Q. What is a National Provider Identifier (NPI)?
A: The administrative simplification provisions of the Health Insurance Portability and Accountability Act (HIPAA) required the Secretary of Health and Human Services (HHS) to adopt a national standard identifier for health care providers for use in the health care industry. On January 23, 2004, HHS published the NPI final rule that adopts the National Provider Identifier (NPI) as the standard unique health identifier for health care providers.
Q. How can a provider learn more about NPI?
A: Visit the Centers for Medicare & Medicaid Services (CMS) HIPAA Web site for more information.
Q. Does a provider need to apply for an NPI to submit claims?
A: Yes. Starting on the compliance date of May 23, 2007, the NPI will be the only health care provider identifier that can be used for identification purposes in all transactions, including paper claims submitted on or after May 23, 2007.
Q. How does a provider apply for an NPI?
A: The Centers for Medicare & Medicaid Services (CMS) has established a National Plan and Provider Enumeration System (NPPES). For additional information, and to complete an application, visit the National Plan and Provider Enumeration System (NPPES) Web site.
Q. If a provider is not a HIPAA covered entity, do they need to apply for an NPI?
A: Please see the Centers for Medicare & Medicaid Services (CMS) HIPAA Web site for information on HIPAA covered entities and who should apply for an NPI. Please note that most states will be requiring an NPI on paper transactions, which would otherwise not be considered a covered transaction. Only those providers considered "atypical" will be exempt from registering an NPI because they do not fit the definition of a HIPAA covered entity.
Q. What is a taxonomy code and how does a provider acquire one?
A: The Health Care Provider Taxonomy Code (HCPTC) set is an external non-medical data code set designed for use in classifying health care providers according to provider type or practitioner specialty in an electronic environment, specifically within the American National Standards Institute (ANSI) Accredited Standards Committee (ASC) health care claim transaction. The HCPTC list is a collection of unique alphanumeric codes, 10 characters in length, called taxonomy codes. The code set is structured into three distinct "levels," including provider type, classification and area of specialization.
The taxonomy codes allow a single provider (individual, group or institution) to identify their areas of specialization. Providers may have one or more areas of specialization. When determining what value or values to associate with a provider, the user needs to review the requirements of the trading partner with which value(s) are being used.
The Health Care Provider Taxonomy Code set can be found on the Washington Publishing Company Web site.
Q. Does a provider need a separate NPI for Medicare and state directs?
A: No. The NPI was established to eliminate having a separate legacy provider number for each health care plan.
Q. For paper claims, should a provider use their current provider number or their NPI?
A: Prior to May 23, 2007, providers should continue to use their current provider number on any claims. On or after May 23, 2007, providers should use only their NPI. The HCFA-1500 claim form and the UB-92 Claim Form will be changing with the industry approved standard forms, the CMS-1500 and UB-04 claim forms. Most states will begin accepting the new claim forms beginning March 26, 2007. More information will become available regarding the transition period and use of NPI in conjunction with the new claim forms in the near future.
Q. If a group of providers have an NPI and each of the rendering providers have individual NPIs, how should the group specify that all the NPIs belong to one provider group?
A: Each rendering provider working under a group must separately register their own NPI. The group must register its own NPI. It is the group’s responsibility to include its NPI along with the rendering provider’s NPI when billing.
Additional Resources:
