We often get questions about billing for providers who are working for a group. It is important to understand not only the difference between the rendering provider NPI and the billing provider NPI, but also how the provider is set up with each insurance carrier.
It is not simply enough to put the rendering provider’s individual NPI in the rendering provider NPI box, which is box 24J on the CMS form, and the group NPI in the billing provider information box, box 33a on the CMS form. You must also make sure that the provider’s individual NPI is linked to the group NPI with each insurance carrier.
It is not simply enough for the provider to be credentialed with the insurance carrier. Their individual NPI must also be linked to the group’s NPI if the payment is to be made to the group. For example, say a provider is in network with their local BCBS but they are set up individually under their ss# and their individual NPI. Then they decide to work part time for another group. The group they are working for cannot simply bill BCBS with that provider’s individual NPI in the rendering provider field and their group NPI in the billing provider field and expect payment to be made to the group. Even if the provider is par with BCBS. The group must notify BCBS that the provider will be working for the group, in addition to their private practice. BCBS will link the provider’s individual NPI to the group’s NPI.
It is important to make sure that all providers that a group will be billing for are set up correctly with the insurance carriers. Not having it set up correctly can cause huge problems with the billing and can really mess up the accounts receivables. Understanding how the NPI’s work is the key.
The rendering provider NPI is the individual NPI of the provider who performed the services on the patient being billed. The billing provider NPI is the NPI of the person or entity that should be paid for the services. In some cases the rendering provider NPI and billing provider NPI is the same. In some cases, a rendering provider may have multiple billing provider NPI’s. They may have a private practice which has it’s own NPI and they may work for another group or clinic that has a different billing NPI. As long as the insurance carriers have the provider set up correctly on their files, it doesn’t matter.
If you are billing for a provider or group, and you are not sure if the all of the provider’s NPI’s are set up correctly, you should call the insurance carriers to confirm. It is always better safe than sorry.