FAQs - NPI

National Provider Identifier (NPI) Information

What is the National Provider Identifier (NPI)?

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 requires the adoption of a standard unique identifier for health care providers. The NPI Final Rule issued January 23, 2004, adopted the NPI as this standard.

The NPI is a 10-digit, intelligence-free numeric identifier (10-digit number). Intelligence-free means the numbers do not carry information about health care providers, such as the state in which they practice or their provider type of specialization.

The NPI replaces health care provider identifiers in use today in HIPAA standard transactions. Those identifiers include the Indiana Health Coverage Programs (IHCP) provider number otherwise known as the legacy provider identifier (LPI) and Medicare legacy provider identifier such as the unique physician/provider identification number (UPIN); Online Survey, Certification, and Reporting (OSCAR); physician/provider identification number (PIN); and National Supplier Clearinghouse (NSC).

The provider's NPI does not change and remains with the provider regardless of job or location changes.

What is the purpose of the NPI?

The NPI is a single identification number assigned to health care providers. It is intended to improve the efficiency of the health care system and help to reduce fraud and abuse. The intent of the NPI is to eliminate the need for payers and providers to keep numerous identifiers and in turn simplify transaction processing between entities.

Who is eligible for an NPI?

In order to get an NPI, a provider must be a health care provider as defined under HIPAA. A "covered entity" is defined as a health care provider, clearinghouse or health plan who conducts standard electronic transactions. The Final Rule for NPI requires a "covered entity" health care provider to get an NPI. These "covered entities" must use the standards when conducting any of the defined transactions covered under HIPAA. Covered entities are further described as the following:

  • Private sector health plans including:
    • Managed care organizations (MCOs)
    • Employee Retirement Income Security Act (ERISA) plans, excluding some small self-administered health plans
  • Government health plans including:
    • Medicare
    • State Medicaid programs
    • Military Health System (for active duty and civilian personnel)
    • Veterans Health Administration
    • Indian Health Service programs
  • Health care clearinghouses
  • Health care providers that choose to submit or receive electronic transactions

With the exception of atypical providers, the IHCP requires all health care providers (individual, organization, and subparts of an organization) submitting electronic and paper claims to obtain an NPI. Atypical providers conducting services like transportation or carpentry are not considered health care services and therefore are ineligible to get an NPI.

Who will issue NPI numbers?

The National Plan and Provider Enumeration System (NPPES) was elected by the Centers of Medicare & Medicaid Services (CMS) to assign the NPI to eligible health care providers. The NPPES also stores the information about enumerated providers.

There is no cost to apply and providers may apply for an NPI in one of three ways:

  • Effective May 2005, providers may apply through an easy web-based application process at the NPPES site.
  • Effective April 2006, the electronic file interchange (EFI) process, also referred to as "bulk enumeration", was made available to providers. EFI allows a health care provider or group of providers to have a particular electronic file interchange organization (EFIO) apply for the NPI on their behalf. In other words, rather than having a provider or group of providers submit a paper or Web NPI application, the EFIO obtains an NPI for them via the submission of an electronic file. More information on EFI can be found at the CMS site.
  • IHCP will not bulk enumerate on behalf of its providers.

Providers must furnish any updates to the NPPES within 30 days of the change if any of the required data submitted on the application changes.

Will NPIs automatically be issued?

The Office of Medicaid Policy and Planning (OMPP) will not conduct bulk enumeration for providers. If a provider wants to obtain an NPI, the provider is responsible for either applying directly for an NPI, or as part of another organization's bulk enumeration process.

How long does it take to obtain an NPI?

As reported on the CMS Web site, "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."

When will a provider begin using the National Provider Identifier (NPI) on standard transactions?

Healthcare providers should be using the NPI on standard transactions now. Before May 23, 2008, the Legacy Provider Identifier (LPI) can also be submitted. Be sure to check remittance advices (RAs) for any NPI-related explanation of benefit (EOB) messages to ensure there is a successful NPI to LPI crosswalk. Effective May 23, 2008, only your NPI can be submitted and there must be a one-to-one NPI to LPI match or your claim or inquiry will be rejected. Only atypical providers, those ineligible to receive an NPI, are exempt from this deadline.

Will a provider's NPI ever change?

In most cases no. The following is a list of situations that could occur for a covered entity with an NPI:

  • If a health care provider is deceased, the NPI will be deactivated.
  • If a health care provider goes out of business, the NPI will be deactivated.
  • If a health care provider moves to a different geographical location, it will not affect the NPI. The provider will maintain the same NPI for life.
  • If a health care provider's NPI is used in the case of fraud, a new NPI will be issued.

Note: Deactivated NPIs will never be issued to other health care provider.

If you do not process electronic transactions, do you need an NPI?

Yes. The IHCP requires all health care providers (individual, organization, and subparts of an organization) who provide health care services and submitting electronic or paper claims to obtain an NPI.

Do you need to use the NPI when billing claims?

Yes. If you are required to have an NPI for other transactions, you must also use it for billing claims.

Do we have to get a different NPI for each service location?

