National Provider Identifier - Frequently Asked Questions

Q: What is the National Provider Identifier (NPI)?
A: The NPI is a 10-position numeric identifier (10-digit number). The number is "intelligence-free, meaning it does not carry other information about healthcare providers, such as the state in which they live or their medical specialty. Beginning May 23, 2007 (May 23, 2008, for small health plans), the NPI must be used in lieu of legacy provider identifiers. Legacy provider identifiers include:
  • Online Survey Certification and Reporting (OSCAR) system numbers;
  • National Supplier Clearinghouse (NSC) numbers;
  • Provider Identification Numbers (PINs), such current Iowa Medicaid numbers;
  • Unique Physician Identification Numbers (UPINs) used by Medicare.

    They do not include taxpayer identifier numbers (TINs) such as:
  • Employer Identification Numbers (EINs); or
  • Social Security Numbers (SSNs).

    Reference: http://www.cms.hhs.gov/mlnmattersarticles/downloads/MM4023.pdf

  • Q: What is the purpose of the NPI? Who must use it, and when?
    A: The purpose of the National Provider Identifier (NPI) is to uniquely identify a health care provider in standard transactions, such as health care claims. NPIs may also be used to identify health care providers on prescriptions, in internal files to link proprietary provider identification numbers and other information, in coordination of benefits between health plans, in patient medical record systems, in program integrity files, and in other ways. HIPAA requires that covered entities (i.e., health plans, health care clearinghouses, and those health care providers who transmit any health information in electronic form in connection with a transaction for which the Secretary of Health and Human Services has adopted a standard) use NPIs in standard transactions by the compliance dates. The compliance date for all covered entities except small health plans is May 23, 2007; the compliance date for small health plans is May 23, 2008. As of the compliance dates, the NPI will be the only health care provider identifier that can be used for identification purposes in standard transactions by covered entities.

    Q: Is a health care provider required to obtain an NPI?
    A: Under the National Provider Identifier Regulation (that was published in the Federal Register on January 23, 2004), a health care provider who is a covered entity, as defined at 45 C.F.R. � 160.103, is required to obtain a National Provider Identifier (NPI) by May 23, 2007.

    Q: Why do I need my National Provider Identifier (NPI) now, when I've been told it's not required until 2007?
    A: While it is true that providers and suppliers will need to use their NPI in all transactions beginning May 23, 2007, timely reporting of the NPI to the IME and other payers will enable them to link a provider's existing billing numbers to the new NPIs, which should in turn, help assure timely claims payment at the deadline.

    Q: Will the ten-digit NPI number replace the current seven-digit MediPASS authorization number on claims requiring a MediPASS referral after NPI is implemented?
    A: Yes. Based upon the Federal HIPAA requirements, Iowa Medicaid will require use of the NPI number for all electronic and paper claims beginning May 23, 2007. This will include the MediPASS authorization (in cases where it is required). This authorization will still be located in box 17 of the CMS 1500 claim form.
    Q: How will a health care provider obtain an NPI?
    A: A health care provider will be able to apply for an NPI in one of three ways:
    • Apply through a web-based application process. The web address is https://nppes.cms.hhs.gov/.
    • Prepare and send a paper application form to the Enumerator (Fox Systems). A copy of the application form, which includes the Enumerator's mailing address, can be found at https://nppes.cms.hhs.gov/. A health care provider may also call the Enumerator and request a blank application form. The Enumerator's phone number is 1-800-465-3203 or TTY 1-800-692-2326.
    • With the permission of the health care provider, an organization may submit a health care provider's application in an electronic file.
    Q: May National Provider Identifiers (NPIs) be used on paper claims transactions?
    A: The use of NPIs on paper claims transactions is allowed. The health plan receiving the claim may make the determination on the use of NPIs on paper claims transactions. HIPAA regulations adopt standards for format and content of certain electronic health transactions; they do not address the content of paper claims transactions. Therefore, individual payers may vary in this respect; IME will require NPI on paper health care claims, just like electronic.
    Q: What is the transition period for the revised CMS-1500 and the UB-04 forms?
    A: The transition period for the revised CMS-1500 began January 1, 2007 and ends March 31, 2007. Effective April 1, 2007, claims received on a non-revised CMS-1500 form will be rejected. The transition period for the UB-04 is scheduled for March 1, 2007 - May 22, 2007. Effective May 23, 2007, claims received on a UB-92 form will be rejected.

    Reference: http://www.cms.hhs.gov/mlnmattersarticles/downloads/MM4023.pdf
    Q: Do I need an NPI?
    A: Providers must determine what services allow for the use of the NPI. Entities who meet the definition of "health care provider", as defined at 45 C.F.R. � 160.103, are eligible to receive National Provider Identifiers (NPIs). When applying for an NPI, providers declare that they meet this definition. For questions on whether a provider's services meet this definition, go to the NPI enumerator (https://nppes.cms.hhs.gov/NPPES/Welcome.do).
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