Billing for an Individual Provider Under a Group

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.

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10 Responses to “Billing for an Individual Provider Under a Group”

  1. Barbara Griswold, MFT, Author, Navigating the Insurance Maze: The Therapist's Complete Guide to Working With Insurance -- and Whether You Should Says:

    Thanks, this was helpful, as I have been getting a lot of questions about groups lately, and it seems many carriers give therapists differing advice on how to handle this. One therapist told me that the insurance plan told her to just use the agency director’s NPI in the “rendering therapist” column (and to get all authorizations under the director’s name) for all the therapists at the center!

    Can I quote you in my monthly e-newsletter? If so, who is the author that I should credit?
    Thanks,
    Barbara

  2. Alice J Scott Says:

    Hi Barbara,
    Yes you can quote us. Glad the info was helpful. Could you please send me your email address. I had a networking idea.
    alice-solutions@cnymail.com

  3. Claudia G Says:

    What happens if the individual provider is not in network but the group is?

    • solutionsmedicalbilling Says:

      Usually it is processed according to the provider who provides the service so likely would be processed out of network.

  4. Hailey Says:

    I know this is an old thread but hoping to get a reply. I am a billing service speaking with a new client. She is a massage therapist who has an llc and employees.about 4 other massage therapist. She has individual provider contracts with most insurances. To bill properly we need to add every employee to her contracts and cannot bill every massage performed under her whether or not she rendered services correct?

    • solutionsmedicalbilling Says:

      The billing must show the rendering provider (the therapist that performed the massage) under 24J and then the billing provider under 33. So the LLC would be the billing provider but the actual therapist that rendered the services must be shown as the rendering. Hope that helps!

  5. Antoneth Says:

    I have recently discovered that I am not credentialed with any of the insurance providers that my clients possess and have been providing services to these clients for almost a year. I am concerned with what is happening with the billing side since I am not credentialed and I do not want to be engaged in unethical and illegal practice. I am assuming that the services I provide are billed through the company under the people who are credentialed with the insurance companies. I’m afraid this doesn’t sound legal as they are not the practitioners rendering services or is there some scenario where this would be acceptable? Also, since I am not credentialed, I am assuming that I am unable to continue to provide services since I am not authorized and unable to bill for these services, correct?

    • solutionsmedicalbilling Says:

      You didn’t mention what type of provider you are. The only instances that it is ok for another provider to bill for your services is if you are an NP or PA and the services are billed under the supervising physician, or some other similar situation. It is not ok for services to be billed under another provider’s name and NPI simply because the rendering provider is not credentialed. If you are not credentialed the services can be billed as out of network. The client may or may not have out of network benefits. If you are not enrolled as a Medicare provider then you cannot treat Medicare patients. Medicaid varies by state, but most states do not allow non credentialed providers to provide covered services to Medicaid patients.

      • Antoneth Says:

        I am a behavior analyst. From my understanding the company I worked for was to complete the two step process with credentialing and adding me to their group NPI. It seems like that has not happened since I contacted HPN, Tricare, BCBS, and Medicaid to confirm if I am in their network and they stated I was not. I am just trying to gather as much information as I can regarding accurate billing before I request for a meeting with them.

  6. solutionsmedicalbilling Says:

    Unfortunately many groups bill under other providers while they are completing the credential process for a new provider but this is not supposed to be done. A provider is supposed to either wait to see patients or hold the billing until the credentialing process is completed.


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