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Dental Insurance 101

What's an NPI and Do I Need One?

What is an NPI?

  • A 10-digit random number unique to each health care provider or organization
  • It contains no coded information about the provider or organization
  • A permanent identifier that does not change over time or expire
  • A replacement for other identifying numbers currently used in electronic transactions, such as Medicaid, Blue Cross and Blue Shield, UPIN, CHAMPUS, and other select “legacy” numbers
  • Not a replacement for social security numbers, DEA numbers, taxpayer ID numbers, taxonomy (specialty) numbers, or state license numbers
  • Issued by the government through a third-party group, the National Plan & Provider Enumeration System (NPPES), which is responsible for processing applications and assigning numbers

 

Who Needs One?

Every health care provider transmitting health information in connection with a standard transaction in electronic form must obtain an NPI. It is required by the federal Health Insurance Portability and Accountability Act (HIPAA) for electronic transactions.

All individual health care providers (including dentists) and organizations such as clinics and group practices are eligible to obtain one.

If you answer “yes” to any one of the following questions, you are considered a “covered entity” under the standard and are required by federal law to obtain an NPI.

  • Do you submit claims electronically?
  • Do you use a clearinghouse?
  • Do you submit claims attachments electronically?
  • Do you use the internet to obtain eligibility and benefits information or check on the status of claims?

 

Type 1 or Type 2 – Which One is Right For You?

There are two types: Type 1 for individual health care providers, such as dentists and hygienists, and Type 2 for incorporated businesses, such as group practices and clinics.

  • Type 1 is for the provider. This is the only type you will need if you receive payments in your name or under your social security number as a solo practitioner. For practices with multiple dentists, obtain a Type 1 NPI for each dentist.
  • Type 2 is for group practices, incorporated dental practices, or other business entities paid under their business or corporate name or under their employer identification number (EIN).

On claims, the Type 2 NPI identifies the payee and may be submitted in conjunction with a Type 1 NPI identifying the dentist who provided the treatment.

Example

On a standard ADA Dental Claim Form (#J400), the treating dentist NPI is entered in field 54, and the billing entity NPI is entered in field 49.

 

Solo Practitioner

Type 1 only, if claims are transmitted in the dentist’s name and social security number

Individual Dentist, One Practice Location

Type 1 for the dentist and Type 2 for the practice, if claims are transmitted in the practice’s name and Tax Identification Number (TIN)

Multiple Dentists, One Practice Location

Type 1 for each dentist and Type 2 for the practice, if claims are transmitted in the practice’s name and TIN

Multiple Dentists, Multiple Practices

Type 1 for each dentist and Type 2 for each practice with a separate TIN

 

How to Apply

  • Visit the National Plan & Provider Enumeration System website.
  • Complete the application and follow instructions to submit either online or by mail. Faxes are not accepted.
  • After confirmation of your application has been received, you should receive it via e-mail within one to five business days if you submitted the application online. Mailed applications may require up to 20 days to process.
  • If any data related to your NPI changes (name, address, etc.), you are responsible for submitting an update to the NPPES within 30 days of the change.

 

Register Your NPI With Delta Dental

Please register your NPI with Delta Dental by providing a copy of the confirmation containing the NPI you receive from the National Plan & Provider Enumeration System (NPPES). Send it to your local Delta Dental by e-mail, fax, or U.S. mail:

California

Dentist_Services@Delta.org
916.852.8995
Delta Dental, Attn: DNAC
P.O. Box 997330
Sacramento, CA 95899-7330

Alabama, Florida, Georgia, Louisiana, Mississippi, Montana, Nevada, Texas, and Utah

dnac@ddic.Delta.org
770.641.5395
Delta Dental, Attn: DNAC
P.O. Box 1809
Alpharetta, GA 30023-1809

Delaware, District of Columbia, Maryland, New York, Pennsylvania, and West Virginia

ddpDentist_Services@DeltaDentalPA.org
717.774.1770
Delta Dental, Attn: DNAC
1 Delta Drive
Mechanicsburg, PA 17055

For other Delta Dental member companies, please check how they prefer you to register. Submitting it on a claim will not ensure it’s entered into the Delta Dental system.

 

When to Use Your NPI on Claims

  • Once you’ve registered your NPI with Delta Dental, you should begin using it on claims. Delta Dental recommends it be used on all claims.
  • Enter the NPI of the billing dentist or dental entity and the treating dentist’s NPI (if they are different).
  • Use new claim forms that accommodate the NPI by providing a specific space for it. (This might require you to upgrade your software.)

 

NPI FAQs

Q: I submit paper claims and don’t use the internet to check patient eligibility and benefits. Do I still need an NPI?

A: If you don’t conduct any electronic transactions governed by HIPAA, you aren’t required to obtain one. However, we strongly encourage you to get one because you can use it as a single unique identifier with all payers.

 

Q: How is it determined?

A: They are issued by the National Plan & Provider Enumeration System (NPPES). They contain no embedded intelligence – for example, there is no coding identifying the dentist’s state or license number. It is only a random number that does not expire.

 

Q: How will the NPI affect other numbers I’ve used in the past?

A: It replaces other identifying numbers used in electronic transactions, such as:

  • Medicaid
  • Blue Cross and Blue Shield
  • UPIN
  • CHAMPUS
  • Certain other legacy numbers

The NPI will not replace these numbers, which are used for purposes other than general identification:

  • Social Security
  • DEA
  • Taxpayer Identification
  • Taxonomy
  • Your state license

 

Q: Where can I get help with the NPI application?

A: The NPI Enumerator will help you with your NPI application and update your information in the NPPES.

Contact the NPI Enumerator:

CustomerService@npiEnumerator.com
1.800.465.3203
1.800.465.3203 FREE
1.800.692.2326
1.800.692.2326 FREE (NPI TTY)

NPI Enumerator
P.O. Box 6059
Fargo, ND 58108-6059

 

Get More Information

The information provided here is for educational purposes only and should not be interpreted as legal advice. Dentists are encouraged to seek their own legal advice about how the NPI pertains to their practices and circumstances.

 


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