NPI Enumeration Strategies Gail Kocher, Highmark Inc January 11, 2006 National HIPAA Audioconference: Analysis of the National Provider Identifier NPI Enumeration Strategies Gail Kocher, Highmark Inc January 11, 2006

Individual Practitioner One NPI for lifetime Required when covered entity, i.e. sole proprietorship

Individual Practitioner Highly recommended for all, but specific examples, when: A member of group professional practice Hospital compensated or facility employed Routinely refers patients to other Health Care Providers

Organizational Provider Required for covered entity Health Care Providers when they are the Legal entity Subpart that would be a covered entity if a separate legal entity Subpart that generates its own standard transactions

Organizational Provider Enumeration Strategy One schema for all Payers Requires communication between Providers and their Payers Requires determination of business need vs. mandated need for subparts Provider Decision Enables Coordination of Benefits

Organizational Provider Enumeration Strategy Highest level of granularity detail needed for internal business processes Evaluate current contracts for reimbursement impacts Determine potential contract changes for reimbursement impacts Evaluate systems capabilities and limitations

Organizational Provider Enumeration Strategy Highest level of granularity detail needed for internal business processes Determine internal billing entity needs Billing Provider Returned Data e.g. remit, utilization Determine Payer capabilities Data supplied e.g. remit, utilization

Organizational Provider Enumeration Strategy Highest level of granularity detail needed for internal business processes Criteria for uniqueness must be met e.g.. Taxonomy, Location Be aware of potential future HIPAA transaction impacts, e.g.. 005010

Contact Information Gail Kocher HIPAA Knowledge Center Highmark, Inc. 717-302-4908 gail.kocher@highmark.com