do I receive two NPIs?
A: An individual is assigned only one NPI (Type 1) regardless of the number of places where he/she may practice.
Q: I am a rendering provider with a group or organization. Should I submit a Type 1 NPI and a Type 2 NPI on my claims?
A: Yes. Rendering providers must submit Type 1 professional NPIs and Type 2 NPIs on their claims.
Because payment is calculated at the individual practitioner level (i.e., psychiatrists, psychologists, social workers, master’s-prepared therapists and clinical nurse specialists/nurse practitioners) for CPT-based services, groups and organizations should submit Type 1 professional NPIs for rendering providers, along with their group/organization Type 2 NPIs.
Because Magellan maintains linkages between group practices and the members of the group practices (and organizations and their independent practice level practitioners), Magellan needs rendering providers to submit Type 2 NPIs on both paper and electronic claims, in order to properly process and pay claims.
Organization and Subpart Information
Q: I am with an organization. Do the individual practitioners with my organization need to apply for individual (Type 1) NPIs?
A: If your organization is contracted for outpatient services with Magellan and your practitioners practice at the independent practice level (i.e., psychiatrists, psychologists, social workers, master’s-prepared therapists and clinical nurse specialists/nurse practitioners), we request that you send us individual (Type 1) NPIs for these practitioners. Please indicate NPI, date of birth and any applicable service addresses for each facility provider.
If your organization is not contracted for outpatient services with Magellan and/or your practitioners do not practice at the independent practice level, we would not need to receive the individual (Type 1) NPIs for these practitioners.
Q: What is a subpart and why is a subpart enumeration necessary?
A: Healthcare organizations may be comprised of components that function as healthcare providers somewhat independently of the “parent.” Subparts are the components that might conduct their own HIPAA standard transactions, might be certified by the state separately from their “parent,” or might be situated at the same location as, or a different location from, their “parent.”
Subpart determination ensures that those entities/components are identified in HIPAA standard transactions by their unique NPIs.
Q: How can an organization choose to enumerate?
A: Organizations can choose to enumerate subparts by taxonomy/specialty, TIN or site address.
Q: Does Magellan prefer that organizations enumerate a certain way?
A: To facilitate a smoother administration in our provider and claims systems for organizations that submit, or plan to submit, electronic claims:
- If you are an organization with a single-site address and multiple TINs, we prefer that you enumerate subparts at the TIN level.
- If you are an organization with multiple site addresses, we prefer that you enumerate subparts at the site address level.
Q: I am with an organization that has not enumerated subparts at the site address level. How can we ensure that our electronic claims will be paid accurately?
A: For electronic claims to be paid accurately, it is imperative that you always submit the exact information, including system-generated abbreviations, as listed in Magellan’s systems: Pay To Name (Billing Loop 2010AB), Rendering Name (Billing Loop 2310B), and Rendering Address (Billing Loop 2310D).
Q: Where do I find more information about subparts?
A: Visit the CMS website.