National Provider Identifier

Background The Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandated that the Secretary of Health and Human Services adopt a standard unique health identifier for health care providers. On January 23, 2004, the Secretary published a Final Rule that adopted the National Provider Identifier (NPI) as this identifier. The NPI must be used by covered entities under HIPAA. The NPI will identify healthcare providers in electronic transactions for which the Secretary has adopted standards (the standard transactions) after the compliance dates. These transactions include claims, eligibility inquiries and responses, claim status inquiries and responses, referrals, and remittance advices.

Background, continued The NPI will replace health care provider identifiers that are in use today in standard transactions. Implementation of the NPI will eliminate the need for health care providers to use different identification numbers to identify themselves when conducting HIPAA standard transactions with multiple health plans. All health plans (including Medicare, Medicaid, and private health plans) and all health care clearinghouses must accept and use NPIs in standard transactions by May 23, 2007 (small health plans have until May 23, 2008). After those compliance dates, health care providers will use only their NPIs to identify themselves in standard transactions, where the NPI is required.

NPI Principles NPI is not a credentialing program NPIs are not tied together in the database NPI is required on standard transactions, optional elsewhere HIPAA does not govern internal systems NPI may be used for any lawful purpose Identifies health care providers or subparts as health care providers in standard transactions Replaces the use of proprietary and legacy provider identifiers in standard transactions for health care providers and subparts who have been assigned NPIs

Structure of NPI NPI is 10 digits: 123456789C PlanID is also 10 digits C = Check digit First digit distinguishes between NPI & PlanID First Digit Capacity Used By 1,2 200 million NPI 8 100 million PlanID 0,3,4,5,6,7,9 700 million Reserve

Eligibility for an NPI All healthcare providers as defined in 45 CFR 160.103, are eligible to obtain an NPI Covered healthcare providers (submitting electronic HIPAA transactions) are required to obtain an NPI Subparts of covered organization health care providers (that conduct any of the standard transactions) are required to obtain an NPI Eligible providers include: physicians, hospitals, dentists, nurses, physician assistants, licensed social workers, DME suppliers, suppliers related to health care such as prosthetics, pharmacies, pharmacists, group practices, medical students who provide care. Providers not eligible include: atypical service providers such as taxis, home & vehicle modifiers, administrative agents for providers such as billing services, clearinghouses, repricers.

NPI Specifics 10-position identifier (9 plus a check digit in the 10th position). The ISO standard check digit will detect keying and data entry errors. All numeric. The numeric NPI will facilitate telephone keypad entry-required for telephone base recognition software. For example, some health plans have established telephone key pad verification software to check on a patient’s eligibility for a particular health care service. Intelligence free NPI. NPI will not contain intelligence about the health care provider’s organization. For example, if an individual health care provider changes their specialty the NPI is not affected and this ensures the lasting nature of the NPI.

Specifics, continued Permanent identifier. The NPI is a permanent identifier for the health care provider, except in certain situations, such as a health care provider who does not wish to continue an association with a previously used NPI which has been used fraudulently. Unique identifier. Safeguards will be established to guard against assigning the same NPI to more than one health care provider or more than one NPI to the same health care provider. Individual health care provider: Each individual health care provider may receive and use only one NPI. Death of a Health Care Provider: An NPI is deactivated upon death or dissolution of a health care provider. Safeguards will be established to ensure a deceased health care provider’s NPI is never reissued.

