Using Your National Provider Identifier (NPI) in HIPAA Standard Electronic Transactions
Aetna is fully prepared to process your HIPAA transactions using just your NPI in real time transactions and your NPI and tax ID number in electronic claim submissions.
You should already be including NPIs in all HIPAA standard electronic transactions submitted to us. Federal regulations require you to submit HIPAA standard electronic transactions with only your NPI number. Please act immediately to address and resolve any problems related to submitting transactions with only your NPI number.
Medical
- How do I use my NPI?
Health care providers must use their NPI on electronic transactions adopted by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Additionally, health care providers need an NPI so that 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. 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.
- What HIPAA standard electronic transactions have been revised to include the NPI?
- Claim
- Encounter
- Eligibiltiy (real-time)
- Claim status inquiry
- Electronic remittance advice
- Precertification add
- Referral add
- NCPDP - Pharmacy
- How do I test use of NPIs with Aetna?
Use the NPI in your transactions and verify your results are what you expected. We recommend you contact your clearinghouse or vendor for assistance.
- Has NPI changed the way Aetna pays claims and to whom?
NPI did not cause any change to claim adjudication. Aetna uses the tax identification number and provider name and address information. The NPI can also be used to identify the appropriate provider.
- Has Aetna continued to maintain old and generate new legacy numbers?
We continue to maintain old and generate new legacy identifiers in our systems since they are needed for other processes not encompassed by the NPI regulation.
- Does Aetna require the NPI on paper claims?
Regulations only require the use of NPIs on electronic transactions. However, the professional and institutional paper claim forms (CMS [previously HCFA] 1500 version 12/90 and UB-92) were revised to allow NPIs to be included. We can accept, but do not require, NPIs on the revised forms (CMS 1500 version 08/2005 and UB-04). Additional information on the new forms is available at www.nucc.org and www.nubc.org.
We also accept, but do not require, the use of legacy ID number on paper claim forms. To assure timely, accurate claim payment, it is recommended that paper forms be completed with either the NPI or the legacy ID.
- Does Aetna send the legacy identifier, the NPI or both on paper Explanation of Benefits (EOBs)?
We do not include NPIs on paper EOBs at this time.
- Is the NPI from the claim included on the payee's electronic remittance advice (ERA), or does Aetna derive the NPI from its internal database?
ERAs include the billing provider's NPI (or pay-to provider, if present), unless you request otherwise. You can request that the payee NPI on the ERA be an NPI you shared with us. Please view the ERA changes 
(1 page) document that outlines changes effective in August 2007.
- 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 ERA, 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."
Matching remittances to claims using the provider ID is normally not necessary.
- Do new agreements need to be signed for Electronic Funds transfer (EFT)?
No, new agreements do not need to be signed as a result of NPI.
- Does Aetna require the referring physician's NPI on claims?
No. While Aetna does not require this information for claim adjudication, it may be necessary under HIPAA regulations.
- Can providers submit a claim or other electronic transaction using only the NPI?
The billing provider's tax ID number is always required on claims. You must now include your NPI on claims as well.
For real-time transactions (eligibility and benefits inquiry, claim status inquiry, referral add and inquiry and precertification add and inquiry), we must have been informed of the provider's NPI and it must have been loaded into our provider database.
- What should I do if I get an error message when I try to transmit my NPI in a real-time transaction?
If you receive an error message when you transmit your NPI in a real-time transaction, you should confirm that Aetna has received and loaded your NPI into its database. You can confirm that your NPI is in Aetna's system by logging into the Aetna secure provider website and selecting "Update Profiles." Then, select the NPI tab. Any NPIs you have submitted to Aetna that have been loaded into Aetna's database will be on the first screen.
- How does NPI affect the referral and precertification inquiry transaction?
When authorization details are returned on an inquiry, the providers will be identified by an NPI, when an NPI is available in our database.
- Are providers allowed to send IDs, 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 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 only applies to billing/pay-to for 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 acting in a way that is not considered to be a "provider" role, such as information submitter or receiver or 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 benefit plans but 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)
- Entities that administer health benefits but do not directly provide health care such as:
- Other health plans
- Individual Practice Associations (IPAs)
For more information, see CMS' answer to question ID 5816 at http://questions.cms.hhs.gov.
- I am an electronic transaction submitter. How do I notify Aetna that I am exempt from the regulations?
If you are exempt from the regulations, notify us by using our NPI Exemption Notification Form.
- How do I start using NPI?
If you are not using your NPI in electronic transactions, find out the steps you need to take to begin including NPIs in your transactions to ensure a smooth transition. 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.
- How will Aetna process claims that were submitted with Medicare OSCAR numbers?
Note: OSCAR numbers, commonly referred to as UPIN or MPN, are six-digit Medicare provider numbers issued to facilities.
To be compliant with the regulations, use of a Medicare Provider Number is not permitted on electronic claims. Because of this, we will require an NPI or NPI and taxonomy code on institutional claims where the submission of a Medicare Provider Number is currently required by Aetna. Depending on your current set-up, you may or may not be required to submit a taxonomy code to Aetna.
Institutional providers that currently bill Medicare for subparts are required to use taxonomy codes on their claims to Aetna. All other providers are encouraged to use taxonomy codes to help ensure accurate identification, but submission of taxonomy codes is not required.
For situations where a provider is unable to send his or her claim electronically, the billing facility taxonomy code should be formatted on the UB04 paper claim form in field 81cc, preceded with the qualifier B3.
Still have questions?
We continue to provide information on NPI through our provider newsletter, OfficeLink Updates™, as well as through direct outreach and communications, and industry events.
