INSURANCE CONNECTION
National Provider Identifiers
All individual Health Insurance Portability and Accountability Act ( HIPAA ) covered health care providers ( physicians , physician assistants , nurse practitioners , dentists , chiropractors , physical therapists , athletic trainers etc .) or organizations ( hospitals , home health care agencies , nursing homes , residential treatment centers , group practices , laboratories , pharmacies , medical equipment companies ) must obtain an National Provider Identifier ( NPI ) for use in all HIPAA standard transactions , even if a billing agency prepares the transaction .
Once assigned , a provider ' s NPI is permanent and remains with the provider regardless of job or location changes .
The NPI is a HIPAA Administrative Simplification Standard . The NPI is a unique identification number for covered health care providers . Covered health care providers and all health plans and health care clearinghouses must use the NPIs in the administrative and financial transactions adopted under HIPAA . The NPI is a 10-position , intelligence-free numeric identifier ( 10-digit number ). This means that the numbers do not carry other information about healthcare providers , such as the state in which they live or their medical specialty . The NPI must be used in lieu of legacy provider identifiers in the HIPAA standards transactions .
As outlined in the Federal Regulation , HIPAA covered providers must also share their NPI with other providers , health plans , clearinghouses , and any entity that may need it for billing purposes ( our emphasis added ).
If you have not already done so , you may apply for an NPI online . For the most efficient application processing and the fastest receipt of NPIs , use the web-based application process . Simply log onto the National Plan and Provider Enumeration System ( NPPES ) and apply on line ( see related links inside CMS . gov ).
Periapical Radiographs
Periapical radiographs ( D0220 , D0230 ) taken in conjunction with a periodic oral evaluation ( D0120 ) will be reviewed on a prepayment basis by a dentist .
• Those taken routinely in the absence of a patient complaint / specific signs and symptoms will be denied . A participating dentist will not be able to bill the member .
• Those taken as the result of specific signs and / or symptoms that are supported by the FDA guidelines for prescribing radiographs will be allowed .
Claims for periapical radiographs must include the following supporting documentation :
1 . A copy of the radiograph ( s ) taken ( If submitting electronically , provide the attachment control number on the electronic claim .)
2 . An explanation of the patient ’ s specific signs and symptoms ( If submitting electronically , provide the explanation in the line level narrative / notes field . If submitting a paper claim , please provide the explanation on the claim form , if possible .)
Without this information , the periapical radiographs will be denied for lack of diagnostic materials .
United Concordia Dental
Dr . Tad Glossner , Chairman of the Dental Benefits Committee , and PDA staff discussed a report from United Concordia Dental ( UCD ) concerning periapical radiographs .
On October 10 , UCD sent a fax to participating dentists stating that effective November 1 , 2012 , periapical radiographs ( PAs ) taken in conjunction with a periodical exam would routinely be rejected . Further , once rejected , if the dentist believes that the PAs were necessary to diagnose a condition , the dentist would need to request a review and submit documentation for consideration .
PDA representatives spoke with UCD representatives and were advised that the fax did not accurately reflect UCD ’ s position . On November 6 , UCD issued another statement via fax clarifying the previously distributed policy , and indicated that PAs taken to diagnose a dental condition will not routinely be rejected . Please note that this policy change does not apply to Pennsylvania at this time .
Following is an excerpt from the statement which initially applies only to the states of Washington , Oregon , Idaho and Montana , effective January 1 , 2013 .
The fax also describes UCD ’ s rationale for the change in policy :
Why United Concordia Is Changing Its Policy for Periapical Radiographs
Taking routine periapicals at preset levels for all patients is not supported by the FDA Guidelines for Prescribing Radiographs , which :
1 . Suggest taking the minimal number of films necessary for both diagnostic review and to limit radiation exposure .
2 . Provide guidance indicating dentists should not prescribe routine radiographs at preset intervals for all patients . Radiographs should be prescribed after evaluation of each patient ’ s needs .
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