LEEDer Group Inc.
8508 North West 66th St.
Miami, Florida 33166 USA

Phone: 305.436.5030
Fax: 305.436.0086
E-mail Address: info {at] LEEDerGroup [dot] com

2012-05 Difference between a National Provider Identifier (NPI) and a Provider Transaction Access Number (PTAN)

Jurisdiction 11 Part B

Examining the Difference between a National Provider Identifier (NPI) and a Provider Transaction Access Number (PTAN)

MLN Matters® Number: SE1216 Related Change Request (CR) #: N/A Related CR Release Date: N/A Effective Date: N/A Related CR Transmittal #: N/A Implementation Date: N/A

  • Provider Types Affected
    This MLN Matters® Special Edition Article is intended for physicians, providers and suppliers who are enrolled in Medicare.
  • What You Need to Know
    This article explains the difference between a National Provider Identifier (NPI) and a Provider Transaction Access Number (PTAN). There are no policy changes in this article.
  • Background: New Enrollees
    All providers and suppliers who provide services and bill Medicare for services provided to Medicare beneficiaries must have an NPI. Upon application to a Medicare contractor, the provider or supplier will also be issued a Provider Transaction Access Number (PTAN). While only the NPI can be submitted on claims, the PTAN is a critical number directly linked to the provider or supplier’s NPI.
  • Revalidation
    Section 6401(a) of the Affordable Care Act established a requirement for all enrolled physicians, providers and suppliers to revalidate their enrollment information under new enrollment screening criteria.
    Providers and suppliers receiving requests to revalidate their enrollment information have asked the Centers for Medicare & Medicaid Services (CMS) to clarify the differences between the NPI and the PTAN.
  • National Provider Identifier (NPI)
    The NPI is a national standard under the Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification provisions.
    The NPI is a unique identification number for covered health care providers
    The NPI is issued by the National Plan and Provider Enumeration System (NPPES)
    Covered health care providers and all health plans and health care clearinghouses must use the NPI in the administrative and financial transactions (for example, insurance claims) adopted under HIPAA
    The NPI is a 10-position, intelligence-free numeric identifier (10-digit number). The NPI does not carry information about healthcare providers, such as the state in which they live or their medical specialty. This reduces the chances of insurance fraud.
    Covered providers and suppliers must share their NPI with other suppliers and providers, health plans, clearinghouses and any entity that may need it for billing purposes. Since May 23, 2008, Medicare has required that the NPI be used in place of all legacy provider identifiers, including the Unique Physician Identification Number (UPIN), as the unique identifier for all providers and suppliers in HIPAA standard transactions.
    You should note that individual health care providers (including physicians who are sole proprietors) may obtain only one NPI for themselves (Entity Type 1 Individual). Incorporated individuals should obtain one NPI for themselves (Entity Type 1 Individual) if they are health care providers and an additional NPI for their corporation(s) (Entity Type 2 Organization). Physicians who are sole practitioners, but who have chosen to incorporate are required to obtain both a Type 1 and a Type 2 NPI. Organizations that render health care or furnish health care supplies may obtain NPIs (Entity Type 2 Organization) for their organizations and their subparts (if applicable).
    For more information about the NPI, visit the NPPES Web site-HERE on the CMS Web site.
  • Provider Transaction Access Number (PTAN)
    A PTAN is a Medicare-only number issued to providers by Medicare contractors upon enrollment to Medicare. When a Medicare Contractor approves enrollment and issues an approval letter, the letter will contain the PTAN assigned to the provider.
    The approval letter will note that the NPI must be used to bill the Medicare program and that the PTAN will be used to authenticate the provider when using Medicare Contractor self-help tools such as the Interactive Voice Response (IVR) phone system, internet portal, on-line application status, etc.
    The PTAN’s use should generally be limited to the provider’s contacts with Medicare Contractors
  • Relationship of the NPI to the PTAN
    The NPI and the PTAN are related to each other for Medicare purposes. A provider must have one NPI and will have one, or more, PTAN related to it in the Medicare system, representing the provider’s enrollment. If the provider has relationships with one or more medical groups or practices or with multiple Medicare Contractors, separate PTANS are generally assigned.
    Together, the NPI and PTAN identify the provider, or supplier in the Medicare program. CMS maintains both the NPI and PTAN in the Provider Enrollment Chain & Ownership System (PECOS), the master provider and supplier enrollment system.
  • Protect Your Information in PECOS
    All providers and suppliers should carefully review their PECOS records in order to protect themselves and their practices from identity theft. PECOS should only contain active enrollment records that reflect current practice and group affiliations. You can review and update your PECOS records in the following ways:
    “Use internet-based PECOS on the CMS Web site
    Use the Paper CMS 855 enrollment application (i.e., 855A, 855B, 855I, 855O, 855R or 855S)
    Note: The Medicare Contractor may not release provider specific information to anyone other than the individual provider, authorized/delegated official of the provider organization or the contact person. The request must be submitted in writing on the provider’s letterhead and signed by the individual provider, authorized/delegated official of the organization or the contact person.
    The MLN fact sheet titled ‘How to Protect Your Identity Using the Provider Enrollment, Chain and Ownership System (PECOS),’ provides guidelines and steps you can take to protect your identity while using Internet-based PECOS. This fact sheet is available-HERE on the CMS Web site.
  • Additional Information
    MLN Matters® Special Edition Article SE 1126 titled ‘Further Details on the Revalidation of Provider Enrollment Information,’ is available-HERE on the CMS Web site.
    ‘Medicare Provider–Supplier Enrollment National Educational Products,’ contains a list of products designed to educate Medicare Fee-For-Service (FFS) providers about important Medicare enrollment information, including how to use Internet-based PECOS to enroll in the Medicare Program and maintain their enrollment information. This resource is available-HERE on the CMS Web site.
  • Disclaimer
    This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2011 American Medical Association.

last updated on 05/18/2012