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Unique Identifiers FAQs

Who is eligible to receive an NPI?

If a health care provider with a National Provider Identifier (NPI) moves to a new location, must the health care provider notify the National Plan and Provider Enumeration System (NPPES) of its new address?

I have a Drug Enforcement Administration (DEA) Number. Do I need a National Provider Identifier (NPI) as well?

Which Healthcare Provider Taxonomy Code(s) should be selected by medical students, interns, residents and fellows when applying for National Provider Identifiers (NPIs)?

What is the difference between a health plan and a payer?

What types of business structures are considered organization health care providers and thus eligible for organization NPIs; what types are not?

Will a health care provider’s National Provider Identifier (NPI) ever change?

What is the purpose of the National Provider Identifier (NPI), who must use it, and when?

Do medical students, interns, and residents need National Provider Identifiers (NPIs)?

How can a health care provider apply for and obtain a National Provider Identifier (NPI)?


Q: Who is eligible to receive an NPI?

A: The National Provider Identifier (NPI) was adopted and became effective May 23, 2007 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. An entity who meets the definition of a “health care provider” – that is, any provider of medical or other health services, and any other person or organization that furnishes, bills, or is paid for health care in the normal course of business – is eligible to receive a provider ID, or NPI. Under HIPAA, a covered health care provider is any provider who transmits health information in electronic form in connection with a transaction for which standards have been adopted. These covered health care providers must obtain an NPI and use this number in all HIPAA transactions, in accordance with the instructions in the adopted Implementation Guides/TR3 Reports. The NPI may also be used on paper claims, but HIPAA does not govern that method of submitting claims. In general, health care providers include hospitals, nursing homes, ambulatory care facilities, durable medical equipment suppliers, clinical laboratories, pharmacies, and many other “institutional” type providers; physicians, dentists, psychologists, pharmacists, nurses, chiropractors and many other health care practitioners and professionals; group practices, health maintenance organizations, and others. For more information and white papers about health care providers, including atypical providers, visit the CMS website at: National Provider Identifier Standard (NPI).

Q: If a health care provider with a National Provider Identifier (NPI) moves to a new location, must the health care provider notify the National Plan and Provider Enumeration System (NPPES) of its new address?

A: Yes. A covered health care provider must notify the NPPES of the address change within 30 days of the effective date of the change. We encourage health care providers who have been assigned NPIs, but who are not covered entities, to do the same. A health care provider may submit the change to NPPES via the internet (https://nppes.cms.hhs.gov/?forward=static.npistart#/) or by paper. If paper is preferred, the health care provider may download the NPI Application/Update Form (CMS-10114) from the Centers for Medicare & Medicaid Services' forms page (www.cms.hhs.gov/cmsforms) or may call the NPI Enumerator (1-800-465-3203) and request a form.

Q: I have a Drug Enforcement Administration (DEA) Number. Do I need a National Provider Identifier (NPI) as well?

A: The NPI does not replace the function of the DEA Number, which is to identify the prescriber of a controlled or dangerous substance. The NPI was adopted to identify a health care provider as a health care provider in standard transactions adopted under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). A health care provider who is a covered entity under HIPAA is required to obtain an NPI, and to use that NPI to identify itself as a health care provider in HIPAA standard transactions. Health care providers who are not covered entities under HIPAA, but who prescribe medications, order services for patients, refer patients to other providers, or who otherwise need to be identified in HIPAA standard transactions that are conducted by other health care providers, will need (but are not required) NPIs so that those other health care providers can use that number to identify them in the HIPAA standard transactions that they conduct. The definition for a HIPAA covered health care provider may be found at 45CFR 162.103.

Q: Which Healthcare Provider Taxonomy Code(s) should be selected by medical students, interns, residents and fellows when applying for National Provider Identifiers (NPIs)?

A: The Healthcare Provider Taxonomy Code set is a code set which may be used in certain standard transactions to indicate health care provider type, classification, and/or specialization. A healthcare provider must select a Healthcare Provider Taxonomy Code from this code set when applying for a National Provider Identifier (NPI). The code set is maintained by the National Uniform Claim Committee (NUCC) and is made available to the public by the Washington Publishing Company (WPC). Information on requesting changes to the code set is available from the NUCC (www.nucc.org/). Frequently Asked Questions and information on printing or downloading the code set is available from the WPC (www.wpc-edi.com). All covered health care providers are eligible for NPIs and may apply for them. Because they are health care providers, medical students, interns, residents, and fellows are eligible for NPIs. If they do not transmit any health data in connection with a transaction for which the Secretary of Health and Human Services has adopted a standard, they are not “covered” health care providers under HIPAA and are not required by the NPI Final Rule to obtain NPIs. If they do, however, they would be covered health care providers and they must get NPIs.• A Healthcare Provider Taxonomy Code for classifying medical students, and interns and residents who are not yet licensed (based on state licensing requirements), is available for use: Student, Health Care (390200000X). The code is defined as follows: An individual who is enrolled in an organized health care education/training program leading to a degree, certification registration, and/or licensure to provide health care. Medical students, interns, and residents who are not licensed should select the Student, Health Care code when applying for NPIs.• Once licensed as an allopathic or osteopathic physician, the physician should update his/her data in the National Plan and Provider Enumeration System (NPPES) by submitting a change in the Healthcare Provider Taxonomy Code to reflect the change in status from medical student to physician. (If they are “covered” health care providers, they are required to do so, and any such change must be provided to the NPPES within thirty days of the change).• If physicians who have been assigned NPIs become board-certified in other specialties or subspecialties, the physicians should update his/her data in the NPPES with these changes or additions in their specializations (i.e., they would indicate the changes or additions by changing their Healthcare Provider Taxonomy Codes). (If they are “covered” health care providers, they are required to do so, and any such change must be provided to the NPPES within thirty days of the change.)

