Correct Use of Provider Identification Numbers At this time of year, many new and recently relocated physicians and non-physician providers (NPPs) begin clinical practices. The proper provider identification numbers (PINs) for each provider must be obtained prior to billing for any clinical service. Insurance companies, managed care corporations, and the Medicare program will not allow payment of claims without the verification and identification of the provider of service. PIN applications are the mechanism that allows insurance carriers to properly identify and verify the credentials of the individual provider. It is important to ascertain whether the physician has been assigned a PIN from a previous practice prior to submitting a PIN application. If the physician has been previously assigned a PIN, a change of address may be the only requirement needed in many circumstances. Each insurance company has a policy regarding the activation date of a provider identification number (PIN). Medicare Part B generally uses the date of state licensure as the effective date for the PIN. Inquires to insurance companies provider relation representatives may clarify the activation date of a PIN, and will assist in establishing the specific criteria for submission of claims pending the assignment of the PIN. Occasionally, practices have utilized one physician’s PIN to expedite claims processing. It is illegal to submit claims for payment by defaulting to the PIN of another physician within the clinical practice. This is considered a false claim. This practice causes those physicians to develop erroneous billing and service utilization pattern profiles. Erroneous profiles may trigger insurance company investigations. The Medicare program has two initiatives designed to correct billing profiles: Focused Medical Review, and Comprehensive Medical Review. Both of these initiatives center on reviewing documentation of billing patterns considered outside the statistical norms. All insurance companies maintain data on the number of services performed by physicians. Physicians with higher than average services may be asked to submit supporting documentation to verify that the services were actually performed, medically necessary for the patient’s diagnosis, and that the correct provider of service was identified. Many practices submit claims with “group” identification numbers. A group number allows for several physicians to receive payment under one tax identification number. The group number consists of the individual physicians' PINs. It is important to maintain the accuracy of the group number by adding and deleting physician PINs in a timely fashion. It is also important to include new physicians' PINs into the electronic submitter number for the group. If this is not completed prior to the submission of claims, the insurance company’s electronic system will reject claims submitted for unidentified physicians. Return to Contents | Return to Billing Compliance