No. The same NPI can be reported for different service locations; however, if the same NPI is reported, there must be a different taxonomy or zip code+4 reported for the various locations.

Atypical Providers

What is the definition of an atypical provider and how will HP handle those transactions?

An individual or business that is not a health care provider and does not meet the definition of a health care provider according to the NPI Final Rule (e.g., carpenters, non-emergency transportation providers, and so forth).

HP will continue to identify providers that are not eligible for an NPI with their LPI.

Can an atypical provider send standard transactions electronically?

Yes, an atypical provider such as a non-emergency transportation provider may use electronic data interchange (EDI). Using EDI does not determine if the provider is providing health care services or not. Since a transportation provider cannot get an NPI, the current LPI must be used.

Contacts

Whom do I contact if the NPI Reporting Tool shows a rendering provider that is no longer in my group?

Contact the Provider Enrollment and Waiver Line at 1-877-707-5750 or write to:

HP Enterprise Services
Provider Enrollment Unit
P.O. Box 7263
Indianapolis, IN 46207-7263

Whom do I call if I am having trouble with my password for the Web?

Call the EDI Solutions Help Desk at (317) 488-5160 in the Indianapolis local area, or 1-877-877-5182.

Whom do I call for all other questions about the NPI Reporting Tool?

Call Customer Assistance at (317) 655-3240 in the Indianapolis local area, or 1-877-577-1278.

How do I request a paper NPI application from the enumerator by telephone?

Call the National Plan and Provider Enumerator System (NPPES) at 1-800-465-3203 to request the paper form. Or, download the CMS form 10114. Mail the completed form to:

NPI Enumerator
P.O. Box 6059
Fargo, ND 58108-6059

HIPAA Standards

What standard transactions are affected by HIPAA?

As required by HIPAA, the Secretary of Health and Human Services is adopting standards for the following administrative and financial health care transactions:

  • Health claims and equivalent encounter information
  • Enrollment and disenrollment in a health plan
  • Eligibility for a health plan
  • Health care payment and Remittance Advice
  • Health plan premium payments
  • Health claim status
  • Referral certification and authorization
  • Coordination of benefits

Standards for the first report of injury and claims attachments (also required by HIPAA) will be adopted at a future date.

Implementation Guides

Where may I obtain Implementation Guides for standard transactions?

Implementation Guides are available from the CMS or from Washington Publishing Company.

Links

Where may I find additional NPI information from CMS?

To get additional information to to the CMS site.

What is the link to the NPI application process on the CMS Web site?

To apply for an NPI through the Internet, go to the NPPES Web site.

Multiple NPIs or Subparts

What are subparts?

Organization providers may have the option to obtain more than one NPI. Some components or subparts of an organization may be eligible to obtain separate NPIs. The following are examples of subparts:

  • Certified separately
  • Licensed separately by the State
  • Required by Federal Regulations to have their own billing number
  • IHCP Subpart Form

Subparts do not apply to individual providers. Only a provider can determine whether they need to apply for multiple IDs or subpart the provider's organization.

Additional information about the types of providers and subparts may be obtained from the Web sites of the CMS site or the NPPES Web site.

NPI Reporting Tool Information

What is the NPI Reporting Tool (Web tool)?

The NPI Reporting Tool is a Web-based application that allows providers to report their NPIs to the IHCP.

What date will the NPI Reporting Tool be available?

The NPI Reporting Tool is scheduled to be available on September 28, 2006.

Is information that you input using the NPI Reporting Tool updated in real-time or in batch mode?

The information you enter into the NPI Reporting Tool is updated in real-time.

Will the NPI Reporting Tool be the only way to report your NPI?

No. You can request a paper NPI Reporting Form to report your NPI. Using the tool is quicker and more efficient. However, if you want to use a paper application, instructions will accompany your notification letter. When the NPI Reporting Form is received, HP will enter the information into the system from the paper document.

How will rendering providers report their NPI to the IHCP?

Groups are required to obtain NPIs from their rendering providers and report them to the IHCP on the rendering providers' behalf.

How do we remove rendering providers from our group using the NPI Reporting Tool?

If the NPI Reporting Tool identifies a rendering provider that is no longer in your group, contact the Provider Enrollment and Waiver line at 1-877-707-5750 to request an IHCP Provider Termination Form or download the form from the IHCP Web site.

The IHCP Provider Termination Form must be completed, signed, dated, and mailed to:

HP Enterprise Services
Provider Enrollment Unit
P.O. Box 7263
Indianapolis, IN 46207-7263

Will the rendering providers who are linked to the group, display?

Yes. When a group logs into the NPI Reporting Tool, all active rendering providers affiliated with the group are accessible under each group's service locations. Groups are required to obtain the NPI from their rendering providers and report it to the IHCP on the rendering providers' behalf.

Can you do anything besides reporting your NPI on the NPI Reporting Tool?

No. You can only report your NPI and associate your Taxonomy codes utilizing this tool.

Can a rendering provider's NPI be reported without reporting the group in the NPI Reporting Tool?

No. Groups are required to report the NPI of their rendering providers and they are required to report their NPI before they can gain access to the screen that allows them to report their rendering providers.

