National Provider
Identifier
Background

The Health Insurance Portability and Accountability Act of 1996
(HIPAA) mandated that the Secretary of Health and Human
Services adopt a standard unique health identifier for health
care providers. On January 23, 2004, the Secretary published a
Final Rule that adopted the National Provider Identifier (NPI) as
this identifier.

The NPI must be used by covered entities under HIPAA.

The NPI will identify healthcare providers in electronic
transactions for which the Secretary has adopted standards (the
standard transactions) after the compliance dates. These
transactions include claims, eligibility inquiries and
responses, claim status inquiries and responses,
referrals, and remittance advices.
Background, continued

The NPI will replace health care provider identifiers that are in
use today in standard transactions.

Implementation of the NPI will eliminate the need for health
care providers to use different identification numbers to identify
themselves when conducting HIPAA standard transactions with
multiple health plans.

All health plans (including Medicare, Medicaid, and private
health plans) and all health care clearinghouses must accept
and use NPIs in standard transactions by May 23, 2007 (small
health plans have until May 23, 2008).

After those compliance dates, health care providers will use only
their NPIs to identify themselves in standard transactions,
where the NPI is required.
NPI Principles

NPI is not a credentialing program

NPIs are not tied together in the database

NPI is required on standard transactions, optional elsewhere

HIPAA does not govern internal systems

NPI may be used for any lawful purpose

Identifies health care providers or subparts as health care
providers in standard transactions

Replaces the use of proprietary and legacy provider identifiers
in standard transactions for health care providers and
subparts who have been assigned NPIs
Structure of NPI




NPI is 10 digits: 123456789C
PlanID is also 10 digits
C = Check digit
First digit distinguishes between NPI & PlanID
First Digit
Capacity
Used By
1,2
200 million
NPI
8
100 million
PlanID
0,3,4,5,6,7,9
700 million
Reserve
Eligibility for an NPI



All healthcare providers as defined in 45 CFR 160.103, are eligible
to obtain an NPI
Covered healthcare providers (submitting electronic HIPAA
transactions) are required to obtain an NPI
Subparts of covered organization health care providers (that
conduct any of the standard transactions) are required to obtain
an NPI

Eligible providers include: physicians, hospitals, dentists,
nurses, physician assistants, licensed social workers, DME suppliers,
suppliers related to health care such as prosthetics, pharmacies,
pharmacists, group practices, medical students who provide care.

Providers not eligible include: atypical service providers such
as taxis, home & vehicle modifiers, administrative agents for
providers such as billing services, clearinghouses, repricers.
NPI Specifics

10-position identifier (9 plus a check digit in the 10th position).

All numeric. The numeric NPI will facilitate telephone keypad

Intelligence free NPI. NPI will not contain intelligence about the
The ISO standard check digit will detect keying and data entry
errors.
entry-required for telephone base recognition software. For
example, some health plans have established telephone key pad
verification software to check on a patient’s eligibility for a
particular health care service.
health care provider’s organization. For example, if an
individual health care provider changes their specialty the NPI is
not affected and this ensures the lasting nature of the NPI.
Specifics, continued

Permanent identifier. The NPI is a permanent identifier for the health
care provider, except in certain situations, such as a health care
provider who does not wish to continue an association with a
previously used NPI which has been used fraudulently.

Unique identifier. Safeguards will be established to guard against
assigning the same NPI to more than one health care provider or more
than one NPI to the same health care provider.

Individual health care provider: Each individual health care provider
may receive and use only one NPI.

