What is a Legacy Number in Medical Billing

Provider Transaction Access Number (PTAN) or Medicare legacy number refers to the code assigned to the Medicare service providers. The purpose of the legacy number is to identify the service providers on Medicare claims. The purpose of Medicare legacy numbers is to file claims and make the reimbursement process easy. Nowadays, PTAN is not used to file Medicare claims. Nevertheless, it is used for Electronic Data Interchange (EDI) enrollment and Medicare inquiry purposes.

However, after the Centers for Medicare and Medicaid Services (CMS) announced the “implementation of the National Provider Identifier (NPI) on May 23, 2008, Medicare ceased accepting legacy provider numbers.” Even though legacy numbers were used temporarily along with NPI numbers for some time, the permanent use of legacy numbers eventually came to a halt. At present, the National Provider Identifier (NPI) is referred to as the legacy number in layman’s terms because it superseded the legacy number.

Moreover, NPI also replaced Unique Physician Identification Number (UPIN) after the CMS discontinued the usage of UPIN in 2007 “due to the changing nature and format of Provider/Profiling Identification Numbers (PINs) and our concerns for accuracy.”

Definition of NPI

The all-numeric 10 digits unique National Provider Identifier (NPI) number is defined by the Centers for Medicare and Medicaid Services (CMS) as a “Health Insurance Portability and Accountability Act (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 National Plan and Provider Enumeration System (NPPES) is responsible to assign and maintain NPIs.

Decoding the NPI

NPI is a 10 digits standard unique number that is numerical in nature. CMS clarifies that the number is free from any intelligence—i.e. it “do not carry other information about health care providers, such as the state in which they live or their medical specialty.” In other words, personal information of the health care provider is safe, restricting the use of NPI only for HIPAA standards transactions.

As per the HIPAA guidelines, CMS indicates that the health care provider is required to share the “NPI with other providers’ health plans, clearinghouses, and any entity that may need it for billing purposes.”

Role of NPI in Medical Billing

NPI plays an important role in medical billing when it comes to filing claims for Medicare. To maintain the integrity of medical programs such as Medicare, the federal government introduced NPI and discontinued the use of PTAN and UPIN. The aim was to prevent the abuse of federal health care programs. NPI helps in preventing fraud in medical billing in the name of Medicare claims made by health care providers. With the help of NPI, the Department of Health and Human Services (HHS) can easily verify Medicare claims by making cross-references. This means a Medicare claim matching the wrong NPI is likely to get denied. Also, a physician without the registered NPI won’t be able to abuse the integrity of Medicare by filing invalid claims.