Q: What is the standard that was adopted as the unique health identifier for health are providers?
A: The National Provider Identifier (NPI) was adopted as the standard unique health identifier for health care providers to carry out a requirement in the Health Insurance Portability and Accountability Act of 1996 (HIPAA) for the adoption of such a standard. The NPI did not exist previously; it was developed as the unique identifier for health care providers because no existing standard met the criteria required of a national standard.
Q: What is the purpose of the NPI? Who must use it, and when?
A: The purpose of the National Provider Identifier (NPI) is to uniquely identify a health care provider in standard transactions, such as health care claims. NPIs may also be used to identify health care providers on prescriptions, in internal files to link proprietary provider identification numbers and other information, in coordination of benefits between health plans, in patient medical record systems, in program integrity files, and in other ways. HIPAA requires that covered entities (i.e., 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 Services has adopted a standard) use NPIs in standard transactions by the compliance dates. The compliance date for all covered entities except small health plans is May 23, 2007; the compliance date for small health plans is May 23, 2008. As of the compliance dates, the NPI will be the only health care provider identifier that can be used for identification purposes in standard transactions by covered entities.
Q: Who is eligible to receive an NPI?
A: Entities who meet the definition of “health care provider”, as defined at 45 C.F.R. § 160.103, are eligible to receive National Provider Identifiers (NPIs). Health care providers include hospitals, nursing homes, durable medical equipment suppliers, clinical laboratories, pharmacies, and many other “institutional” type providers; physicians, dentists, pharmacists, nurses, and many other health care practitioners and professionals; group practices, health maintenance organizations, and others.
Q: Is a health care provider required to obtain an NPI?
A: Under the National Provider Identifier Regulation (that was 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, is required to obtain a National Provider Identifier (NPI) by May 23, 2007.
Q: Who will assign NPIs to health care providers?
A: The Department of Health and Human Services will contract with an organization, known as the enumerator, to do this work. In addition to receiving and processing National Provider Identifer (NPI) applications and notifying health care providers of their NPIs, the enumerator will: use the National Provider System (NPS) to ensure the unique identification of a health care provider; answer questions about the processes of applying for and obtaining NPIs and furnishing updates; collect information, via the applications and updates, and maintain the NPS database containing NPIs and information about the health care providers to which they are assigned; and furnish information upon request and in accordance with established guidelines.
Q: How will a health care provider obtain an NPI?
A: A health care provider will obtain a National Provider Identifier (NPI) by submitting an application for an NPI—either on paper through the postal service or electronically over the Internet. After the application is successfully processed, the health care provider will be notified of its NPI. The CMS web site (www.cms.hhs.gov/hipaa/hipaa2) will contain information on when, where and how the NPI application can be obtained.
Q: When can a health care provider apply for an NPI?
A: Health care providers can apply for National Provider Identifiers (NPIs) beginning on the effective date of the final rule, which is May 23, 2005.
Q: How long will it take to get an NPI?
A: We cannot predict the amount of time it will take to obtain a National Provider Identifier (NPI) because several factors come into play. Such factors include the volume of applications being processed at a given time, whether the application was submitted electronically or on paper, and whether the application was complete and passed all edits. We expect that a health care provider who submits a properly completed electronic application could have its NPI in 10 days.
Q: What is the format of the NPI?
A: The National Provider Identifier (NPI) is all numeric and is 10 positions in length: the first 9 positions are the identifier and the last position is a check digit. The check digit helps detect invalid NPIs. There is no embedded intelligence in the NPI with respect to the health care provider that it identifies.
Q: Will a health care provider’s NPI ever change?
A: The National Provider Identifier (NPI) is meant to be a lasting identifier, and would not change based on changes in a health care provider’s name, address, ownership, membership in health plans, or Healthcare Provider Taxonomy classification. There may be situations where use of an NPI for fraudulent purposes results in a health care provider requesting a different NPI; such situations will be investigated and a different NPI may be assigned to the requesting health care provider.
Q: If a health care provider with an NPI moves to a new location, must the health care provider notify the enumerator of its new address?
A: A covered health care provider must notify the enumerator of changes in any of the information that it furnished on its application for a National Provider Identifier (NPI), and must do so within 30 days of the change. We encourage health care providers who have been assigned NPIs, but who are not covered entities, to do the same.
Q: Will a health care provider continue to use other numbers besides the NPI to identify itself in standard transactions after the compliance date?
A: Upon the compliance dates, only the National Provider Identifier (NPI) may be used for identification purposes for a health care provider in standard transactions; legacy identifiers (such as the Unique Physician Identification Number (UPIN), Medicaid Provider Number, Medicare Provider Number, and others) may not be used. Where a health care provider must be identified in standard transactions for tax purposes, it would use its Taxpayer Identifying Number as required by the implementation specifications. Health care provider identification numbers other than the NPI may continue to be used in the internal processes and files of health plans or health care clearinghouses if they wish to continue to use those identification numbers in those internal processes and files.
Q: Will there be a crosswalk of UPINs to NPIs?
A: The extract file that will be produced by the National Provider System will contain the information required for a Unique Physician Identification Number (UPIN) crosswalk. The extract file may also include other health care provider identification numbers (such as Medicaid numbers and drug enforcement administration (DEA) numbers) if those numbers were furnished by health care providers when they applied for National Provider Identifiers (NPIs).
Q: May National Provider Identifiers (NPIs) be used on paper claims transactions?
A: The use of NPIs on paper claims transactions is allowed. The health plan receiving the claim may make the determination on the use of NPIs on paper claims transactions. HIPAA regulations adopt standards for format and content of certain electronic health transactions; they do not address the content of paper claims transactions.
Q: Can a health plan require its enrolled health care providers who are not covered entities to obtain and use NPIs?
A: Yes. The National Provider Identifier (NPI) Final Rule requires health care providers, who are covered entities, to obtain and use NPIs in standard transactions. If a health care provider is not a covered entity under HIPAA, the NPI Final Rule does not require that it obtain or use an NPI. The NPI Final Rule does not prohibit health plans from requiring their enrolled health care providers to obtain and use NPIs, as long as the enrolled health care providers are eligible for an NPI, as discussed in the NPI Final Rule (69 FR 3434). Note, however, that the NPI Final Rule (at 45 CFR 162.412(b)) prohibits health plans from requiring a health care provider with an NPI from obtaining additional NPIs.
Q: Can a health plan require that a health care provider who is a covered entity obtain and utilize NPIs after the effective date, but prior to the compliance date?
A: Covered entities are required to use National Provider Identifiers (NPIs) in standard transactions no later than May 23, 2007. However, as with any other data requirement, health plans are free to require that their enrolled health care providers who are covered entities use NPIs in standard transactions prior to May 23, 2007. This is a business issue and decision, not a HIPAA requirement until the compliance date.
Q: Will a health care provider have to pay for an NPI?
A: No. A health care provider will not be charged, nor have to pay, a fee in order to obtain an National Provider Identifier (NPI).
Q: Will there be enough NPIs to enumerate all health care providers? Will we ever run out?
A: The format of the National Provider Identifier (NPI) and the assignment strategy will enable the enumeration of over 200 million health care providers. At the current rate of increase in the number of providers in the United States, this should enable the Department of Health and Human Services to enumerate health care providers for 200 years.
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