The Health Insurance Portability and Accountability Act of 1996 (HIPPA) mandated that the Department of Health and Human Services (HHS) adopt a standard form of unique identification for health care providers. Accordingly, the development of the National Provider Identifier (NPI) is one of the steps the Centers for Medicare and Medicaid Services (CMS) and third-party payers have taken to improve electronic transactions for the health care industry.

The final rule that adopted the NPI as the standard unique health identifier for health care providers was published in January 2004. However, the compliance date for all covered entities is May 23, 2007.



The National Plan and Provider Enumeration System (NPPES) will assign NPIs. Performing under a CMS contract, the NPPES will operate the National Provider System (NPS). The NPPES will receive NPI applications and updates from health care providers. This entity will also assist health care providers in completing applications and furnishing updates, and will be responsible for resolving problems and answering questions. The NPS will process the applications, ensure the uniqueness of the health care provider and generate the NPIs.

When the NPI is implemented, covered entities will use only the NPI to identify health care providers in all standard transactions. The legacy identification numbers (e.g., UPIN, Blue Cross and Blue Shield numbers, CHAMPUS numbers, Medicaid numbers, etc.) will no longer be permitted. When you apply for your NPI, CMS encourages you to include legacy identifiers not only for Medicare but also for all payers. If you are reporting a Medicaid number, include the associated state name. This information is critical for payers in the development of crosswalks to aid in the transition to the NPI.

The good news is health care providers will no longer have to keep track of multiple numbers to identify themselves in standard transactions with one or more health plans. However, providers will need to provide the Taxpayer Identifying Number (Tax ID) for tax purposes.

Key Tips To Remember About The NPI
The National Provider Identifier (NPI) is a 10-digit number. The first nine numbers are the identifier and the last number is a check digit, which helps detect invalid NPIs. There is no embedded intelligence in the NPI with respect to the health care provider that it identifies. The numbers do not carry any information about the health care providers such as the state in which they practice, their provider type or their specialty.

All health care providers will be assigned NPIs after they have successfully completed an application. HIPAA will cover health care providers whether they are individuals or organizations but all must obtain an NPI to identify themselves in HIPAA standard transactions. Once you have a NPI, it will not change. The NPI remains with the individual provider regardless of his or her job or location changes.

Health care providers will be classified in this process as either an “individual” or an “organization.” Individuals include physicians, physician assistants (PAs), nurse practitioners (NPs), certified nurse midwives (CNMs), physical therapists, chiropractors and other nurses that bill. Organizations include hospitals, group practices, laboratories, clinics, etc.

Organizational providers may also obtain NPIs for their subparts. Subparts are HIPAA-covered organizations that are comprised of health care providers who are part of another primary organization. Examples of a subpart may include different departments of a hospital with a separate physical location. If the subpart of an organization conducts its own HIPAA standard transactions and is certified by the state separately from the primary organization, the primary organization must determine if it needs to obtain a separate NPI for the subpart.

What You Need To Fill Out The NPI Application

- Individual Provider Information • Provider name • Date of birth • Country of birth • State of birth • Gender • Mailing address (Do not use a P.O. Box address) • Primary practice address and phone number • Taxonomy (specialty code, MD, DO, etc.) • State license information • Provider numbers (Medicare, Medicaid, private payers) • Contact name, number and e-mail Organizational Information • Organization name • Employer identification number (EIN) • Name of authorized official for the organization • Phone number of authorized official for the organization • Organization mailing address • Primary practice location address and phone number • Taxonomy (specialty code, MD, DO, etc.) • State license Information • Contact person name, phone, number and e-mail

How To Apply For A NPI
When it comes to applying for a NPI, providers can either fill out the application online, mail in a hard copy application or apply through an electronic file interchange (which was formerly called bulk enumeration). One can find the online application at https://nppes.cms.hhs.gov. Currently, it only takes a maximum of 10 days to receive your NPI for online applications and it will be sent by e-mail. To apply by mail, you can obtain a copy of the application online (http://www.cms.hhs .gov/forms/cms10114.pdf), call customer service at (800) 465-3203 or (800) 692-2326, or send an e-mail to customerservice@npienumerator.com.

If health care providers choose to use the electronic file interchange, they will need to submit for approval as an Electronic File Interchange Organization. This is the process that allows you to file claims and information electronically to CMS. If health care providers choose to use the electronic option, they will have to file claims electronically. Please keep in mind that you must report any data changes for your NPI application within 30 days of the effective date of change.

Antanya A. Chung, CPC

Also, in regard to changes, providers must submit them in the same way they submitted their original NPI application. For example, if you submitted an online application, you must submit changes online as well. (Also see “What You Need To Fill Out The NPI Application.”)

Assessing The Initial Impact Of NPIs
The implementation of the NPI will have an impact on certain forms and procedures for health care providers. There will be new CMS 855 forms, new private payer applications and new CMS 1500 forms (with a release date of October 1, 2006). Additionally, the credentialing and enrollment process will change but the NPI will not take the place of enrollment. Updated information will come from electronic medical record (EMR) and practice management system vendors.

In Conclusion
While it is not mandatory to use an NPI number for CMS until May 23, 2007, you can go ahead and apply for a NPI. As for now, you can continue to bill with your current UPIN number or you may bill with your UPIN and your new NPI number through October 1, 2006. During the period of Oct. 2, 2006 to May 22, 2007, you have a few options. You can still bill with only your own UPIN, bill with your UPIN and the new NPI or bill with only the new NPI. Finally, starting on May 23, 2007, providers can only bill with the new NPI number.

Melesia R. Collins, CPC

You will need to talk to your third-party payers as to when they will begin accepting the NPI number for claims. Keep in mind that some payers plan to begin accepting the NPI long before the May 23, 2007 compliance date.

As a suggestion, during the period of Oct. 2, 2006 to May 22, 2007, you may want to test out billing with the NPI number alone. Doing so will help identify any potential problems with the NPI number before it is mandatory for you to use it.