Difference between the Medicare Provider Numbers
In order for a provider to enroll into Medicare program, the provider must have a National Provider Identifier (NPI) issued by the National Plan and Provider Enumeration System (NPPES). The NPI is used to identify providers in the HIPAA standard process, such as the claims submission process. Once the NPI is issued the provider can complete a CMS 855 provider enrollment application and send it to Medicare Administrative Contractor's (MAC's) Provider Enrollment Department.
The MAC's Provider Enrollment department issues Medicare Providers a Medicare Transactions Number called the Provider Transaction Access Number (PTAN). The PTAN is the same number as a previously issued Provider Identification Number (PIN). After the Carrier issued the PTAN, a Unique Provider Identification Number (UPIN) was issued to the provider through the UPIN Registry. The PTAN is used for claims processing system and access to information purposes and the UPIN was used for ordering and referring purposes. However, CMS discontinued assigning UPINs on June 29, 2007. Refer to the CMS MLN Matters article, "Discontinuance of the Unique Physician Identification Number (UPIN) Registry" (MM 5584) for more information.
NPPES requires providers to submit an application for an NPI. Each type 1i provider is issued one NPI for his/her lifetime. The NPI follows him/her anywhere the provider practices in the United Stated. Type 2ii providers are issued one number per organization and can decide if subpartsiii need an NPI. The NPI is submitted for all claims sent to Medicare. Claims without a NPI will be returned as unprocessable. There are no appeal rights for claims deemed unprocessable; you must correct the claim and resubmit it. To learn more see "How to complete the CMS 1500 Claim Form" on the CMS website.
To learn more about NPIs visit the CMS National Provider IdentifierExternal Link web page or to apply for an NPI visit the NPI Enumerators websiteExternal Link. To check on a referring or ordering provider's NPI you may go to the NPI Enumerators RegistryExternal Link website.
A Medicare Provider is issued a PTAN for each entity they work for. The PTAN identifies who rendered services to a Medicare Beneficiary in the Medicare claims processing system. A provider will need the PTAN to access data on the Interactive Voice Response (IVR) phone system. A group claim will also receive a PTAN and can be used for identification purposes when contacting Medicare. The provider may choose to submit the PTAN on a claim until May 23, 2008. To learn more see "How to complete the CMS 1500 Claim Form" on the CMS website.
i Type 1 providers are people, such as a doctor, nurse, therapist, etc.
ii Type 2 providers are entities, such as hospital, clinics, doctor's groups, other medical facilities, etc.
iii Subpart are area of the group that have a different function, such as a hospital owned lab, or a mental health section of the hospital.
Page Last Updated: Friday, 18-Jul-2014 08:32:34 CDT