Submit clinical records before pay a claim if the claim includes:
- A code appended with Modifier 22 (unusual procedural service). For example, we may request an operative report for surgical procedures or office notes for non• surgical procedures.
- An “unlisted code” as defined in the Index of CPT Codes under “unlisted services and procedures.”
- A code from our list of non-specific codes.
How do I use my NPI?
Health care providers must use their NPIs on electronic transactions adopted by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Additionally, health care providers need an NPI so they can be identified on electronic transactions performed by other entities. For example, pharmacies must use the NPI of the prescribing physician to submit a claim.
Also, health care providers need the NPIs of referring physicians to submit their own claims electronically. And hospitals need the NPIs of admitting and attending physicians to submit electronic claims to a health plan. We strongly urge providers 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 how to begin including it. 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.
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Does the NPI replace the tax ID number?
The billing provider’s tax ID number (TIN) and NPI are always required on claims. Any other providers identified on the claim, such as rendering provider or service facility, must be identified with their NPI only. The TIN should not be included.
For eligibility, claim status inquiry, referral and precertification, only the NPI is used. We must have the provider’s NPI in our provider database.
Is Aetna maintaining old provider ID numbers and generating new ones?
Yes. We continue to maintain both sets of provider ID numbers. They are needed for other processes.
Are providers allowed to send other identification numbers, such as PIN, PVN 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 permitted only 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 providers in claims and to payees in remittance advices. An NPI also must be used to identify covered health care providers “as providers” in these situations.
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Other identification numbers may be used in certain situations:
- Providers acting in another role, such as an information submitter or receiver, or as a utilization management organization.
- Non-covered health care providers. For example, a referring provider who does not conduct any electronic transactions is a non-covered provider who may have chosen not to obtain an NPI.
- Individuals and entities who are not considered health care providers (also known as atypical providers). Atypical providers are persons or groups whose services may be paid for by health benefits plans but who do not directly provide health care. Some common examples include:
- Personal care workers (for example, aides providing assistance with daily living)
- Non-medical living arrangements (for example, assisted living, certified family homes, boarding homes, supervised independent living and community residential facilities)
- Non-emergency transportation providers (for example, taxi services)