How do I correct errors made on the NPI Reporting Tool?

Once an entry is submitted using the NPI Reporting Tool, all changes require HP intervention. You must contact Provider Enrollment at 1-877-707-5750.

How do I update our address in the NPI Reporting Tool?

If address information is incorrect in the NPI Reporting Tool, you can download and complete the Name Address Maintenance form or go to Web interChange to change service location address.

How can I tell if the NPI was successfully reported in the NPI Reporting Tool?

In each provider subsection of the NPI Reporting Tool, the provider number (nine-digit number) and the service location code (alpha character) displays in the green, red, or blue header, and the status of the provider/service location/NPI record. Before any NPI is reported the header will be Blue (not reported), an unsuccessful entry will be Red (conflict), and a successfully reported NPI will have a Green (Active) header.

Reporting NPI

Can I fax the NPI Reporting Form instead of mailing it?

No. The NPI Reporting Form must be completed, signed, dated, and mailed to:

HP Enterprise Services
Provider Enrollment Unit
P.O. Box 7263
Indianapolis, IN 46207-7263

Can I report my NPI over the phone?

No. A provider's NPI can be reported using the NPI Reporting Tool.

Can we enter more than 15 taxonomy codes?

No. The NPI Reporting Tool will only allow a user to enter 15 taxonomy codes.

Do I have to report my NPI using the online tool and the paper reporting form?

No. Use only one method, either the paper form or the online NPI Reporting Tool. You do not need to use both. Best is the online tool, since it will print an immediate receipt to confirm the proper reporting of your NPI.

Do I need to report the NPI if the physician is deceased?

If a physician is deceased, and claims or adjustments will be submitted on his behalf on or after May 23, 2008, an NPI must be reported for the physician.

Do we have to report an NPI for all provider locations?

Yes, every service location submitting claims for services by a healthcare provider must have an NPI reported if you plan to bill Medicaid after the final compliance date.

Do we have to report contact information for each provider number?

No. Contact information is required only once for each time a user logs into the system to report NPIs. If a user logs out of the system and logs back in, contact information will be required.

Do we have to report our NPI if we do not file electronic claims?

Yes. The NPI will be required on both electronic claim transactions and paper claims transactions.

Do we have to report our NPI to the MCOs?

Providers must contact the MCO with whom they are affiliated to find out what their NPI solution will involve.

If a provider is no longer part of our practice, do we still need to report their NPI if they are showing up on the tool?

If transactions will continue to be submitted for the departed practitioner by the practice on or after May 23, 2008, it is necessary to report the provider's NPI.

If I don't know the NPI for all of our rendering doctors, can I go back and report them later?

Yes. You can log back into the NPI Reporting Tool at any time to report the NPI for providers.

Paper Claims

Where do I put my NPI number on the claim form?

Providers should refer to the appropriate paper claims bulletin listed on the IHCP website. The bulletins provide detailed information on the various claim form fields.

Related Web Sites

Where may I learn more about NPI?

Medicare NPI policy and recommendations are available on the CMS Web site.

Where may I learn more about the NPI Application and Enumeration?

Information about NPI Application and Enumeration is available from the NPPES Web site.

Standard Transactions (Claims, RAs, etc.)

If a batch of claims is submitted and one is missing the NPI, will the batch be rejected?

No. The batch will be accepted, but effective May 23, 2008, the individual claim with the missing NPI will not.

Do I have to bill the rendering NPI on the claims transactions?

Yes. The rendering NPI will be required on claims transactions.

What is the definition of a Taxonomy code?

The health care provider Taxonomy code is a unique, 10-digit, alphanumeric code that allows a provider to identify a specialty category. Providers applying for an NPI are required to submit their Taxonomy codes. Providers may have one or more Taxonomy codes associated to them. Waiver providers are not required to enter their Taxonomy codes when reporting their NPI to the IHCP.

Does the Taxonomy code need to be reported on claims?

The taxonomy code is used for the NPI to LPI crosswalk and is needed only when a provider with multiple billing provider office locations share a single NPI, and one or more billing provider office locations are within the same ZIP Code + 4.

Where will the NPI and Taxonomy code be reported on the CMS-1500 form?

A copy of the revised claim form can be found on the National Uniform Claim Committee Web site at http://www.nucc.org. The billing provider NPI is reported in form locator 33a and the taxonomy code, with qualifier ZZ, in 33b. The rendering provider NPI is reported in the bottom half of 24J, the taxonomy code is reported in the top half of 24J. Qualifier ZZ, which indicates Taxonomy code, should be reported in the top half of 24I.

Do I use my LPI or my NPI on claims with a date of service on or after the final compliance date?

Regardless of the date of service, any claim received on or after May 23, 2008, must use the NPI.

Waiver Providers and other Atypical Providers

Q: Are all waiver providers atypical?

Not all waiver providers are atypical providers. Workgroup for Electronic Data Interchange (WEDI) developed a white paper that may assist in determining an atypical provider.

Directory of Other Providers' NPIs

Q: Will HP offer a directory of NPIs for other providers?

No. NPPES provides an online NPI Registry. Users may search the registry by NPI or legal business name.