Denials Reported on Bills by Sole Proprietors/Practitioners

By the FCA Help Desk

Some sole proprietors and some incorporated sole practitioners are reporting being denied reimbursement because they are not billing as a group (business) in field 33. Although an official explanation has not been obtained that describes what is occurring, this appears to involve the need for a second NPI number.

For ALL bills submitted in the 1500 Uniform Billing Form:

• The individual NPI number of the rendering provider is placed in field 24J.
• The NPI number in field 33 should represent the entity to whom the money is being reimbursed.
• The tax identification number in field 25 should match the NPI in field 33.
• If you are a sole proprietor (or an incorporated sole practitioner) and have a tax I.D. number other than your social security number that you enter in field 25 on the billing form, a​n insurer ​may​ require​​ an NPI number other than your individual, Type 1, practitioner NPI number in field 33.
• Although regular Medicare does not require this for sole proprietors, they do require it for incorporated sole practitioners.  Private insurers have the discretion to require two NPI numbers whether or not you are incorporated – if the tax number in field 25 is not a social security number.  Medicare Advantage or replacement plans are administered by private insurers and so may require this second (business or type 2) NPI number.
• If you are a sole proprietor that has a tax identification number other than your social security number, but do not have a second NPI number, you may obtain one “for billing purposes only”.
• If you are an incorporated sole practitioner and do not have a type 2 (business) NPI number you should obtain the Type 2 NPI and use it in field 33 of the billing form.