Federal regulations require you to submit HIPAA standard electronic transactions with only your NPI number. Additional information on this requirement follows.
Health care providers must use their NPIs on electronic transactions adopted by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Additionally, health care providers need an NPI so 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. And 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.
Tips on using organizational NPIs in electronic transactions (PDF)
If you are not using your NPI in electronic transactions, contact your EDI vendor to find out how to begin including it. 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.
The billing provider's tax ID number (TIN) and NPI are always required on claims. Any other providers identified on the claim, such as rendering provider or service facility, must be identified with their NPI only. The TIN should not be included.
For eligibility, claim status inquiry, referral and precertification, only the NPI is used. We must have the provider's NPI in our provider database.
Yes. We continue to maintain both sets of provider ID numbers. They are needed for other processes.
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 permitted only 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 to payees in remittance advices. An NPI also must be used to identify covered health care providers "as providers" in these situations.
Other identification numbers may be used in certain situations:
Providers acting in another role, such as an information submitter or receiver, or as a 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 benefits plans but who do not directly provide health care. Some common examples include:
No, the NPI did not cause any change to claims adjudication. We use the billing provider tax ID number and provider name and address. The NPI also can be used to identify the appropriate provider.
The billing provider's tax ID number (TIN) and NPI are always required on claims. Any other providers identified on the claim, such as rendering provider or service facility, must be identified with their NPI only. The TIN should not be included.
For eligibility, claim status inquiry, referral and precertification, only the NPI is used. We must have the provider's NPI in our provider database.
No. Although we do not require this information for claims adjudication, it may be necessary for you to send it in order to comply with HIPAA regulations.
Note: OSCAR numbers, commonly referred to as UPIN or MPN, are six-digit Medicare provider numbers issued to facilities.
To comply with the regulations, use of a Medicare provider number is not permitted on electronic claims. Because of this, we require an NPI, or an NPI and taxonomy code, on institutional claims where we required the submission of a Medicare provider number. 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 taxonomy codes are not required.
When a provider cannot send claims electronically, the billing facility taxonomy code should be formatted on the UB-04 paper claim form in field 81cc, preceded with the qualifier B3.
Some providers have multiple tax ID numbers, for example, SSN and EIN or multiple EINs. We are 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. However, 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 communicate this change as you do any other demographic update by doing one of the following:
For claims that reject for National Provider Identifier, use the NPI as the primary ID for the Billing Provider and resubmit electronically.
Depending on the format of your vendor's claim status report, you may see codes as listed below and/or text similar to that below:
Code Text:
A3 — Acknowledgement/Returned as unprocessable claim. The claim/encounter has been rejected and has not been entered into the adjudication system.
562 — National Provider Identifier (NPI)
85 — Billing Provider
ERAs include the billing provider's NPI at the payee level unless you request otherwise. To reduce the number of ERAs and EFTs you receive, you can request that the payee NPI on the ERA be an NPI you shared with us. If you choose this “override” option, the ERA will still include the billing provider’s NPI, but it will be at the subgroup level, rather than the payee level.
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.
No.
For eligibility, referral and precertification transactions, federal regulations require submission of the provider's NPI number unless the provider is not considered a health care provider as defined under HIPAA.
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), but the billing provider ID can be an NPI, Tax ID or PIN/PVN.
You should confirm that we have received and loaded your NPI into our database. You can confirm that your NPI is in our system by logging in to our provider portal. From the home page, select:
Although the referral inquiry and precertification inquiry transactions are not covered by the regulations, we can process them using the NPI as the provider identifier.
When authorization details are returned in response to these inquiries, the providers will be identified by NPI (if one is available in our database).
Find answers to your questions about joining our network, Clinical Policy Bulletins, the dispute process and more.
Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates (Aetna).
Links to various non-Aetna sites are provided for your convenience only. Aetna Inc. and its subsidiary companies are not responsible or liable for the content, accuracy or privacy practices of linked sites, or for products or services described on these sites.
Links to various non-Aetna sites are provided for your convenience only. Aetna Inc. and its subsidiary companies are not responsible or liable for the content, accuracy or privacy practices of linked sites, or for products or services described on these sites.
Links to various non-Aetna sites are provided for your convenience only. Aetna Inc. and its subsidiary companies are not responsible or liable for the content, accuracy or privacy practices of linked sites, or for products or services described on these sites.
Links to various non-Aetna sites are provided for your convenience only. Aetna Inc. and its subsidiary companies are not responsible or liable for the content, accuracy or privacy practices of linked sites, or for products or services described on these sites.
You are now being directed to the CVS Health site.
Links to various non-Aetna sites are provided for your convenience only. Aetna Inc. and its subsidiary companies are not responsible or liable for the content, accuracy, or privacy practices of linked sites, or for products or services described on these sites.
Links to various non-Aetna sites are provided for your convenience only. Aetna Inc. and its subsidiary companies are not responsible or liable for the content, accuracy, or privacy practices of linked sites, or for products or services described on these sites.
Links to various non-Aetna sites are provided for your convenience only. Aetna Inc. and its subsidiary companies are not responsible or liable for the content, accuracy, or privacy practices of linked sites, or for products or services described on these sites.
Links to various non-Aetna sites are provided for your convenience only. Aetna Inc. and its subsidiary companies are not responsible or liable for the content, accuracy, or privacy practices of linked sites, or for products or services described on these sites.
Links to various non-Aetna sites are provided for your convenience only. Aetna Inc. and its subsidiary companies are not responsible or liable for the content, accuracy, or privacy practices of linked sites, or for products or services described on these sites.
The information you will be accessing is provided by another organization or vendor. If you do not intend to leave our site, close this message.
Just enter your mobile number and we’ll text you a link to download the Aetna Health app from the App Store or on Google Play.
Message and data rates may apply*
Each main plan type has more than one subtype. Some subtypes have five tiers of coverage. Others have four tiers, three tiers or two tiers. This search will use the five-tier subtype. It will show you whether a drug is covered or not covered, but the tier information may not be the same as it is for your specific plan. Do you want to continue?
By clicking on “I Accept”, I acknowledge and accept that:
The Applied Behavior Analysis (ABA) Medical Necessity Guide helps determine appropriate (medically necessary) levels and types of care for patients in need of evaluation and treatment for behavioral health conditions. The ABA Medical Necessity Guide does not constitute medical advice. Treating providers are solely responsible for medical advice and treatment of members. Members should discuss any matters related to their coverage or condition with their treating provider.
Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply.
The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna) for a particular member. The member's benefit plan determines coverage. Some plans exclude coverage for services or supplies that Aetna considers medically necessary.
Please note also that the ABA Medical Necessity Guide may be updated and are, therefore, subject to change.
Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. In the event that a member disagrees with a coverage determination, member may be eligible for the right to an internal appeal and/or an independent external appeal in accordance with applicable federal or state law.
