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National Provider Identifier (NPI)

The National Provider Identifier (NPI) final rule was mandated as part of HIPAA and published in the Federal Register on January 23, 2004. The effective date of the rule is May 23, 2007.  Providers may apply for an NPI on line at https://nppes.cms.hhs.gov/NPPES/Welcome.do

This system is available for individual or groups of providers to register and obtain their NPI.  You can apply individually or upload groups of names.  Instructions are on the site along with additional information regarding the NPI.

1.  Who needs it?  The standard states:

• Each health care provider must obtain, by application if necessary, an NPI
• Each health care provider must accept and transmit NPIs whenever required on all standard transactions it accepts or transmits electronically
• Each health care provider must communicate to the National Provider System (NPS) any changes to the data elements in its record in the NPS within 60 days of the change
• Each health care provider may receive and use only one NPI. An NPI is inactivated upon death or dissolution of the health care provider

2.  What is a healthcare provider?  The standard published in the Federal Register defines in Para 160.163 as a provider of services as defined in section 1861(u) of the Act (HIPAA) as a provider of medical or other health services as defined in section 1861(s) of the Act (HIPAA), and any other person who furnishes health care services or supplies. Section 160.103 further states that a health care provider includes any other person or organization that furnishes, bills or is paid for health care in the normal course of business.

3. What are the types of NPI? There are two types of NPI:

• Type 1 - An individual human being furnishes health care. the described individual is a health care provider and will be assigned a an NPI with and entity type code of 1.  This includes not only physicians but nurses and any other person that delivers health care.
• Type 2 - An organization that furnishes health care services is a type 2.  An organization can have distinct subparts will also be a type 2 entity.  These subparts may obtain separate NPIs if the there is a reason to distinguish them from the parent organization.  These subparts are included in all definitions as health care providers.

4.  What is the NPI used for?  An NPI will be used to identify the health care provider on a health care claim or equivalent encounter information transaction. 
Under the HIPAA Transaction Standards, the NPI is required field in all electronic transactions. This includes the following transactions 270/271, 834, 276/277, 835, 837P, 837I, 837D, and 278.  It is used to identify all providers associated with the claim.  This includes the billing provider, rendering provider and any other providers listed in the claim or other electronic transaction.

There is some confusion regarding the NPI and other provider numbers.  Hope this helps:

The Tax ID or SSN

The Tax ID is used to identify the tax status of an organization or individual.  There are places in some transactions, 837 and 835 are examples, that require the Tax ID in a fixed location.  The provider identification field is separate from the Tax ID field and the Tax ID can not be used as the provider identifier. The SSN can not be used as a provider identifier but can be used to identify the tax status of a provider if that provider uses his/her SSN as their tax id.

DEA Number

The DEA number is used to identify prescribers that have a legal right to prescribe controlled or dangerous drugs.  The DEA number can not be used as the provider identifier.  It can only be used in electronic transmissions that require information regarding the prescribing level of the provider.

Local ID Numbers

Providers or payers can not use local identifiers as the provider id in electronic transmissions.  This does not mean that all internal systems have to be changed, only that crosswalks may be needed to send and receive transmissions that use the NPI. 

General

The importance of the NPI is an integral part of the future of electronic transactions. With electronic health records and electronic claim attachments coming, identifying providers in a standard way becomes critical.

Less than 20% of providers (CMS figure) have applied and obtained their NPI.  Even less have notified their payers and other trading partners of the NPI.  Please keep in mind that the only way payers and others have of knowing these numbers is by you informing them. 

The compliance date is May 23, 2007.  After that date, payers can not accept electronic claims from providers that do not contain the NPI.  Keep in mind that a payer may have thousands of providers both in and out of network.  It will take time to enter these numbers into our systems.  You should start as soon as possible in obtaining your NPI and also to notify payers of these numbers.  If you wait until the last minute, your claims be rejected by payers or others.

Please visit the CMS site for the latest updates.  To get your NPI go to:

https://nppes.cms.hhs.gov/NPPES/Welcome.do

How to submit your NPI to CHNCT

Collecting and updating thousands of providers records to reflect the NPI is a huge task.  We ask you assistance to make this procedure as painless as possible.

Providers may fax a copy of the NPI approval letter from CMS to 203-265-3590.

CHNCT is currently accepting the 837 Electronic Claims transactions that include the providers NPI.

If you have questions, contact our Network Management Department at 800-440-5071.