National Provider Identifier (NPI) and the Sole Practitioner
Are you having problems understanding what WPS Medicare and the NPI Enumerator are telling you to do?
We would like to offer some tips for providers to help ease the confusion between the different answers providers are receiving from WPS Medicare and the NPI Enumerator.
1) How does WPS Medicare have your provider file?
The Medicare system is designed to categorize providers based on the information given in the applications. A sole practitioner is a person who practices on his/her own.
Medicare's system further categorizes sole practitioners by looking to see if they are employed by a corporation. The practitioner may own the corporation and be the only employee, and in this situation a sole-practitioner will need two NPIs. One NPI will be for the sole practitioner himself/herself, while the second will be for the corporation.
A sole practitioner may also be paid directly by Medicare and not have a corporation of any kind set-up. The practitioner will only receive one NPI and Medicare will not look for a corporate NPI.
If you are not sure what Medicare files indicate for you as a sole practitioner, contact Provider Enrollment at:
WI, IL, MI: (877) 908-8476 8am-4pm (CT)
MN: (866) 564-0315 8am-4pm (CT)
You may also need to complete CMS-855 provider enrollment applications to correct any incorrect information Medicare has on file about a sole practitioner or the corporation. To determine if this is the situation contact Provider Enrollment at the above phone numbers.
2) Are you presenting the same information to both WPS Medicare and NPI Enumerator?
After you determine how Medicare has you set-up in our system, be sure that every contact with the Enumerator, WPS Medicare Customer Service, or WPS Medicare Provider Enrollment is given all the same complete information.
When speaking with any of the three above entities explain that you are a sole practitioner, and be sure to include that you own a corporation (if this applies to you). If you own a corporation and do not explain this to the enumerator and WPS Medicare, the staff at the Enumerator will indicate a sole practitioner is only eligible for one NPI while WPS Medicare staff will use the national Medicare system which indicates you are eligible for two NPIs.
3) What are the two NPIs a sole practitioner who owns a corporation should receive?
An individual (person) is eligible for only one NPI. In the above example, there are two health care providers: the practitioner and the corporation. The practitioner would obtain an NPI (Entity Type Code 1, Individual). The corporation would obtain an NPI (Entity Type Code 2, Organization). Generally, the corporation's NPI would represent the Billing and Pay-to Providers (Item 33A or electronic equivalent) and the physician's NPI would represent the Rendering (Item 24 J or electronic equivalent), Referring/Ordering (Item 17B or electronic equivalent), Attending, Operating and/or Other Providers.
Always remember a sole practitioner, who does not own a corporation, will receive one NPI (type 1) regardless of the number of physical practice locations.
Page Last Updated: Thursday, 18-Mar-2010 05:55:34 CDT
