HIPAA regulations dictate that, as a health care provider working with health insurance companies, you need a National Provider Identifier (NPI) number. These 10-digit numbers are a way for the healthcare sector to identify health professionals consistently and they are publicly searchable.
There are actually two types of NPIs, logically referred to as “Type I” and, yes, “Type II”. Type I NPIs are also sometimes called individual or personal NPIs, while Type II NPIs can be referred to as either organizational or group NPIs.
So, what’s the difference between those types? Do you need one of each? Can you have one without the other? If you’re a sole practitioner, does a group NPI even need to be on your radar?
Sole Practitioner = Get a Type I NPI
Here's how it works: if you have a private practice, to file claims with health insurance companies, you'll only need a Type I NPI. This will always be your unique identifier across all companies (believe it or not, you used to need a different identifier for each company with which you were in-network). Your Type I NPI will stay with you throughout your career and won’t be affected by geographic changes, if, for example, move and relocate your practice.
Group Practices = Get a Type II NPI
A group (Type II) NPI is associated with a business entity comprising of more than a single provider. If you own a practice and have additional RDNs on staff, a Type II is necessary for your business.
If a new hire is joining your group, they will still need to obtain an individual (Type I) NPI. On a claim, the Type I NPI will identify them as the rendering provider - the healthcare professional actually providing the service. They will also include the group (Type II) NPI number in a claim so that the insurance reimbursement goes to the right place.
The Exception: Medicare
The exception for the “sole practitioner = get a Type I NPI” rule of thumb is Medicare. If you are a sole owner operating under your LLC, you will need a Type II NPI if you plan to accept Medicare. You will have to apply for a Type II NPI using your EIN (Employer Identification Number) instead of with an SSN. (If you indicate on the Medicare application that you are Self Employed/Sole Proprietor then you can use your Type I.) You will also need a different type II NPI for each state in which you practice when applying for Medicare.
If you do apply to Medicare with your Type II NPI, you can file Medicare claims with that information once you’re approved and contracted. Continue to file claims with private payers using your Type I NPI.
What questions do you have about NPI numbers?