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National National Provider Provider IdentifierIdentifier
BackgroundBackground
The Health Insurance Portability and Accountability Act The Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandated that the Secretary of Health of 1996 (HIPAA) mandated that the Secretary of Health and Human Services adopt a standard unique health and Human Services adopt a standard unique health identifier for health care providers. On January 23, 2004, identifier for health care providers. On January 23, 2004, the Secretary published a Final Rule that adopted the the Secretary published a Final Rule that adopted the National Provider Identifier (NPI) as this identifier.National Provider Identifier (NPI) as this identifier.
The NPI must be used by covered entities under HIPAA.The NPI must be used by covered entities under HIPAA.
The NPI will identify healthcare providers in electronic The NPI will identify healthcare providers in electronic transactions for which the Secretary has adopted transactions for which the Secretary has adopted standards (the standard transactions) after the standards (the standard transactions) after the compliance dates. compliance dates. These transactions include These transactions include claims, eligibility inquiries and responses, claim claims, eligibility inquiries and responses, claim status inquiries and responses, referrals, and status inquiries and responses, referrals, and remittance advices.remittance advices.
Background, continuedBackground, continued
The NPI will replace health care provider identifiers that The NPI will replace health care provider identifiers that are in use today in standard transactions.are in use today in standard transactions.
Implementation of the NPI will eliminate the need for Implementation of the NPI will eliminate the need for health care providers to use different identification health care providers to use different identification numbers to identify themselves when conducting HIPAA numbers to identify themselves when conducting HIPAA standard transactions with multiple health plans.standard transactions with multiple health plans.
All health plans (including Medicare, Medicaid, and private All health plans (including Medicare, Medicaid, and private health plans) and all health care clearinghouses must health plans) and all health care clearinghouses must accept and use NPIs in standard transactions by May 23, accept and use NPIs in standard transactions by May 23, 2007 (small health plans have until May 23, 2008). 2007 (small health plans have until May 23, 2008).
After those compliance dates, health care providers will After those compliance dates, health care providers will use only their NPIs to identify themselves in standard use only their NPIs to identify themselves in standard transactions, where the NPI is required.transactions, where the NPI is required.
NPI PrinciplesNPI Principles
NPI is not a credentialing programNPI is not a credentialing program
NPIs are not tied together in the databaseNPIs are not tied together in the database
NPI is required on standard transactions, optional NPI is required on standard transactions, optional elsewhereelsewhere
HIPAA does not govern internal systemsHIPAA does not govern internal systems
NPI may be used for any lawful purposeNPI may be used for any lawful purpose
Identifies health care providers or subparts as health Identifies health care providers or subparts as health care providers in standard transactionscare providers in standard transactions
Replaces the use of proprietary and legacy provider Replaces the use of proprietary and legacy provider identifiers in standard transactions for health care identifiers in standard transactions for health care providers and subparts who have been assigned NPIsproviders and subparts who have been assigned NPIs
Structure of NPIStructure of NPI
NPI is 10 digits: NPI is 10 digits: 123456789C123456789C PlanID is also 10 digitsPlanID is also 10 digits C = Check digitC = Check digit First digit distinguishes between NPI & PlanIDFirst digit distinguishes between NPI & PlanID
First DigitFirst Digit CapacityCapacity Used ByUsed By
1,21,2 200 million200 million NPINPI
88 100 million100 million PlanIDPlanID
0,3,4,5,6,7,90,3,4,5,6,7,9 700 million700 million ReserveReserve
Eligibility for an NPIEligibility for an NPI
All healthcare providers as defined in 45 CFR 160.103, areAll healthcare providers as defined in 45 CFR 160.103, are eligibleeligible to obtain an NPI to obtain an NPI
Covered healthcare providers (submitting electronic HIPAA Covered healthcare providers (submitting electronic HIPAA transactions) transactions) are requiredare required to obtain an NPI to obtain an NPI
Subparts of covered organization health care providers (that Subparts of covered organization health care providers (that conduct any of the standard transactions) conduct any of the standard transactions) are requiredare required to to obtain an NPIobtain an NPI
Eligible providers includeEligible providers include: physicians, hospitals, dentists, : physicians, hospitals, dentists, nurses, physician assistants, licensed social workers, DME nurses, physician assistants, licensed social workers, DME suppliers, suppliers related to health care such as prosthetics, suppliers, suppliers related to health care such as prosthetics, pharmacies, pharmacists, group practices, medical students pharmacies, pharmacists, group practices, medical students who provide care.who provide care.
Providers not eligible includeProviders not eligible include: atypical service providers : atypical service providers such as taxis, home & vehicle modifiers, administrative agents such as taxis, home & vehicle modifiers, administrative agents for providers such as billing services, clearinghouses, repricers.for providers such as billing services, clearinghouses, repricers.
NPI SpecificsNPI Specifics
10-position identifier10-position identifier (9 plus a check digit in the 10th (9 plus a check digit in the 10th position). The ISO standard check digit will detect keying position). The ISO standard check digit will detect keying and data entry errors.and data entry errors.
