Examples of NPI Compliant Transactions | NPI Exemption Notification Form

Please select your segment

Medical Dental Pharmacy Behavioral Health

Medical

Important information regarding NPI compliance

Aetna is fully prepared to process HIPAA standard electronic transactions using just a provider's NPI in real-time transactions and an NPI and tax ID number in electronic claims.

We continue to work diligently with providers to educate them and bring them into compliance according to the HIPAA regulation. However, due to the state of provider readiness and until transaction compliance is at a level that will not negatively impact our constituents and our business operations, we will continue to accept HIPAA transactions with or without NPI and legacy identifiers.

View a list of transaction examples that outline provider identifier requirements for compliant transactions.

The HIPAA standard transactions initiated by medical providers are:

• Claim
• Encounter
• Real-time eligibility
• Claim status inquiry
• Precertification add
• Referral add

Our responses to these transactions will include NPIs. While not required by the regulations, Aetna will process precertification and referral inquiry transactions with NPIs.

If you have not already obtained an NPI and shared it with us please visit:

Get Your NPI

Share Your NPI

Use NPIs on claims. However, NPIs must be loaded into our system before they can be used in eligibility, claim status inquiry, precertification or referral transactions. Aetna individual participating providers and hospitals can confirm that their NPIs are in our system before using them in these transactions by reviewing them in our Provider Referral Directory.

View our help document for guidance on submitting transactions with NPIs for organizations  (3 pages)

How to find other providers' NPIs

The federal government's database of NPIs can be searched at https://nppes.cms.hhs.gov/NPPES/NPIRegistrySearch.do.

Our Provider Referral Directory also includes NPIs that have been shared with us.

In addition to their own NPIs, many health care providers will need to know and use the NPIs of other providers to submit transactions electronically. Therefore, you should share your NPI with other providers who may require it to conduct electronic transactions.

For example:

• Primary care providers will need to know and use the NPIs of specialists they refer to in referral transactions.
• Specialists will need to know and use the NPIs of facilities associated with care that requires precertification.
• Hospitals will need to know and use the NPIs of admitting and attending physicians in claims.

For professional claims, if there is a referring provider, that provider should be identified by name. The named provider's ID must also be sent, if known. If the referring provider NPI is not known, do not include a referring provider ID on the claim.

Claims must continue to include the billing provider's tax ID number to identify the billing entity as a taxpayer.

NPI in Electronic Remittance Advice (ERA)
We include the NPIs received on claims unless a provider has requested otherwise.

If you submit or plan to submit claims with multiple billing provider NPIs yet receive a bundled Electronic Remittance Advice (ERA), please view the ERA changes  that outlines changes that became effective August 2007.

Non-covered entities
If you are not a health care provider as defined under HIPAA and the regulations do not apply to you, your transactions will still be processed with legacy identifiers if you submit our NPI Exemption Notification Form.