National Provider Identifier NPI

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National Provider Identifier(NPI)

• HIPAA COW
• April 28, 2006
• Patricia Peyton
• CMS/OFM/PIG/DPSE

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NPI

• Adopted standard health identifier for health
  care providers
• To be used in HIPAA standard transactions to
  identify health care providers as health care
  providers
• Replaces all current identifiers used for that
  purpose
• Never expires should last indefinitely

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Important Dates

• HIPAA enactment - August 21, 1996
• NPI NPRM - May 7, 1998
• NPS SoR Notice - July 28, 1998
• NPI Final Rule - January 23, 2004
• Effective Date - May 23, 2005
• Compliance Date for all but small health
  plans - May 23, 2007
• Small health plans May 23, 2008

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NPI Enumeration To Date

• As of April 10
• 439,859 providers have been assigned NPIs
• Slightly more than 19 percent of estimated
  covered providers have their NPIs

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Enumeration Strategy

• Generally speaking One provider/one NPI
• Individuals (doctors, nurses, dentists) 1 NPI
  per provider, regardless of numbers of practice
  locations, contracts, etc.
• Organizations (hospitals, nursing facilities,
  group practices, DME suppliers) 1 NPI or
  some/all subparts may also need to have NPIs

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Subparts

• Organization health care provider
• Legal entity
• Furnishes health care
• Conducts one or more HIPAA transactions
• Provider Subpart
• Not a legal entity (A subpart cannot be a
  person)
• Furnishes health care
• May or may not conduct one or more HIPAA
  transactions
• Needs to be identified in HIPAA transactions

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Responsibilities of covered organization providers

• Must determine if they have subparts
• If they have subparts, they must determine if the
  subparts need NPIs
• If they need NPIs, must ensure NPIs are obtained
• Once NPIs are obtained, must ensure the subparts
  comply with NPI Final Rule requirements

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Determining subparts

• Components of the covered provider
• Do any conduct their own HIPAA transactions?
• Enrollment in health plans
• Health plan legacy identifiers
• Contract arrangements
• Need for identification in HIPAA transactions
• Will the health plan have what it needs to
  properly pay/adjudicate the claim?

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Subpart examples

• Hospital subparts
• excluded units
• HHAs
• Hospices
• Emergency room
• DME supplier subparts
• Each location
• Clinic subparts
• Different functions (Taxonomies)

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Medicares Subpart Paper

• NPI Final Rule foundation
• Medicare provider enrollment
• Many enrolled Medicare providers are subparts
  with their own legacy numbers
• Federal regulations require each DME supplier
  location to have unique billing number
• Analyses of billing scenarios

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Medicares Subpart Paper

• Eliminate possibility of rejected claims
• Cant recognize who sent the claim, furnished the
  service, or wants payment
• Dual strategy
• Medicare crosswalk
• NPI to legacy number for claims processing
• One-to-many and many-to-one
• Mirror Medicare enrollment

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NPPES Data Dissemination

• System of Records Notice
• NPI Final Rule discussion
• Data Dissemination Notice
• In HHS clearance
• Will be published in Federal Register
• Who can have what data, and how are the data
  obtained
• Effective date

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Changes in the NPPES

• Visible to the industry
• License requirements
• NPI Notifications, Change Notifications
• EFI
• Paper applicants can update via the web
• NPPES web page
• Military phone numbers
• Behind the scenes
• Bugs, fixes
• Enumerators workflow and processing reports
• Record resolution reports and processes

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Tips

• Print each screen when applying/updating via the
  web
• Photocopy the completed paper application when
  applying/updating
• Do not use browsers Back button (use
  Previous button at bottom of screen)
• Retain your Tracking Number (web only)
• RETAIN YOUR NPI NOTIFICATION

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NPI Resources

• CMS NPI page
• www.cms.hhs.gov/NationalProvIdentStand/
• NPI Enumerator
• customerservice_at_npienumerator.com
• 1-800-465-3203
• https//NPPES.cms.hhs.gov
• Industry organizations (e.g., WEDI, AMA, NCPDP,
  X12, many others)