The National Provider Identifier NPI

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The National Provider Identifier (NPI)
Background Information and How to Obtain the NPI
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Are you drowning in a sea of provider numbers?
Do you have to keep track of many different
identifiers, provider numbers (PINS or UPINS)?
Is it hard to remember which number to use with
which insurance company?
If your answer is yes, HELP IS ON THE WAY
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What is the Purpose of this Presentation
The purpose of this presentation is to describe
the National Provider Identifier (NPI) which is a
standard unique health care provider identifier
that must be accepted by all health plans as of
5/23/07. Todays discussion is intended to
explain the NPI, provider a brief description of
the system behind the NPI, and lastly help you
through the NPI application process.
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What is the National Plan and Provider
Enumeration System?
The National Plan and Provider Enumeration System
(NPPES) is a central electronic enumerating
system developed by the Centers for Medicare
Medicaid Services (CMS). It is designed to
improve the efficiency and effectiveness of the
national health care system.
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What is the National Plan and Provider
Enumeration System? (cont.)
All health care providers, whether individuals or
organizations, are eligible to receive National
Provider Identifiers (NPIs), which are designed
to be lifelong identifying numbers. All health
plans must accept and use NPIs on or before May
23, 2007, except small health plans which have
until May 23, 2008. The result? Simpler
electronic transmission of health related
standard transactions.
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Why NPI?

• The reason for the development of the NPI process
  came from the The Health Insurance Portability
  and Accountability Act of 1996 (HIPAA). This
  Federal Law required the Department of Health and
  Human Services (HHS) to
• Establish standards for the electronic exchange
  of health care data
• Establish standard unique health identifiers for
  health care providers, health plans, and
  employers
• Specify the standards required to protect the
  security and privacy of protected health
  information

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Why NPI? (cont)
On January 23, 2004, the NPI Final Rule was
published. It adopted the NPI standard unique
identifier for health care providers, placed
requirements on covered entities concerning the
NPI, and set the effective date and the
compliance dates for the NPI.
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What is the National Provider Identifier?
The NPI is a 10-position, intelligence-free
numeric identifier. Intelligence-free means that
the numbers do not have any information about the
provider, such as the state in which they live or
their medical specialty.
By making the number 10 digits long enables
enough unique NPIs to last about 200 years,
allowing for significant growth in the number of
health care providers.
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Who can apply for a NPI?
All health care providers are eligible to receive
NPIs, but covered health care providers are
required to receive and use the
identifier. Covered health care providers as
defined under HIPAA, are entities that

• Meet the definition of a health care
  provider in the Privacy Final Rule and
• Transmit health information in an electronic form
  on their own behalf, or that use a business
  associate to do so, in connection with a
  transaction for which the Secretary of the Health
  and Human Services has adopted as a standard (a
  covered transaction).

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Who can apply for a NPI? (Cont)
If you are a covered health care provider, you
MUST comply with HIPAA regulations, and use your
NPI to identify yourself as a health care
provider in standard transactions, including
claims. However, any health care provider,
whether covered or not, may obtain a NPI. Many
health care providers must be identified in some
of the standard transactions, even though they
may not be conducting them.
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When may health care providers begin
to apply for NPIs?
The NPI implementation start date was May 23,
2005. That is when the enumeration process
began. HIPAA covered entities must accept and
use NPIs in standard transactions (except small
health plans) by May 23, 2007. Small health
plans(5 million in annual revenue or less) must
do so no later than May 23, 2008 (36-months after
the effective date of the final rule). HIPAA
covered entities are health plans, health care
clearinghouses, and certain health care providers.
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Will I become a covered health care provider if
I receive a NPI?
Applying for and receiving a NPI does not mean
that you become a covered health care provider.
Examples of health care providers who are
eligible to receive and use the NPI but who are
not covered health care providers might be
registered nurses, dental hygienists, and lab
technicians. They are health care providers
because they provide health care, but do not
necessarily conduct standard transactions.
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Who is not eligible for a NPI?
An entity that does not render health care is not
eligible for a NPI. Health care is defined in 45
CFR Section 160.103 of the Final Privacy Rule.
Examples of entities that are not eligible for
NPIs include Billing Services, value-added
networks, re-pricers, health care clearinghouses,
and atypical service providers. Although some
atypical service providers may be reimbursed by
some health plans for their services, their
services are not health care services.
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Who is not eligible for a NPI? (continued)