An NPI will not… Be assigned to entities that do not meet “health care provider” definition in regulation Eliminate or replace the provider enrollment processes conducted by health plans Guarantee reimbursement by any health plan Convey covered entity status Assure licensure or credentials Require a health care provider or a subpart to conduct standard transactions

The NPI Timeline Health care providers began applying for NPIs on May 23, 2005 important to apply for NPI before the compliance date of May 2007 because health plans may require you to use your NPI before that date NPI Implementation deadline is 5/23/07 Small health plans have until 5/23/08 to comply

NPI Application Methods Methods include Apply by paper (via mail) Available 2005 Apply via web Available May 23, 2005 Apply using the Electronic File Interchange (EFI) Future development

Individual Providers vs. Group Practices An individual who is a covered health care provider and is a member of an organizational health care provider is not considered to be a subpart of the organizational health care provider The individual would receive a Type I-Individual NPI Only one NPI assigned for an individual The organizational health care provider would receive a Type II-Organizational NPI Defined subpart(s) may receive organizational NPI(s)

NPI Enumerator Fox Systems, Inc. Responsible for provider enumeration process using the National Provider and Plan Enumeration System (NPPES) Handles NPI applications/update forms The NPPES will not Link subparts to covered organization health care providers or vice versa Capture memberships in groups or multiple practice location addresses Know whether or not a health care provider is a covered entity

The National Plan and Provider Enumeration System (NPPES) National Provider System (NPS) is synonymous with NPPES Developed under CMS contract Uniquely identifies health care providers and subparts and assigns them NPIs Sets up and maintains a record for every enumerated health care provider and subpart Creates reports and output files Ask about the meaning of the first byte of the NPI… The NPPES is the system – the enumerator administers the NPPES?

The NPPES will not… Link subparts to covered organization health care providers or vice versa Capture memberships in groups Capture multiple practice location addresses Know whether or not a health care provider is a covered entity If a provider has multiple locations, can they sub-part themselves?

What information must be furnished to obtain an NPI? The minimum data needed to ensure unique identification Basic and identifying information, certification statement, signatures, contact person More information will be required if necessary to establish uniqueness Federal Register contains list of data elements I do not understand this screen… NPI Provider Minutes – document sent to the enumerator has all of the data they are to collect and how to determine duplicates, situational elements

Obtaining NPIs (cont.) NPPES uses data on application or in EFI to ensure unique identification SSN validation, address verification, duplicate check Edits to detect incomplete and illogical data If application is OK, health care provider or subpart is notified of NPI If application is not OK, Enumerator communicates with health care provider or subpart

Use of the Taxpayer Identification Number (TIN) TIN established by regulation to identify a taxpayer (SSN, EIN or ITIN) Required in many standard transactions to identify entities (including health care providers or subparts) as taxpayers When TIN is to be reported in standard transactions for its regulatory purpose, it must be used. NPI cannot be used as a substitute for a TIN

Use of DEA, CLIA and Mammography Certification Numbers Not considered to be healthcare provider identification numbers When Number is to be reported for its regulatory purpose, it must be used. NPI cannot be used as a substitute for a DEA, CLIA or Mammography Certification Number

Options for Obtaining NPI Information Four different sources (maybe more…) NPPES Provider to Plan/Clearinghouse Provider to Provider Plan/Clearinghouse to Plan/Clearinghouse

What should you be doing now? Become informed about the NPI, the enumeration process and its implementation Identify processes/systems that are affected by provider identifiers Develop enumeration strategy and submit NPI applications Develop implementation plans (internal, external with trading partners and others) Educate staff

Implementation Activities Check CMS website for updates Watch/ask for instructions/communications from CMS, vendors, health plans and trading partners Determine impact of NPI on contracts, systems, processes, files Identify/resolve issues early

NPI Resources WEDI www.wedi.org DSMO’s Named in HIPAA as consulting organization NPI PAG, SNIP NPI listserv, white papers DSMO’s NCPDP, X12, HL7, NUCC, NUBC, DeCC Other professional organizations and associations www.nppes.cms.hhs.gov NPI Enumerator Call Center 800-465-3203

CMS NPI Resources www.cms.hhs.gov HIPAA Hotline 1-866-282-0659 regulations FAQs Regulations and Outreach Listservs Outreach materials, announcements HIPAA Hotline 1-866-282-0659 AskHIPAA@cms.hhs.gov CMS “NPI” Web site now available