Federal regulations require you to submit Health Insurance Portability and Accountability Act (HIPAA) standard electronic transactions with only your NPI number.
General information
What is a National Provider Identifier (NPI)?
It’s a unique 10-digit number assigned to health care providers and organizations defined as covered entities under HIPAA. The NPI is a permanent identifier assigned for life.
What is a covered entity?
Health care providers who send standard electronic transactions (for example, claims submissions, referrals, etc.) are covered entities and are required by the HIPAA NPI regulations to apply for and receive an NPI.*
What does an NPI do?
It does:
- Replace all other provider identifiers previously used by health care providers (for example, UPIN, Medicare/Medicaid numbers, etc.)
- Establish a national standard and unique identifier for all health care providers
- Simplify health care system administration
- Make it easy to send health care information electronically
What does an NPI not do?
It doesn’t:
- Replace the tax identification number (TIN), which is an IRS requirement
- Convey information about the provider (for example, provider type, service location, etc.)
- Guarantee payment by health plans
- Enroll providers in health plans
Who should apply for an NPI?
- Individual health care providers, such as physicians, dentists and pharmacists
- Organizational health care providers, such as hospitals, pharmacies, group practices, laboratories, ambulatory care facilities and nursing homes
Using your NPI in HIPAA standard electronic transactions
Which HIPAA-standard electronic transactions have to include the NPI?
- Claims
- Claim Encounters
- Claim Status Inquiries (CSI)
- Electronic Remittance Advice (ERA)
- Interactive Voice Response (IVR)
- Real-time Eligibility (RTE)
How do I use my NPI?
You need to use your NPI on electronic transactions covered by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). You also need an NPI to be identified on electronic transactions performed by other entities.
And you need the NPIs of referring dentists to submit your claims electronically. We urge you to share your NPI with these other entities.
Contact your electronic data interchange (EDI) vendor to find out how to begin including NPIs in your transactions. 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 help.
Does the NPI replace the tax ID number?
No, both the billing provider's tax ID number and NPI are always required on claims. Any other providers identified, such as rendering provider or service facility, must be identified with their NPI only. Their tax ID number should not be included.
We use only the NPI (no tax ID number) for eligibility, claim status inquiry, referral and precertification. But you need to submit your NPI to us ahead of time. Then we need to add it to our provider database.
Send us your NPI
Is Aetna maintaining old and generating new Aetna provider identification numbers?
We maintain old and also generate new Aetna provider ID numbers in our systems. These are needed for other processes not covered by the NPI regulation.
Are providers allowed to send other identification numbers, such as PIN and TIN, in electronic transactions?
To comply with the regulations, covered entities must use the NPI of any health care provider (or subpart) that’s been assigned an NPI to identify that health care provider in HIPAA standard transactions.
The use of other IDs is only permitted 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 payees in remittance advices. An NPI must be used to identify covered health care providers "as providers" in these situations.
- Providers who are not acting in a "provider" role. Examples include providers who are information submitters or receivers or utilization management organizations.
I submit electronic transactions but am not eligible for an NPI. How do I notify Aetna?
Notify us by using our NPI Exemption Notification Form.
My organization has multiple NPIs. Which should I use in transactions?
View this document for help on submitting transactions with NPIs for organizations.
Claims and encounters
Has the NPI changed the way Aetna pays claims and to whom?
No, the NPI didn’t cause any changes to claim adjudication. We use the billing Tax Identification Number (TIN) and provider name and address information. The NPI will now also be used to identify the appropriate provider.
Does Aetna require the NPI on paper claims?
The rules only require the use of NPIs on electronic transactions. But we recommend that you send NPIs on paper claims.
Another payer has notified me that in addition to my NPI, I must submit a different tax ID number on my claims. Should I make the same change in my Aetna claims submissions?
Some providers have multiple tax ID numbers. For example, you may have an SSN and one or more EINs. We're aware that other payers, such as Medicare, have asked some providers to submit claims with a different tax ID number than they used in the past.
But if you make changes to the tax ID number on your Aetna claims, it may affect our ability to process your claims in a timely manner.