• CMS identified provider taxonomy codes that dont
  appear to be healthcare providers
• Individuals
• Contractor (home modifications) 171W00000X
• Funeral Director 176P00000X
• Driver 172A00000X
• Lodging 177F00000X
• Specialist/Graphics designer 174M00000X
• Veterinarian 174M00000X
• Non Individuals
• Bus 347B00000X
• Non-emergency medical transport (VAN) 343900000X
• Private vehicle 347C00000X
• Taxi 344600000X
• Train 347D00000X
• Transportation Broker 347E00000X

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Who is not eligible for a NPI? (continued)

• National Medicaid EDI Healthcare (NMEH) and the
  Workgroup for Electronic Data Exchange (WEDI)
  Strategic National Implementation Process (SNIP)
  have additionally identified list of entities
  that have atypical status
• Custodial care facility
• Adult day care provider
• School based service providers
• Personal Emergency Response System company
• Assisted Living Facility
• Massage therapist

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What is a Health Care Provider Identifier Type?
Health care providers are divided into two
categories, Individual and organization, for the
purpose of enumeration (obtaining NPIs)

• Although there is no complete list of all covered
  individual health care providers, individual
  health care providers include but are not limited
  to providers such as
• Physicians
• Nurses
• Dentists
• Chiropractors
• Pharmacists
• Physical Therapist

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What is a Health Care Provider Identifier Type?
(cont)

• Although there is no complete list of covered
  organizations, organization health care providers
  include but are not limited to
• Hospitals
• Home Health Agencies
• Clinics
• Nursing Homes
• Residential Treatment Centers
• Laboratories
• Ambulance Companies
• Group Practices
• Health Maintenance Organzations
• Suppliers of Durable Medical Equipment
• Pharmacies

This includes sub-parts of organizations also.
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What is an Organization Health Care Providers
NPI-related Responsibilities
It is unnecessary to consider entities as
subparts unless the covered organization has a
need for such assignment. For example, it is not
necessary for a group practice to determine that
each of its multiple practice locations be
subparts and assigned NPIs in order to report the
service location in a standard professional
transaction. That transaction captures this
information without the assignment of a NPI to
every practice location address.
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What are subparts of a Covered Organization
Health Care Provider?
Many covered organization health care providers
(e.g., hospitals, chains of suppliers of durable
medical equipment, pharmacies) may be made up of
components or have separate physical locations
that furnish health care, but are not themselves
legal entities.
These separate components or separate physical
locations may be certified separately or licensed
separately by the State of the covered
organization health care providers.
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What are subparts of a Covered Organization
Health Care Provider? (cont)
Some of these components or separate physical
locations conduct standard transactions some
might need to be identified in standard
transactions even if they don not conduct them
and some might be required by Federal regulations
to have their own billing numbers to be used when
billing a Federal health plan such as Medicare.
Components and separate physical locations for
which these three situations apply may be
considered subparts of the covered organization
health care provider. They are eligible for NPIs.
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What are subparts of a Covered Organization
Health Care Provider? (cont)
If the subparts conduct standard transactions,
they must obtain and use NPIs in those
transactions. If the subparts are entities that
are required by Federal regulations to have
billing numbers to use when billing Federal
programs such as Medicare, the covered
organization health care provider must ensure
that those
subparts have NPIs so that they can comply with
those Federal regulations. After the NPI
compliance dates, the NPIs will replace those
billing numbers.
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What are subparts of a Covered Organization
Health Care Provider? (cont)
The legal entity (i.e., the covered organization
health care provider), is the covered entity. It
is ultimately responsible for complying with the
NPI Final Rule and for ensuring that its
subparts, if assigned NPIs, also comply. For
example a hospital might have an emergency room
that bills for its services separately. The
hospital gets an
NPI as the legal entity the emergency room (ER),
as a subpart of the hospital would get an NPI.
The hospital is responsible for ensuring that the
ER complies with the NPI Final Rule.
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What are an Organization Health Care Providers
NPI-related responsibilities with regards to
subparts?
The covered organization health care provider has
to decide if it has a subpart or multiple
subparts, and if they must be assigned NPIs. If
so, it must either apply for the NPIs for its
subparts or instruct its subparts to apply for
NPIs themselves.
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Is a NPI permanent?
For the most part, once you have been assigned an
NPI, you will never need another one. It will be
permanent, except in certain situations, such as
when a health care providers NPI was used
fraudulently by another, and the health provider
requests a replacement NPI.
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Is a NPI permanent? (continued)