All numericAll numeric.. The numeric NPI will facilitate telephone The numeric NPI will facilitate telephone keypad entry-required for telephone base recognition keypad entry-required for telephone base recognition software. For example, some health plans have software. For example, some health plans have established telephone key pad verification software to established telephone key pad verification software to check on a patient’s eligibility for a particular health care check on a patient’s eligibility for a particular health care service.service.
Intelligence free NPIIntelligence free NPI.. NPI will not contain intelligence NPI will not contain intelligence about the health care provider’s organization. For about the health care provider’s organization. For example, if an individual health care provider changes example, if an individual health care provider changes their specialty the NPI is not affected and this ensures the their specialty the NPI is not affected and this ensures the lasting nature of the NPI.lasting nature of the NPI.
Specifics, continuedSpecifics, continued
Permanent identifierPermanent identifier. The NPI is a permanent identifier for the . The NPI is a permanent identifier for the health care provider, except in certain situations, such as a health health care provider, except in certain situations, such as a health care provider who does not wish to continue an association with a care provider who does not wish to continue an association with a previously used NPI which has been used fraudulently.previously used NPI which has been used fraudulently.
Unique identifierUnique identifier. Safeguards will be established to guard against . Safeguards will be established to guard against assigning the same NPI to more than one health care provider or assigning the same NPI to more than one health care provider or more than one NPI to the same health care provider. more than one NPI to the same health care provider.
Individual health care providerIndividual health care provider: Each individual health care : Each individual health care provider may receive and use only one NPI. provider may receive and use only one NPI.
Death of a Health Care ProviderDeath of a Health Care Provider:: An NPI is deactivated upon death An NPI is deactivated upon death or dissolution of a health care provider. Safeguards or dissolution of a health care provider. Safeguards willwill be be established to ensure a deceased health care provider’s NPI is established to ensure a deceased health care provider’s NPI is never reissued.never reissued.
An NPI will not…An NPI will not…
Be assigned to entities that do not meet Be assigned to entities that do not meet “health care provider” definition in regulation“health care provider” definition in regulation
Eliminate or replace the provider enrollment Eliminate or replace the provider enrollment processes conducted by health plansprocesses conducted by health plans
Guarantee reimbursement by any health planGuarantee reimbursement by any health plan
Convey covered entity statusConvey covered entity status
Assure licensure or credentialsAssure licensure or credentials
Require a health care provider or a subpart to Require a health care provider or a subpart to conduct standard transactionsconduct standard transactions
The NPI TimelineThe NPI Timeline
Health care providers began applying for NPIs Health care providers began applying for NPIs on May 23, 2005 on May 23, 2005
important to apply for NPI before the compliance important to apply for NPI before the compliance date of May 2007 because health plans may require date of May 2007 because health plans may require you to use your NPI before that dateyou to use your NPI before that date
NPI Implementation deadline is 5/23/07NPI Implementation deadline is 5/23/07
Small health plans have until 5/23/08 to complySmall health plans have until 5/23/08 to comply
NPI Application MethodsNPI Application Methods
Methods include Methods include
Apply by paper (via mail)Apply by paper (via mail)
Available 2005Available 2005
Apply via webApply via web
Available May 23, 2005Available May 23, 2005
Apply using the Electronic File Interchange (EFI)Apply using the Electronic File Interchange (EFI)
Future developmentFuture development
Individual Providers vs. Individual Providers vs. Group PracticesGroup Practices
An individual who is a covered health care provider An individual who is a covered health care provider and is a member of an organizational health care and is a member of an organizational health care provider is not considered to be a subpart of the provider is not considered to be a subpart of the organizational health care providerorganizational health care provider
The individual would receive a Type I-Individual NPIThe individual would receive a Type I-Individual NPI
Only one NPI assigned for an individualOnly one NPI assigned for an individual
The organizational health care provider would The organizational health care provider would receive a Type II-Organizational NPIreceive a Type II-Organizational NPI
Defined subpart(s) may receive organizational NPI(s)Defined subpart(s) may receive organizational NPI(s)
NPI EnumeratorNPI Enumerator
Fox Systems, Inc.Fox Systems, Inc. Responsible for provider enumeration process Responsible for provider enumeration process
using the National Provider and Plan Enumeration using the National Provider and Plan Enumeration System (NPPES)System (NPPES)
Handles NPI applications/update formsHandles NPI applications/update forms The NPPES will notThe NPPES will not
Link subparts to covered organization health care Link subparts to covered organization health care providers or vice versaproviders or vice versa
Capture memberships in groups or multiple practice Capture memberships in groups or multiple practice location addresseslocation addresses
Know whether or not a health care provider is a covered Know whether or not a health care provider is a covered entityentity
The National Plan and Provider The National Plan and Provider Enumeration System (NPPES)Enumeration System (NPPES)
National Provider System (NPS) is synonymous National Provider System (NPS) is synonymous with NPPESwith NPPES
Developed under CMS contractDeveloped under CMS contract
Uniquely identifies health care providers and Uniquely identifies health care providers and subparts and assigns them NPIssubparts and assigns them NPIs
Sets up and maintains a record for every Sets up and maintains a record for every enumerated health care provider and subpartenumerated health care provider and subpart
Creates reports and output filesCreates reports and output files
The NPPES will not…The NPPES will not…
Link subparts to covered organization health Link subparts to covered organization health care providers or vice versacare providers or vice versa
Capture memberships in groupsCapture memberships in groups
Capture multiple practice location addressesCapture multiple practice location addresses
Know whether or not a health care provider is Know whether or not a health care provider is a covered entitya covered entity
What information must be What information must be furnished to obtain an NPI?furnished to obtain an NPI?
