NPI Required for ALL Providers
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. Confusion for many physicians exists as to whether they must apply for the National Provider Identifier (NPI). On the face, it appears that the NPI is required only for covered entities under HIPAA. CMS has changed the rules that will require all providers to have the NPI. To date, approximately 530,000 providers who are Individuals and Organizations have obtained their NPI.
All HIPAA covered healthcare providers, whether they are individuals or organizations, must obtain the NPI to identify themselves in HIPAA and standard transactions. Once enumerated, a provider's NPI will not change. The NPI remains with the provider regardless of job, state, or location changes. HIPAA covered entities such as providers completing electronic transactions, healthcare clearinghouses, and large health plans, must use only the NPI to identify covered healthcare providers in standard transactions by May 23, 2007. Small health plans must use only the NPI by May 23, 2008. All Individuals and Organizations who meet the definition of health care providers as described at 45 CFR 160.103 are eligible to obtain a National Provider Identifier. CMS has declared that if you are a HIPAA covered provider OR if you are a health care provider/supplier who bills Medicare for your services, you need a NPI. It is apparent that all providers, regardless of their claim status with Medicare, will be mandated to obtain a NPI. The mandate applies to participating and non-participating physicians.
The NPI is a 10-digit number that will be used to identify you to your health care partners. The NPI will replace the UPIN identifiers you currently use in all paper and HIPAA standard transactions that you conduct with Medicare and with other health plans. HIPAA transactions include the electronic claim, eligibility inquiry and response, claim status inquiry and response, payment and remittance advice, prior authorization or referral, and coordination of benefits transactions. Providers who conduct any of those electronic transactions must have their National Provider Identifiers (NPIs) and be ready to use them to identify themselves, and possibly other providers, in those transactions before May 23, 2007. That is less than a year from now. Some health plans might be ready to accept NPIs much earlier than next May. The health plans with which you do business, will inform you as to when you may begin using your NPI in these electronic transactions.
CMS reminds health care providers that they need to obtain their National Provider Identifiers. CMS has adopted a policy for all Medicare and Medicaid providers that mandates the use of the NPI. We have received confirmation from various sources including CMS, that the NPI is required for all providers, regardless of their status with HIPAA. The only known exclusion to the NPI initiative is for small health plans, which is the relatively small group of insurers that process a minimum number of medical claims each year. There is no exclusion for small providers, such as those with less than 10 full-time employees. These physicians will also be required to complete the enumeration process for an NPI number.
CMS is implementing a new 1500 claim form later this year , which will require a NPI. It has been 15 years since a revision to the 1500 claim form. The National Uniform Claim Committee (NUCC) has approved a Revised 1500 Health Insurance Claim Form. This new version will replace the existing 1500 Claim Form (version 12/90), often referred to as the HCFA-1500 or CMS-1500. Essentially then, neither electronic nor paper submitters of Medicare claims are exempt from the enumeration process. It is believed that the acquisition of the NPI by a non-covered entity will not alter your status under HIPAA guidelines.
If you are a new provider or one that does not have a current UPIN number with CMS, you will need a NPI prior to enrolling with Medicare. There are two types of health care providers in terms of NPIs:
- Type 1 - Health care providers who are individuals, including physicians, dentists, and all sole proprietors. An individual is eligible for only one NPI.
- Type 2 – Health care providers who are organizations, including physician groups, hospitals, 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. A subpart is a component of an organization that furnishes health care and is not itself a separate legal entity. If you are an individual who is a health care provider and who is incorporated, you may need to obtain the NPI for yourself (Type 1) and a NPI for your corporation or LLC (Type 2).
The NPI compliance date is May 23, 2007. However, CMS recommends that you obtain your NPI at least six months prior to this date to provide you with ample time to test your NPI and share it with all of your health care partners, including payers, clearinghouses, vendors, and other providers.
When applying for your NPI, CMS urges you to include your legacy identifiers (UPIN), not only for Medicare, but also for all payors. If reporting a Medicaid number, include the associated state name. This information is critical for payors in the development of crosswalks to aid in the transition to the NPI.
There are three ways that you can obtain your NPI. You can:
- Complete the on-line application at the NPPES web site:
( https://NPPES.cms.hhs.gov/NPPES/Welcome.do );
- Download the paper application form at www.cms.hhs.gov/NationalProvIdentStand/ and mail it to the address on the form; or,
- After asking you for your permission, authorize an employer or other trusted organization to obtain an NPI for you through bulk enumeration, or Electronic File Interchange (EFI).
Regardless of how you obtain your NPI, it is important that you retain the notification document that NPPES sends to you that contains your NPI. You may need to share this notification with other health care partners.
Pertinent websites:
http://www.cms.hhs.gov/NationalProvIdentStand/ to find additional NPI information.
https://nppes.cms.hhs.gov to fill out the application for the NPI on line.
http://www.wpsmedicare.com/provider/npi_information.shtml for links to other information.
Dr. Fucinari received his Doctor of Chiropractic degree from Palmer College of Chiropractic in 1986. After graduating from Palmer College, Dr. Fucinari completed studies in chiropractic orthopedics and attained his certification as a chiropractic sports physician, and a certified Insurance Consultant. Dr. Fucinari is a Diplomate of the American Academy of Pain Practitioners. He is also a member of the American Academy of Professional Coders and International Association of Privacy Professionals (IAPP). He currently practices full time in Decatur, IL. He has produced classes and publications on HIPAA, Clinical Documentation, Medicare, and Stroke and Cervical Manipulation. He is a frequent national speaker for NCMIC and several state associations on HIPAA, Clinical Documentation and Medicare Guidelines. |
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