Welcome | News | News Archives | Frequently Asked Questions | Submission Form | Other Resources
General NPI FAQs
1. What are National Provider Identifiers (NPIs)?
National Provider Identifiers (NPIs) are new and unique identification numbers that are required for all eligible health care providers. A single 10-digit NPI number will ultimately replace your current provider identification number(s) used to conduct standard transactions with health plans. While this may sound simple, the process to make this work is complex. To transition to the NPI involves many internal and external steps, and if not handled properly, will affect the processing and payment of claims.
top
2. Why are NPIs being issued?
The Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandated the adoption of standard unique identifiers for health care providers. The purpose of these provisions is to improve the efficiency and effectiveness of the electronic transmission of health information.
top
3. Who assigns NPIs to practitioners?
The Centers for Medicare & Medicaid Services (CMS) have developed the National Plan and Provider Enumeration System (NPPES) to assign these unique identifiers. All individual and organizational healthcare providers, who conduct electronic transactions covered by HIPAA, should begin using their NPI number by the compliance date of May 23, 2007.
To learn more about the implementation of the National Provider Identifier standard, visit the dedicated NPI section of the Centers for Medicare and Medicaid Services (CMS) Web site at: http://www.cms.hhs.gov/apps/npi/01_overview.asp.
top
4. Who should apply for the NPI?
All eligible health care providers should apply. There are two types of providers:
- Type 1 - Health care providers who are individuals, including physicians, dentists, and all sole proprietors.
- Type 2 - Health care providers who are organizations, including physician groups, hospitals, nursing homes, and the corporation formed when an individual incorporates him/herself.
For example: A practice has five practitioners. Each practitioner needs an NPI number (Type 1) the group will also need an NPI number (Type 2).
top
5. Should paper billers obtain an NPI number?
It is our recommendation that all eligible health care providers; regardless of their participation in electronic submissions should obtain an NPI. In addition, some states have mandated that paper billers obtain an NPI, but Maryland, Washington, D.C., and Northern Virginia have not made this a requirement at this time.
top
6. I thought that some providers were NOT eligible for an NPI. Is this true?
Yes, some non-medical providers are not eligible to obtain an NPI, including taxis, home and vehicle modifiers, administrative agents such as billing services, and clearinghouses.
top
7. What is the difference between a Type 2 NPI and a Type 1 NPI?
A Type 2 NPI is the number assigned to an organization, facility or practice. Examples of health care providers that are issued Type 2 NPIs are hospitals, independent laboratories, ambulatory surgery centers, multiple physician practices or incorporated solo practices.
A Type 1 NPI is issued to practitioners. When the practitioner represents his/her own unincorporated solo practice, the practice will not be issued a Type 2 NPI; the practitioner will be issued a Type 1 NPI only. If you represent an unincorporated solo practice and have received only a Type 1 NPI, please do not submit that NPI as a Type 2 Organizational NPI. Instead, submit the NPI as the practitioner’s NPI.
top
8. When should I apply for the NPI?
Health care providers should apply immediately, if they haven’t already.
top
9. How do I apply for an NPI?
Health care providers can apply for an NPI through the National Plan and Provider Enumeration System (NPPES) set up by the Centers for Medicare & Medicaid Services (CMS). To apply:
- Obtain a copy of the paper NPI Application/Update Form (CMS-10114) by contacting the NPI Enumerator in one of three ways:
Then mail the completed, signed application to the NPI Enumerator located at the mailing address above.
top
10. What information do I need to apply for an NPI?
Below is an example of a few data elements needed to obtain an NPI number. See the NPI fact sheet on the CMS website at http://www.cms.hhs.gov/NationalProvIdentStand/03_apply.asp. To apply, you should have the following information available:
- Provider Name
- Provider Date of Birth
- Country of Birth
- State of Birth (if Country of Birth is U.S.)
- Provider Gender
- Social Security Number or other proof of identity
- Mailing Address
- Practice Location Address and Phone Number
- Taxonomy (Provider Type)
- State License Information for certain taxonomy codes
- Contact Person Name, Phone Number and E-mail
NPI application help is available on the NPPES Web site.
top
11. Does my NPI replace my Tax Identification Number (TIN)?
No, the NPI does not replace the TIN.
top
12. Is there a cost for getting an NPI?
No, obtaining an NPI is absolutely free.
top
13. How will the NPI work?
The NPI will be the primary identifier used by all health plans, including Medicare, Medicaid, and all other private and public payers on HIPAA compliant transactions.
Your NPI number will identify you as a health care provider in HIPAA standard transactions with other health care providers, health plans, and health care clearinghouses. Examples of standard transactions include: electronic claims and encounter information transactions, coordination of benefits transactions, claims status inquiries/responses, eligibility inquiries/responses, payment and remittance advices, enrollment or termination of health plans, and referrals.
top
14. Do I need to share my NPI with others?
Yes. Providers must share their NPI number with anyone they do business with including:
- Health plans
- EDI clearinghouses, billing vendors, etc.
- Referring providers, physicians who deliver services in a hospital, nursing homes, or other institutional settings, providers who order tests from clinical or imaging laboratories, etc.
top
15. What is a sub-part?
There is no strict definition of a sub-part as part of the HIPAA regulations. It appears that this was left ambiguous to provide some flexibility for businesses. Below are the parameters of a sub-part:
- Only organizations, group practices, health systems (Type 2) can subpart
- A sub-part is simply a unique or distinct part of a larger business, organization or practice
- An NPI that has been issued to a sub-part does not behave any differently than any other NPI
- An organization may choose to sub-part for any number reasons including:
- Different specialties or departments
- Different locations
- Unique contractual arrangements with health plans
- Not all organization providers have sub-parts
top
16. How should I sub-part? How many NPIs should I obtain?
The way an organization sub-parts and obtains NPI numbers is entirely up to that organization. CareFirst and CareFirst BlueChoice are not equipped to offer advice or guidance regarding the number of NPIs an organization should request.
top
17. Where can I find more information about the NPI?
Check out the NPI Viewlet, which provides an overview of the NPI, a walk through of the NPI application, and links to the NPPES Web site where you can apply for an NPI. This instructional tool is designed for all health care providers and can be found at http://www.cms.hhs.gov/apps/npi/npiviewlet.asp.
CMS has contracted with Fox Systems, Inc. to serve as the NPI Enumerator. The NPI Enumerator is responsible for dealing with health plans and providers on issues relating to unique identification. Enumerator staff will be available to assist health care providers with questions regarding the processing of an NPI application. The NPI Enumerator may be contacted by:
top
|
General NPI FAQs
