NPI Frequently Asked Questions
- What is a National Provider Identifier (NPI)?
- Is a health care provider required to obtain an NPI?
- Why do health care providers need National Provider Identifiers?
- How many NPIs do health care providers need?
- How long will it take to receive an NPI?
- What is the timeline for NPI?
- What is the Revised CMS-1500 Form?
- What is the timeline for the Revised CMS-1500 Form?
- In general, what is ENS' NPI implementation strategy?
- Is ENS accepting the NPI on standard transactions today?
- Has ENS established a timeline for submitting NPI to the Payer?
- Will ENS validate all NPIs that are sent for all transactions?
- Will ENS require testing with your Trading Partners?
- After May 23, 2007 , will ENS reject transactions that do not contain an NPI?
1. What is a National Provider Identifier (NPI)?
An NPI is a unique 10-digit, intelligence-free numeric identifier. Intelligence-free means that the numbers do not carry information about health care providers, such as the state in which they practice, their provider type, or their specialization. NPIs will replace health care provider identifiers that are currently being used for Health Insurance Portability and Accountability Act (HIPAA) standard transactions. Those numbers include payor-specific IDs and Medicare legacy IDs (e.g. UPIN, OSCAR, PIN, and National Supplier Clearinghouse or NSC). A provider's NPI will not change and will remain with the provider regardless of job or location change(s).
2. Is a health care provider required to obtain an NPI?
Yes. Under the National Provider Identifier Regulation (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, and who transmits any health information in connection with a standard transaction, is required to obtain an NPI.
3. Why do health care providers need National Provider Identifiers?
HIPAA requires the adoption of a standard unique identifier for health care providers. NPI allows for simpler electronic transmission of HIPAA standard transactions. By May 23, 2007 , the NPI will be the only health care provider identifier that can be used for identification purposes in standard transactions by covered entities. Covered entities include 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 Service s has adopted a standard.
4. How many NPIs do health care providers need?
An individual is eligible for a single NPI. An Individual cannot have subparts and cannot designate subparts. In terms of NPI assignment, an Individual is an Entity Type 1 (Individual).
A sole proprietor/sole proprietorship is eligible for a single NPI. A sole proprietor/sole proprietorship cannot have subparts and cannot designate subparts. In terms of NPI assignment, a sole proprietor/sole proprietorship is an Entity Type 1 (Individual).
Organizations must also apply for a single NPI. In terms of NPI assignment, Organization health care providers who are covered entities under HIPAA must apply for NPIs as Entity Type 2 (Organization). Organization health care providers are corporations or partnerships or other types of businesses that are considered separate from an individual by the state in which they exist. Subparts of such Organization health care providers who apply for NPIs are also Entity Type 2 (Organization).
- A subpart must have its own NPI if it conducts any of the HIPAA standard transactions separately from the covered Organization health care provider of which it is a part. If your organization has subparts, please ensure that they obtain their own unique NPIs, or obtain the NPIs for them.
- Example : A health care provider (a hospital) owns 10 home health agencies, all operating under the Tax Identification Number (TIN) of the hospital. Because the hospital and each of the 10 home health agencies is separately surveyed and enters into its own provider agreement with Medicare, a total of 11 unique NPIs should be obtained: one by the hospital and one by each of the 10 home health agencies.
- For further clarification regarding Entity Types and Subparts, please visit the Centers for Medicare & Medicaid Services Web site, select the Medicare NPI Implementation link, and select the Medicare Subpart Expectations PDF.
5. How long will it take to receive an NPI?
The Centers for Medicare & Medicaid Service s (CMS) cannot predict the amount of time it will take to obtain an NPI due to the volume of applications being processed at a given time, whether the application is submitted electronically or on paper or whether the application is complete and free of errors. When gathering information for the application, be sure that all provider information, such as Social Security Number and Federal Employer Identification Number (FEIN), are correct. CMS estimates that, in general, a health care provider who submits a properly completed electronic application could have an NPI within 10 days.
6. What is the timeline for NPI?
The final National provider Identifier rule was published in the Federal Register on January 23, 2004 . The effective date of the rule is May 23, 2005 . The compliance date that all covered entities except small health plans must abide by is May 23, 2007 . Small health plans must comply by May 23, 2008 .
7. What is the Revised CMS-1500 Form?
The current version of Form CMS-1500 (12-90) is being revised to accommodate the reporting of the NPI. The revised version will be Form CMS-1500 (08-05).
8. What is the timeline for the Revised CMS-1500 Form?
The revised CMS-1500 Form will be effective October 1, 2006 , but will not be mandated for use until February 1, 2007 . There will be a dual acceptability period for both the existing and the revised forms.
Click here to link to a view of the Revised CMS-1500 Form.
9. In general, what is ENS' NPI implementation strategy?
Our goal is to ensure that transaction processes are in place and available to facilitate the submission of the NPI prior to the NPI adoption date of May 23, 2007 .
10. Is ENS accepting the NPI on standard transactions today?
Yes, ENS continues to see an increase in the number of transactions being received containing NPI data and expects these volumes to increase within the next few months.
11. Has ENS established a timeline for submitting NPI to the Payer?
• CLAIMS
In order for ENS to guarantee appropriate processing of claims containing NPI data, the Payer must be receiving the ASC X12N 4010A1 format. ENS supports the dual use strategy approach as defined by WEDI Strategic National Implementation Process (SNIP) whereby claims submitted from October 2, 1006 through May 22, 2007 , may contain both the NPI and Legacy Identifiers.
• TIMELINE FOR PROCESSING NPI TO PAYER
- Medicare – September 1, 2006 through May 22, 2007
- Medicaid – November 1, 2006 through May 22, 2007
- Blue Shield – January 1, 2006 through May 22, 2007
- Commercial – December 1, 2006 through may 22, 2007 (based on Commercial Payers who have indicated their readiness to receive NPI data)
• REAL-TIME
- TIMELINE FOR PROCESSING NPI TO PAYER
12. Will ENS validate all NPIs that are sent for all transactions?
ENS has created check digit logic using the Luhn Check Digit and will edit every NPI received for validity. If the NPI that is received is not a valid NPI, the transaction will reject at ENS prior to submission to the Payer.
13. Will ENS require testing with your Trading Partners?
ENS does not anticipate requiring testing for NPI submission, but will accommodate those Payers /Vendors/Gateways who do require it.
14. After May 23, 2007 , will ENS reject transactions that do not contain an NPI?
There is a caveat to the deadline of May 23, 2007 . Small health plans must abide by the NPI mandate by May 23, 2008 . Due to this alternative date, ENS will not be rejecting transactions received without an NPI between May 23, 2007 and May 23, 2008 without receiving edit requirements from the Payer. In order for ENS to implement a front-end rejection for transactions received without an NPI, the Payer MUST contact ENS.
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