Medical Services

Provider Information

National Provider Identification (NPI) Number

As mandated by the Health Insurance Portability and Accountability Act (HIPAA) and in compliance with the Centers for Medicare and Medicaid Services (CMS), covered providers must have a National Provider Identification (NPI) number and share it with other providers, health plans, clearinghouses and other entities for billing purposes.

On May 23, 2008, the NPI number will be required in all billing transactions. All electronic and paper claims submitted after May 23, 2008 without NPI information identified in the appropriate fields will be denied or returned for correct submission. Also, only CMS 1500 professional claim forms and UB-04 institutional claim forms will be accepted on or after May 23, 2008. These forms are not supplied by South Dakota Medical Assistance (SDMA).  For more information on the professional claim forms, please view http://www.nucc.org/ and for institutional claim forms, please refer to http://www.nubc.org/
Health care providers who bill SDMA for services need an NPI number, except for non-emergency community transportation services who only transport ambulatory individuals. This provider type will continue to bill SDMA with the seven digit Medicaid provider number.

To apply for an NPI number, go online at https://nppes.cms.hhs.gov/ or call 1-800-465-3203 to request paper application. 

For general information on NPI numbers refer to www.cms.hhs.gov/NationalProvIdentStand.

When submitting NPI information, please consider how you are billing Medicare and/or SDMA. If an entity has been assigned various group NPI numbers for its subparts, then SDMA will need to know those group NPI numbers and associate those numbers with the matching SDMA seven digit Medicaid provider number. If an entity has been assigned a group NPI number for the clinic and/or taxing entity (Federal Tax Identification Number), SDMA must know this NPI group number and associate it with the individual NPI numbers assigned to the rendering/servicing provider of this clinic. Except for rural health clinics, Federally Qualified Health Centers, Indian Health Service facilities and mental health clinics who only need to submit and bill a group NPI number.

For these exceptions, individual rendering/servicing NPI number will not be accepted.

Please Note Information On Taxonomy Codes:

  1. When an individual provider practices at multiple service locations, with the same zip code and same individual and/or group billing NPI number, SDMA requires an unique taxonomy code designated for that service location. This taxonomy code replaces the legacy provider number and must be indicated on the electronic and paper claim along with the individual NPI number and group NPI, if applicable.  If you are using a taxonomy code as an unique identifier, SDMA must be notified to update the provider file.
  2. The issue of one NPI number to multiple provider numbers also applies to non-individual providers such as laboratories, durable medical equipment, residential treatment facilities, nursing/long term care facilities. An unique taxonomy code will be required for each provider number.

The SDMA has been collecting NPI numbers from providers for several months. As with any process change, there are a few clarifications SDMA would like to make to ensure the upcoming transition on May 23, 2008 of using only NPI numbers goes more smoothly. To assist providers with completing the paper claim form, please reference this document Provider Billing Instructions.
If you are experiencing difficulty with billing SDMA, it may be that the NPI information submitted is not consistent with how Medicare is billed or that the NPI information is not on file for the provider. 
NPI information can be submitted to SDMA by:

  • Email at medical@state.sd.us,
  • Fax to 605-773-5246, or
  • Mail to Division of Medical Services, Provider Enrollment, 700 Governors Drive, Pierre, South Dakota 57501-2291.

For questions regarding NPI numbers, please call SDMA at 1-800-452-7691 or 605-773-3495.