The minimum data needed to ensure unique The minimum data needed to ensure unique identificationidentification Basic and identifying information, certification Basic and identifying information, certification
statement, signatures, contact person statement, signatures, contact person
More information will be required if necessary to More information will be required if necessary to establish uniquenessestablish uniqueness
Federal Register contains list of data elementsFederal Register contains list of data elements
Obtaining NPIs (cont.)Obtaining NPIs (cont.)
NPPES uses data on application or in EFI to NPPES uses data on application or in EFI to ensure unique identificationensure unique identification SSN validation, address verification, SSN validation, address verification,
duplicate checkduplicate check Edits to detect incomplete and illogical dataEdits to detect incomplete and illogical data
If application is OK, health care provider or If application is OK, health care provider or subpart is notified of NPIsubpart is notified of NPI
If application is not OK, Enumerator If application is not OK, Enumerator communicates with health care provider or communicates with health care provider or subpartsubpart
Use of the Taxpayer Use of the Taxpayer Identification Number (TIN)Identification Number (TIN)
TIN established by regulation to identify a taxpayer TIN established by regulation to identify a taxpayer
(SSN, EIN or ITIN)(SSN, EIN or ITIN)
Required in many standard transactions to identify Required in many standard transactions to identify
entities (including health care providers or subparts) entities (including health care providers or subparts)
as taxpayersas taxpayers
When TIN is to be reported in standard transactions When TIN is to be reported in standard transactions
for its regulatory purpose, it must be used. for its regulatory purpose, it must be used.
NPI cannot be used as a substitute for a TINNPI cannot be used as a substitute for a TIN
Use of DEA, CLIA and Mammography Use of DEA, CLIA and Mammography Certification NumbersCertification Numbers
Not considered to be healthcare provider Not considered to be healthcare provider identification numbersidentification numbers
When Number is to be reported for its When Number is to be reported for its regulatory purpose, it must be used. regulatory purpose, it must be used.
NPI cannot be used as a substitute for a DEA, NPI cannot be used as a substitute for a DEA, CLIA or Mammography Certification NumberCLIA or Mammography Certification Number
Options for Obtaining NPI Options for Obtaining NPI InformationInformation
Four different sources (maybe more…)Four different sources (maybe more…)
NPPESNPPES
Provider to Plan/ClearinghouseProvider to Plan/Clearinghouse
Provider to ProviderProvider to Provider
Plan/Clearinghouse to Plan/ClearinghousePlan/Clearinghouse to Plan/Clearinghouse
What should you be doing What should you be doing now?now?
Become informed about the NPI, the Become informed about the NPI, the enumeration process and its implementationenumeration process and its implementation
Identify processes/systems that are affected Identify processes/systems that are affected by provider identifiersby provider identifiers
Develop enumeration strategy and submit Develop enumeration strategy and submit NPI applicationsNPI applications
Develop implementation plans (internal, Develop implementation plans (internal, external with trading partners and others)external with trading partners and others)
Educate staffEducate staff
Implementation ActivitiesImplementation Activities
Check CMS website for updatesCheck CMS website for updates
Watch/ask for instructions/communications Watch/ask for instructions/communications from CMS, vendors, health plans and trading from CMS, vendors, health plans and trading partnerspartners
Determine impact of NPI on contracts, Determine impact of NPI on contracts, systems, processes, filessystems, processes, files
Identify/resolve issues Identify/resolve issues earlyearly
NPI ResourcesNPI Resources
WEDI WEDI www.wedi.orgwww.wedi.org Named in HIPAA as consulting organizationNamed in HIPAA as consulting organization
NPI PAG, SNIP NPI listserv, white papersNPI PAG, SNIP NPI listserv, white papers
DSMO’sDSMO’s NCPDP, X12, HL7, NUCC, NUBC, DeCCNCPDP, X12, HL7, NUCC, NUBC, DeCC
Other professional organizations and Other professional organizations and associationsassociations
www.nppes.cms.hhs.govwww.nppes.cms.hhs.gov
NPI Enumerator Call CenterNPI Enumerator Call Center 800-465-3203800-465-3203
CMS NPI ResourcesCMS NPI Resources
www.cms.hhs.govwww.cms.hhs.gov regulationsregulations
FAQsFAQs
Regulations and Outreach ListservsRegulations and Outreach Listservs
Outreach materials, announcementsOutreach materials, announcements
HIPAA Hotline 1-866-282-0659HIPAA Hotline 1-866-282-0659
[email protected]@cms.hhs.gov
CMS “NPI” Web site now availableCMS “NPI” Web site now available