Death of a Health Care Provider: An NPI is deactivated upon death or
dissolution of a health care provider. Safeguards will be established to
ensure a deceased health care provider’s NPI is never reissued.
An NPI will not…

Be assigned to entities that do not meet “health care
provider” definition in regulation

Eliminate or replace the provider enrollment
processes conducted by health plans

Guarantee reimbursement by any health plan

Convey covered entity status

Assure licensure or credentials

Require a health care provider or a subpart to
conduct standard transactions
The NPI Timeline

Health care providers began applying for NPIs on
May 23, 2005


important to apply for NPI before the compliance date of
May 2007 because health plans may require you to use your
NPI before that date
NPI Implementation deadline is 5/23/07

Small health plans have until 5/23/08 to comply
NPI Application Methods

Methods include

Apply by paper (via mail)


Apply via web


Available 2005
Available May 23, 2005
Apply using the Electronic File Interchange (EFI)

Future development
Individual Providers vs.
Group Practices

An individual who is a covered health care provider and
is a member of an organizational health care provider is
not considered to be a subpart of the organizational
health care provider

The individual would receive a Type I-Individual NPI


Only one NPI assigned for an individual
The organizational health care provider would receive a
Type II-Organizational NPI

Defined subpart(s) may receive organizational NPI(s)
NPI Enumerator
 Fox
Systems, Inc.
 Responsible for provider enumeration process using the
National Provider and Plan Enumeration System (NPPES)
 Handles NPI applications/update forms
 The NPPES will not



Link subparts to covered organization health care providers or
vice versa
Capture memberships in groups or multiple practice location
addresses
Know whether or not a health care provider is a covered entity
The National Plan and Provider
Enumeration System (NPPES)

National Provider System (NPS) is synonymous with
NPPES

Developed under CMS contract

Uniquely identifies health care providers and subparts
and assigns them NPIs

Sets up and maintains a record for every enumerated
health care provider and subpart

Creates reports and output files
The NPPES will not…

Link subparts to covered organization health care
providers or vice versa

Capture memberships in groups

Capture multiple practice location addresses

Know whether or not a health care provider is a
covered entity
What information must be furnished
to obtain an NPI?

The minimum data needed to ensure unique
identification



Basic and identifying information, certification statement,
signatures, contact person
More information will be required if necessary to establish
uniqueness
Federal Register contains list of data elements
Obtaining NPIs (cont.)



NPPES uses data on application or in EFI to ensure
unique identification
 SSN validation, address verification, duplicate
check
 Edits to detect incomplete and illogical data
If application is OK, health care provider or subpart is
notified of NPI
If application is not OK, Enumerator communicates
with health care provider or subpart
Use of the Taxpayer
Identification Number (TIN)

TIN established by regulation to identify a taxpayer
(SSN, EIN or ITIN)

Required in many standard transactions to identify
entities (including health care providers or subparts)
as taxpayers

When TIN is to be reported in standard transactions
for its regulatory purpose, it must be used.
NPI cannot be used as a substitute for a TIN
Use of DEA, CLIA and Mammography
Certification Numbers

Not considered to be healthcare provider
identification numbers

When Number is to be reported for its regulatory
purpose, it must be used.
NPI cannot be used as a substitute for a DEA, CLIA or
Mammography Certification Number
Options for Obtaining NPI
Information

Four different sources (maybe more…)

NPPES

Provider to Plan/Clearinghouse

Provider to Provider

Plan/Clearinghouse to Plan/Clearinghouse
What should you be doing now?

Become informed about the NPI, the enumeration
process and its implementation

Identify processes/systems that are affected by
provider identifiers

Develop enumeration strategy and submit NPI
applications

Develop implementation plans (internal, external
with trading partners and others)

Educate staff
Implementation Activities

Check CMS website for updates

Watch/ask for instructions/communications from
CMS, vendors, health plans and trading partners

Determine impact of NPI on contracts, systems,
processes, files

Identify/resolve issues early
NPI Resources


WEDI www.wedi.org

Named in HIPAA as consulting organization

NPI PAG, SNIP NPI listserv, white papers
DSMO’s

NCPDP, X12, HL7, NUCC, NUBC, DeCC

Other professional organizations and associations

www.nppes.cms.hhs.gov

NPI Enumerator Call Center

800-465-3203
CMS NPI Resources

www.cms.hhs.gov

regulations

FAQs

Regulations and Outreach Listservs

Outreach materials, announcements

HIPAA Hotline 1-866-282-0659

AskHIPAA@cms.hhs.gov

CMS “NPI” Web site now available