Medical Provider Newsletter - October 2018

May a provider bill EMI Health under another provider’s name and NPI?

In general, EMI Health requires providers to submit claims under their own names and NPIs. There are a limited number of circumstances where a provider may submit a claim to EMI Health under another provider’s name and NPI.

What if one provider is employed by another provider?

If a provider works for a healthcare organization or incorporated individual, that organization’s name and Type 2 NPI is submitted as the billing provider. However, the provider performing the services must report his or her name and Type 1 NPI as the rendering provider. Just because a provider works for another provider does not mean the employing provider may submit claims on behalf of the employee—even temporarily while a new employee waits for credentialing to be completed.

What if one provider is supervised by another provider?

A supervising physician may bill on behalf of a midlevel provider who is not directly contracted with EMI Health, if the supervising physician is practicing in the same location and is immediately available to support the midlevel provider. A midlevel provider who is individually contracted with EMI Health should submit claims using his or her own name and Type 1 NPI. Physicians must bill EMI Health directly for services they render, regardless of whether they are contracted with EMI Health or supervised by another physician.

NPI Basics

Type 1: Individual providers are each required to obtain a Type 1 (individual) NPI. An individual is eligible for only one Type 1 NPI, and Type 1 NPIs may not be shared among providers in an organization.

Type 2: Providers who are organizations, including healthcare groups and individuals who have incorporated their practices, must also obtain a Type 2 (organizational) NPI. Large corporations may have subparts that need to be uniquely identified with their own Type 2 NPIs.

Billing: When submitting claims, the individual Type 1 NPI is used to identify the provider who performed the service, while the organizational Type 2 NPI identifies the entity to be paid. Individual unincorporated providers may use the Type 1 NPI for billing and rendering.