NPI
stands for National Provider Identifier
What is an NPI?
The NPI is a 10-position, intelligence-free numeric identifier (10-digit number). This means that the numbers do not carry other information about health care providers, such as the state in which they live or their medical specialty. The NPI must be used in lieu of Provider Transaction Access Number (PTAN) or Legacy Provider Identifiers in the HIPAA standard transactions.
The NPI is a 10-position, intelligence-free numeric identifier (10-digit number). This means that the numbers do not carry other information about health care providers, such as the state in which they live or their medical specialty. The NPI must be used in lieu of Provider Transaction Access Number (PTAN) or Legacy Provider Identifiers in the HIPAA standard transactions.
Why it is NPI number is so important to the physician or health care provider?
The
answer is simply because this will be the single provider identifier, replacing
the different provider identifiers use for each health plan. This identifier
was implemented by Health Insurance Portability and Accountability Act of 1996
(HIPAA). Implementation of the NPI will eliminate the need for health care
providers to use different identification numbers to
identify themselves when conducting standard transactions with multiple health
plans. Many health plans, including Medicare, Medicaid, Medi-Cal (in California) and private health
insurance issuers and all health care must accept and use NPI.
Who uses NPI number?
The NPI is used by most HIPAA covered entities, which are:
- - ->Health plans
- - ->Health care clearinghouses
- - ->Healthcare providers
HIPAA covered entities must use NPI to identify health care providers in standard transactions. These transactions include:
- - ->Claims
- - ->Eligibility inquiries and responses
- - ->Claim status inquiries and responses
- - ->Referrals
- - ->Remittance advices
The NPI is used by most HIPAA covered entities, which are:
- - ->Health plans
- - ->Health care clearinghouses
- - ->Healthcare providers
HIPAA covered entities must use NPI to identify health care providers in standard transactions. These transactions include:
- - ->Claims
- - ->Eligibility inquiries and responses
- - ->Claim status inquiries and responses
- - ->Referrals
- - ->Remittance advices
The NPI
is one of the steps that CMS is taking to improve electronic transactions for
health care. National standards for electronic health care transactions
encourage electronic commerce in the health care industry and simplify the
processes involved to reduce the administrative burdens on health care
providers. With national and identifiers in place for electronic claims and
other transactions, health care provider will be able to submit transactions to
any health plan in the United States.
Health plans will be able to send standard transactions such as remittance advice and referral authorizations to health care providers. These national standards will make electronic data interchange a viable and preferable alternative to paper processing for health care providers and health plans alike.
How to apply NPI?
Health care providers can apply for NPIs in one of three ways:
1. For most efficient application processing and fastest receipt of NPIs use the web-based application process. Simply log onto the National Plan and Provider Enumeration System (NPPES) and apply online.
2. Health care providers can agree to have an Electronic File Interchange (EFI) organization (EFIO) submit application data on their behalf (e.g., through a bulk enumeration process) if an EFIO requests their permission to do so.
3. Health care providers may wish to obtain a copy of paper NPI Application/Update Form (CMS-10114) and mail the completed application data into NPPES. This form is now available for download from the CMS website or by clicking here.
What are the requirements for NPI application?
A. Information Required for Individual Providers:
1. Provider name
2. SSN (or ITIN if not eligible for SSN)
3. Provider Date of birth
4. Country of Birth
5. State of Birth (if Country of Birth is U.S.)
6. Provider Gender
7. Mailing Address
8. Practice Location and Phone Number
9. Taxonomy (Provider Type)*
10. State License Information (required for certain taxonomies only)
11. Contact Person Name
12. Contact Person Phone Number and E-mail
Note: (*) The Healthcare Provider Taxonomy Codes (HPTC) are a HIPAA standard code set named in the implementation specifications for some of the ASC X12 standard HIPAA transactions. The “Healthcare Provider Taxonomy Code” is a situational data element in the 4010 X12 Implementation Guides and the 5010 X12 TR3 Reports for the 837 Professional and Institutional. If the Taxonomy code is required in order to properly pay or process a claim/encounter information transaction, it is required to be reported. Thus, reporting of the Healthcare Provider Taxonomy Code varies from one health plan to another. The Healthcare Provider Taxonomy code set divides health care providers into hierarchical groupings by type, classification, and specialization, and assigns a code to each grouping. The Taxonomy consists of two parts: individuals (e.g., physicians) and non-individuals (e.g., ambulatory health care facilities). All codes are alphanumeric and are 10 positions in length. These codes are not “assigned” to health care providers; rather, health care providers select the taxonomy code(s) that most closely represents their education, license, or certification. If a health care provider has more than one taxonomy code associated with it, a health plan may prefer that the health care provider use one over another when submitting claims for certain services. The Healthcare Provider Taxonomy code set is available at no charge from the Washington Publishing Company’s website: http://www.wpc-edi.com/codes/taxonomy. The Healthcare Provider Taxonomy code set is maintained by the National Uniform Claim Committee (NUCC). The NUCC accepts requests for new codes and requests for changes to existing codes or descriptions. The criteria for review of a request for a new code or a change are available on the NUCC web site at: www.nucc.org The code set is updated twice a year.