• You will not be permitted to change your NPI
  number for any reason except
• Change of Ownership
• Change from partnership to Ownership
• Change of address
• Change in health care providers name,
  

Employer Identification Number, Health Care
Provider Taxonomy Code classification, State of
licensure or State License number
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Is a NPI permanent? (continued)
You also will not be permitted to change your NPI
for any of the following reasons

• Corporate mergers (the surviving organization may
  continue to use its NPI)
• Sanctioning or barring from one or more health
  plans
• Reactivation of a previously disbanded or
  deactivated NPI

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What do I do if I move, change my name, or change
other information?
Although you will not apply for a new NPI due to
any of the previously mentioned changes, you will
need to give your new information if any of the
required information you supplied when you
applied for your NPI changed. This would include
name, address, licensing, etc. The new
information will be sent to the National Plan and
Provider Enumeration System (NPPES) using the NPI
Application/Update Form. The NPPES will then
update your information.
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How long to I have to notify NPPES about changes?
Covered health care providers must notify the
NPPES of changes in their required NPI data
within 30 calendar days of the changes.
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What will this process cost?
Health care providers pay nothing to apply for
and be assigned NPIs. Federal funds will support
the cost of the enumeration process and the
NPPES. Covered entities will incur costs,
however, in implementing the NPI. These costs
will generally be initial up-front costs for
software and system changes. Business associates
will incur costs for similar activities. These
costs will diminish after the initial enumeration
period. In the long-term, the standard NPI
identifier will be cost-effective.
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What are my NPI related responsibilities as a
health care provider?
Each health care provider who is a covered entity
will be required to

• Obtain from the NPPES, by application a NPI for
  and, if appropriate, for subparts
• Use the NPI to identify in all standard
  transactions where the health care provider
  identifier is required
• Disclose the NPI, when requested, to any entity
  that needs the NPI to identify you as the health
  care provider in a standard transaction

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What are my NPI related responsibilities as a
health care provider? (continued)

• Communicate to the NPPES any changes in the
  required data elements of the NPPES system within
  30 days of the changes.
• If you use one or more business associates to
  conduct standard transactions, require its
  business associate(s) to use the NPI and the NPIs
  of other health care providers appropriately as
  required by the transactions the business
  associate(s) conducts on your behalf

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What are my NPI related responsibilities as a
health care provider? (continued)

• If you have been assigned NPIs for one or more
  subparts, comply with the above requirements with
  respect to each of those NPIs.

This can all be found in the NPI Final Rule in
the Federal Register, January, 2004
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What are my NPI related responsibilities as a
health care provider? (continued)
The transition from the use of existing health
care provider identifiers to NPIs will occur over
the next year. Each health plan with which you
conduct business will notify you when it will be
ready to accept NPIs on the standard transactions.
Just remember to mark your calendar May
23, 2007
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Use of NPI, DEA, CLIA and Mammography
Certification Numbers
NPI will be used to replace Legacy Numbers
including UPINS, referring doctor numbers,
supervising doctor numbers, etc.
NPI cannot be used as a substitute for a DEA,
CLIA or Mammography Certification Number

• Not considered to be health care provider
  identification numbers

When a NPI is to be reported for its regulatory
purpose, it must be used.

• Keep NPI notification in a safe place
• Share copies of your NPI notification with those
  who need it (health plans, billing service,
  vendor, clearinghouse)

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