If you want to change your tax ID number for Aetna, you can notify us as you do with any other demographic update. You can:
- Fax your information to: 1-859-455-8650
- Contact the Dentist Contracting Hotline: 1-800-776-0537
- Fax your information to the network fax line: 1-860-754-1602 (for participating providers)
- Contact your network account manager
My claim was rejected for missing "Billing Provider" NPI. What action do I need to take on these claims to have them processed?
Use the NPI as the primary ID for the Billing Provider and resubmit electronically.
Use only the NPI for eligibility, claim status inquiry, referral and precertification. But first you need to send us your NPI. Then we need to add it to our provider database.
What error codes will I see if my claim submissions are rejected due to lack of an NPI?
Depending on the format of your vendor's claim status report, you may see the codes below:
Code Text
- A3 Acknowledgement/Returned as a claim that can't be processed: The claim/encounter has been rejected and has not been entered into the adjudication system.
- 562 National Provider Identifier (NPI)
- 85 Billing Provider
Remittance advice
Does Aetna include NPIs on Explanation of Benefits (EOB) formats other than the electronic remittance advice (ERA)?
Only ERAs include NPIs at this time.
If an electronic remittance advice (ERA) can have a different NPI than submitted on the claim, how can I tell which claim the ERA is responding to?
The submitter's claim number (from CLM01 in an 837 EDI claim) is returned in the CLP01 element in the 835, and this is not affected by the NPI regulations or related changes. The 835 ERA implementation guide states the following about the CLP01: "This data element is the primary key for posting the remittance information into the provider's database. We also recommend that it be used for that purpose rather than matching by provider IDs."
It's generally not necessary to match remittances to claims using the provider ID.
Is the NPI from the claim included on the payee's electronic remittance advice, or does Aetna derive the NPI from its internal database?
ERAs include the billing provider's NPI unless you request otherwise. You can request that the payee NPI on the ERA be an NPI you shared with us.
Attention dentists who receive Electronic Remittance advices (ERA):
We’ll only generate ERAs that are NPI-compliant. If you want to receive an ERA, you must include your NPI on paper claims. Otherwise, you’ll receive a paper or online Explanation of Benefits (EOB).
Do new agreements need to be signed for electronic funds transfer (EFT) as a result of the NPI?
No, new agreements don’t need to be signed as a result of the NPI.
Does the NPI replace the tax ID number on eligibility, claim status inquiry, referral and precertification transactions?
Federal rules require submission of the provider's NPI number for eligibility, referral and precertification transactions. That is, unless the provider is not considered a health care provider as defined under HIPAA. We also need to be informed of the provider’s NPI and it must be in our database.
For claim status inquiry, NPI is required in the servicing provider field (it should be the same NPI that was submitted on the claim you are inquiring about). The billing provider ID can be an NPI, Tax ID or PIN/PVN.
What should I do if I get an error message when I try to transmit my NPI in an eligibility, claim status inquiry, referral or precertification transaction?
Confirm that we’ve received and loaded your NPI into our database. You can do this by logging in to our secure provider website and selecting "Update Profiles." Then, select the NPI tab. Any NPIs you’ve submitted to Aetna that have been loaded into our database will be on the first screen.
Other resources (for participating providers)
We post information in our dentist newsletter, Dental Dialog. We also provide information through outreach and industry events. If you have questions, call our National Dentist Line at 1-800-451-7715.
* Aetna does not believe it is necessary to enter into Business Associate Agreements with most Providers (including Dentists), Hospitals, Labs, etc.
Aetna does not consider most of our providers a business associate of ours as defined in §160.103 of the HIPAA Privacy Rule, and we are exempt of the need to sign a business associate agreement by §164.502(e)(1)(ii)(A). Furthermore the Rule preamble (in the comments to the definition of “business associate”) clearly states that “For example when a health care provider discloses protected health information to health plans for payment purposes, no business associate relationship is established. While the covered entity may have an agreement to accept discounted fees as reimbursement for services provided to health plan members, neither entity is acting on behalf of or providing a service to the other”. Therefore, Aetna considers it unnecessary to enter into Business Associate Agreements with most Providers (including Dentists), Hospitals, Labs, etc.
News
You are now leaving the Aetna Dental Web site and linking to ClaimConnect*.
Aetna Dental works with ClaimConnectTM offered by EDI Health Group (EHG) to provide easy access to check patient eligibility, file a claim, check claim status, view patient rosters and Electronic Remittance Advice.
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