Medical billing is a complex process that requires the submission of, usually, several applications to get started. The enrollment team at Workflow Services handles your applications but accurate information from you is important for timely processing. This document lists the information that is required and why it is needed to get set up with medical billing.
TIN
Tax Identification Number. Your facility is required to include its TIN when submitting medical billing claims to government and commercial payers. This number assures payment for services rendered are routed and paid to the Pharmacy. The payers and clearinghouses require the TIN when they enroll your pharmacy for electronic claims submission as well. Apply for a TIN here.
Type 2 NPI (Pharmacy-Identifies Organization)
National Provider Identification, (NPI) is a unique 10 digit number assigned by CMS to identify your organization / entity. Pharmacies receive a Type 2 NPI which indicates the entity as the billing organization and is who the insurance company will issue checks to for services rendered. This number is included on all claims submitted to insurance companies for processing.
Pharmacies select taxonomy codes to be associated with their NPI that reflect a distinct line of service. ie. The type 2 NPI number used for medical billing for clinical services would have different taxonomy code than an NPI number used for DME claims.
A pharmacy should have a separate Type 2 NPI for each line of business that they submit insurance claims for. This process allows each line of business to have a unique processing and accounting system. If all lines of business are submitted under the same NPI it is very difficult to reconcile claims submitted and understand profitability of each division. i.e. DME, Medical Billing, and Pharmacy claim
Type 1 NPI (Pharmacist- Identifies Individual)
Pharmacists receive a Type 1 NPI and select a taxonomy code that is associated with pharmacists. The provider NPI is required to be added to medical billing claims to verify the provider who rendered the service (s) being billed to the government and commercial payers.
Providers select taxonomy codes to be associated with their NPI reflecting their clinical specialty/education. (e.g., Clinical Pharmacist) A provider’s NPI remains the same throughout their professional career and practice.
When used with the TIN and NPI associated with the pharmacy where they render services, payments are directed to the correct provider and location.
CLIA #
National Clinical Lab certification indicates a site is certified by CMS to perform CLIA waived point of care tests. Application for CLIA certification is made thru CMS (see link) This number is included on medical billing claims to verify the testing site is certified.
Medicare Information
Pharmacy Part B PTAN
Provider Transaction Access Number. This number is assigned by CMS to entities /providers when enrolling for Medicare provider status and is required in order to bill Medicare Part B services.
Pharmacies can add multiple PTAN to their site to report and bill specific services such as medical billing of point of care/clinical lab services, DME supplies, and pharmacy compounding and roster billing for Pharmacy specific services.
Independent Clinical Lab PTAN
Pharmacies can add multiple PTANs to their site to report and bill for specific services such as medical billing of point of care/clinical lab services. IF A PHARMACY ALREADY HAS A PTAN, they should check for and /or add Independent Clinical Lab.
Roster PTAN
Pharmacies can add multiple PTANs to their site to report and bill for specific services such as roster billing for Pharmacy specific services. IF A PHARMACY ALREADY HAS A PTAN, they should check for and /or add Roster Enrollment.
Pharmacies add/apply for Roster PTAN to support Medicare billing via a roster format versus individual claims. This is a model used by pharmacies when billing for specifically allowed services to be reported as one file.
Medicaid Information
Pharmacy Medicaid ID
Number assigned to pharmacy by state Medicaid upon successful enrollment with payer. The Medicaid pharmacy provider number is included on the claim to verify the billing pharmacy is an approved Medicaid provider and eligible to render and bill services. It also assures payments are directed to the correct entity.
Pharmacist Individual Medicaid ID
Number assigned to provider by state Medicaid upon successful enrollment with payer. The Medicaid provider number is included on the claim to verify the provider billing is an approved Medicaid provider and eligible to render and bill services in accordance with the Pharmacist's scope of practice. It also assures payments are directed to the correct provider and entity.
Pharmacist ROP Enrollment
When a pharmacist enrolls with Medicaid, the clinician needs to enroll as an ROP provider. It indicates the Pharmacist is approved by the Medicaid plan as a Rendering / Ordering / Prescribing provider. This status supports medical billing for services like point of care testing. The status is an option on the application.
Which insurance plans do you have a Medical Contract with?
Let us know what insurance plans you are in-network with. You will be able to continue working with these plans using the Workflow Services workflows but we will need to configure the settings to allow Workflow Services to submit claims and receive remittances from these plans for you.
Which insurance companies would you like to be credentialed with?
This lets our Enrollment and Credentialing departments get to work right away getting you set up with the plans you want to be in-network with. If you aren’t sure which plans these are, check your area to learn what the most common insurance plans are.
Please refer to your Workflow Services Terms of Service for any charges related to the credentialing and enrollment process.
CPA Provider Name
If you are working under a collaborative practice agreement (CPA) to provide clinical services, payers often require the name of the provider and their NPI. They use this information to verify that the CPA provider is an active practitioner in the pharmacist’s state. They may also request the provider’s specialty.
W-9
The W9 is required by payers in order to validate the tax ID of the provider and to direct payments accordingly.