The Health Insurance Portability and Accountability Act (HIPAA) of 1996 requires the adoption of a standard unique
identifier for health care providers. The NPI Final Rule issued January 23, 2004 adopted the NPI as this standard.
- The NPI is a 10-digit, intelligence free numeric identifier (10 digit number). Intelligence free means that the numbers do not carry information about health care providers, such as the state in which they practice or their provider type or specialization.
- The NPI will replace health care provider identifiers in use today in HIPAA standard transactions. Those numbers include Medicare legacy IDs (UPIN, OSCAR, PIN, and National Supplier Clearinghouse or NSC).
- The provider’s NPI will not change and will remain with the provider regardless of job or location changes.
- Ensure a provider is licensed or credentialed;
- Guarantee payment by a health plan;
- Enroll a provider in a health plan;
- Turn a provider into a covered provider; and
- Require a provider to conduct HIPAA transactions.
- Simpler electronic transmission of HIPAA standard transactions;
- Standard unique health identifiers for health care providers, health plans, and employers; and
- More efficient coordination of benefits transactions.
- All health care providers (e.g., physicians, suppliers, hospitals, and others) are eligible for NPIs. Health care providers are individuals or organizations that render health care.
- All health care providers who are HIPAA-covered entities, whether they are individuals (such as physicians, nurses, dentists, chiropractors, physical therapists, or pharmacists) or organizations (such as hospitals, home health agencies, clinics, nursing homes, residential treatment centers, laboratories, ambulance companies, group practices, HMOs, suppliers of durable medical equipment, pharmacies, etc.) must obtain an NPI to identify themselves in HIPAA standard transactions.
It is a health care provider who transmits any health information in electronic form in connection with a transaction for
which the Secretary of HHS has adopted a standard, even if the health care provider uses a business associate to do
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so. Go to http://www.cms.hhs.gov/HIPAAGenInfo/Downloads/CoveredEntitycharts.pdf to access a tool to help establish whether one is a covered entity.
A sole proprietor/sole proprietorship is an individual and is elegible for a single NPI. The sole proprietor must apply for the NPI using his or her own SSN, not an EIN even if he/she has an EIN. Because a sole proprietor/sole proprietorship is an individual, he/she cannot be a subpart and cannot designate subparts.
Any entity that does not meet the definition of a “health care provider” at 45 CFR 160.103, which would include billing services, value-added networks, re-pricers, health care clearinghouses, non-emergency transportation services, and others.
Health care providers can apply now for their NPI on the National Plan and Provider Enumeration System (NPPES) web site https://nppes.cms.hhs.gov/NPPES/Welcome.do.
All Entities:
• HIPAA covered entities such as health care providers who conduct HIPAA standard transactions, health care clearinghouses, and all but small health plans, must use only the NPI to identify HIPAA covered health care providers in standard transactions by May 23, 2007. Small health plans (less than 5 million dollars in annual revenues) must use only the NPI by May 23, 2008.
Medicare Providers:
- Medicare Fee-For-Service (FFS) providers can begin to use the NPI January 3, 2006. Medicare systems will accept claims with an NPI, but an existing Medicare legacy identifier must also be on the claim.
- Starting October 2, 2006, Medicare FFS providers may submit an existing Medicare legacy identifier and/or an NPI on claims.
- If you are not a Medicare FFS provider or supplier, you need to be aware of the NPI readiness schedule for each of the health plans with which you do business, as well as any practice management system companies or billing companies (if used). They should determine when each health plan intends to implement the NPI in HIPAA standard transactions.
No. The NPI will not change or replace the current Medicare enrollment or certification process. A HIPAA covered provider or supplier will not receive payment from Medicare until it is properly enrolled and certified in the Medicare program.
A CMS web page dedicated to providing all the latest NPI news for health care providers is available at
http://www.cms.
hhs.gov/
NationalProvIdentStand/ on the web. This page also contains a section for Medicare Fee-For-Service (FFS) providers with helpful information on the Medicare NPI implementation.
This fact sheet was prepared as a service to the public and is not intended to grant rights or impose obligations. This fact sheet may containreferences or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.