B. Information Required for Organizations
1. Organization Name
2. Employer Identification Number (EIN)
3. Name of Authorized Official for the Organization
4. Organization Mailing Address
5. Practice Location Address and Phone Number
6. Taxonomy (Provider Type)*
7. Contact Person Name
8. Contact Person Phone Number and E-mail
When can I receive my NPI number?
Turn around time for obtaining a number is from 1 to 20 days if completed using web-based NPPES application.
Health plans will be able to send standard transactions such as remittance advice and referral authorizations to health care providers. These national standards will make electronic data interchange a viable and preferable alternative to paper processing for health care providers and health plans alike.
How to apply NPI?
Health care providers can apply for NPIs in one of three ways:
1. For most efficient application processing and fastest receipt of NPIs use the web-based application process. Simply log onto the National Plan and Provider Enumeration System (NPPES) and apply online.
2. Health care providers can agree to have an Electronic File Interchange (EFI) organization (EFIO) submit application data on their behalf (e.g., through a bulk enumeration process) if an EFIO requests their permission to do so.
3. Health care providers may wish to obtain a copy of paper NPI Application/Update Form (CMS-10114) and mail the completed application data into NPPES. This form is now available for download from the CMS website or by clicking here.
What are the requirements for NPI application?
A. Information Required for Individual Providers:
1. Provider name
2. SSN (or ITIN if not eligible for SSN)
3. Provider Date of birth
4. Country of Birth
5. State of Birth (if Country of Birth is U.S.)
6. Provider Gender
7. Mailing Address
8. Practice Location and Phone Number
9. Taxonomy (Provider Type)*
10. State License Information (required for certain taxonomies only)
11. Contact Person Name
12. Contact Person Phone Number and E-mail
Note: (*) The Healthcare Provider Taxonomy Codes (HPTC) are a HIPAA standard code set named in the implementation specifications for some of the ASC X12 standard HIPAA transactions. The “Healthcare Provider Taxonomy Code” is a situational data element in the 4010 X12 Implementation Guides and the 5010 X12 TR3 Reports for the 837 Professional and Institutional. If the Taxonomy code is required in order to properly pay or process a claim/encounter information transaction, it is required to be reported. Thus, reporting of the Healthcare Provider Taxonomy Code varies from one health plan to another. The Healthcare Provider Taxonomy code set divides health care providers into hierarchical groupings by type, classification, and specialization, and assigns a code to each grouping. The Taxonomy consists of two parts: individuals (e.g., physicians) and non-individuals (e.g., ambulatory health care facilities). All codes are alphanumeric and are 10 positions in length. These codes are not “assigned” to health care providers; rather, health care providers select the taxonomy code(s) that most closely represents their education, license, or certification. If a health care provider has more than one taxonomy code associated with it, a health plan may prefer that the health care provider use one over another when submitting claims for certain services. The Healthcare Provider Taxonomy code set is available at no charge from the Washington Publishing Company’s website: http://www.wpc-edi.com/codes/taxonomy. The Healthcare Provider Taxonomy code set is maintained by the National Uniform Claim Committee (NUCC). The NUCC accepts requests for new codes and requests for changes to existing codes or descriptions. The criteria for review of a request for a new code or a change are available on the NUCC web site at: www.nucc.org The code set is updated twice a year.
B. Information Required for Organizations
1. Organization Name
2. Employer Identification Number (EIN)
3. Name of Authorized Official for the Organization
4. Organization Mailing Address
5. Practice Location Address and Phone Number
6. Taxonomy (Provider Type)*
7. Contact Person Name
8. Contact Person Phone Number and E-mail
When can I receive my NPI number?
Turn around time for obtaining a number is from 1 to 20 days if completed using web-based NPPES application.
As a reminder once you receive your NPI, safeguard its use.
NPI Resources Link:
NPI Booklet
NPI Guidance Fact Sheet
