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Am I required to share my National Provider Identifier (NPI) with health plans, other providers and any other entity that requests it?
As stated in the Final Rule for the National Provider Identifier, covered health care providers must disclose their NPIs and those of their subparts to entities that need those identifiers so that all providers can be identified consistently in standard transactions (as adopted under the Health Insurance Portability and Accountability Act of 1996 - HIPAA). In fact, CMS is strongly encouraging all health care providers and their subparts to get an NPI and share it with other providers and entities with whom they conduct standard transactions.
What are the significant dates associated with applying for and using the NPI?
- May 23, 2005: Health care providers could start applying for a NPI.
- May 23, 2007: By this date, all health care providers who utilize HIPAA standard electronic transactions must have a NPI and use the NPI in all those transactions. Providers who do not utilize HIPAA standard electronic transactions may have a NPI.
- May 23, 2007: By this date, WPS and all other health plans and payers must have the capability to use the NPI to identify providers in standard electronic transactions.
Who should obtain a NPI?
Any health care provider or organization defined as a covered entity under HIPAA is required to obtain a NPI. Providers who transmit health care information via HIPAA standard electronic transactions are covered entities under HIPAA, whether they transmit the transactions themselves or use a vendor or clearinghouse to transmit them. Providers who do not utilize HIPAA standard electronic transactions may obtain an NPI.
What is the difference between a covered entity and a non-covered entity?
- Covered entities: Health care providers who transmit standard electronic transactions (for example, claims submissions, referrals, etc.) are required by the HIPAA NPI regulation to apply for and receive a NPI prior to the May 23, 2007, compliance date. Covered entities may apply for a Type 1 or Type 2 NPI depending on their status as a legal entity.
- Non-covered entities: Providers whose services are not considered health care services and who do not meet the definition of health care provider.
What are standard electronic transactions?
837 Professional Claim
837 Institutional Health Claims
270 Eligibility Benefit Inquiry
271 Eligibility Benefit Response
835 Health Care Remittance Advice
276 Health Claim Status Inquiry
277 Health Claim Status Response
278 Health Care Services and Response
What is the difference between Type 1 and Type 2 NPI?
A Type 1 NPI is assigned to individual health care providers, including physicians, dentists, and all sole proprietors.
A Type 2 NPI is assigned to health care providers
who are organizations, including physician groups, hospitals,
skilled nursing homes, and the corporation formed when an individual
incorporates him/herself. Organizations must determine if they
have “subparts” that need to be uniquely identified
in HIPAA standard transactions with their own NPIs.
What is a Type 2 “Subpart”?
A subpart is a component of an organization health care provider that furnishes healthcare and is not itself a separate legal entity. Only organizations are eligible for subpart designation.
What will a NPI do? As of May 2007, it will:
- Replace all other provider identifiers previously used by health care providers (for example, UPIN, Medicare/Medicaid numbers, etc.)
- Establish a national standard and unique identifier for all health care providers
- Simplify the administration of the health care system and encourage the electronic transmission of health care information
What will a NPI not do? As of May 2007, it will not:
- Replace the tax identification number (TIN), which is an IRS requirement
- Convey information about the provider (for example, provider type, service location, etc.)
- Guarantee reimbursement by health plans
- Enroll providers in health plans
How can a health care provider or organization apply for a NPI?
The Centers for Medicare & Medicaid Services (CMS) has contracted with a vendor to administer the assignment of NPIs and deal with health plans and providers on issues concerning unique identification. There are two ways a health care provider can apply for a NPI:
When should health care providers begin submitting their NPI to WPS?
Providers can begin submitting their NPI on standard electronic transactions today. The Healthcare Insurance Portability and Accountability Act (HIPAA) requires that providers submit the NPI with all standard electronic transactions by the compliance date of May 23, 2007. During the transition, providers should continue to submit the identifiers they currently use on all transactions.
Where can additional information about HIPAA NPI regulations be found?
The CMS Web site: www.cms.hhs.gov/hipaa/hipaa2/regulations/indentifier
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