Q: What is the difference between a health plan and a payer?

A: A health plan (as defined in 45 CFR 160.103) is an individual plan or group health plan that provides or pays the cost of medical care. The term “payer” is an industry term and may include a health plan, but may also designate other entities that do not meet the definition of a health plan, such as a third party administrator (TPA).

Q: What types of business structures are considered organization health care providers and thus eligible for organization NPIs; what types are not?

A: The NPI final rule defines “organization health care providers” as providers who are not individuals (persons). These are classified as Entity Type 2 providers. Examples are hospitals, home health agencies, clinics, nursing homes, residential treatment centers, laboratories, ambulance companies, group practices, health maintenance organizations, suppliers of durable medical equipment or pharmacies, among others. Some health care provider organizations are made up of components or business units that function somewhat independently of the ”parent” health care organization of which they are a part. These components, which are referred to as “subparts” in the regulation, might conduct their own standard transactions, might be at the same or at a different address than the organization provider “parent”, might furnish a type of service different from the organization provider “parent.” These subparts or business units might be required by Federal regulations to have unique identifiers for billing purposes. Each organization must make a determination regarding the status of its subparts, and apply for NPIs as it deems appropriate. The Work group for Electronic Data Exchange (WEDI) has a white paper on this topic that can be helpful for covered entities in making their decisions. A sole proprietorship is a form of business in which one person owns all of the assets of the business and is solely liable for all debts on an individual basis. Sole proprietors are individuals, and they must apply for their NPIs as Individuals (Entity Type I). The subpart concept does not apply to a sole proprietorship, even one with multiple locations, because the sole proprietorship is not an organization as defined in the Final NPI Rule (69FR3434). State laws enable the creation of many other different types of businesses. While we cannot address every possible type of business structure, we apply the following broad principle to determine whether a business is eligible for an organization NPI: Any organization that is recognized by the State as separate and distinct from the individual is eligible for an organization NPI. The law in each State will govern how different business types are recognized by the State.

Q: Will a health care provider’s National Provider Identifier (NPI) ever change?

The National Provider Identifier (NPI) is meant to be a lasting identifier, and is expected to remain unchanged even if a health care provider changes his or her name, address, provider taxonomy, or other information that was furnished as part of the original NPI application process. There are some situations, however, in which an NPI may change such as when health care provider organizations determine they may need a new NPI due to, for example, certain changes of ownership, the conditions of a purchase, or a new owner’s subpart strategies. There also may be situations where a new NPI is necessary because the current NPI was used for fraudulent purposes.

Q: What is the purpose of the National Provider Identifier (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 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 was May 23, 2007; the compliance date for small health plans was May 23, 2008. As of the compliance dates, the NPI is the only health care provider identifier that can be used for identification purposes in standard transactions by covered entities.

Q: Do medical students, interns, and residents need National Provider Identifiers (NPIs)?

A: All health care providers are eligible for NPIs and may apply for them. Because medical students, interns, residents, and fellows are health care providers, they are eligible for NPIs. If they do not electronically transmit any health data in connection with a transaction for which the Secretary of Health and Human Services has adopted a standard, they are not “covered” health care providers under HIPAA and are not required by the NPI Final Rule to obtain NPIs. If they do, however, they would be covered health care providers and they must get NPIs. If interns or residents prescribe medications for patients whose prescriptions are filled by pharmacies, refer patients to other health care providers, or order tests for patients from other health care providers, those pharmacies and other health care providers will need to identify them as prescribers or as providers who referred patients or who ordered tests for patients in the claims transactions that they submit to health plans. Health plans may require that the NPI be used in those claims to identify the prescriber, the referring provider, and the ordering provider. Therefore, while the NPI Final Rule might not require these providers to obtain NPIs, it may be necessary for them to have NPIs in order for the pharmacies and providers described in the scenarios above to be reimbursed by health plans.

Q: How can a health care provider apply for and obtain a National Provider Identifier (NPI)?

A: A health care provider may apply for an NPI in one of three ways: 1. Apply through a web-based application process. The web address to the National Plan and Provider Enumeration System (NPPES) is https://nppes.cms.hhs.gov/#/. 2. If requested, give permission to have an Electronic File Interchange Organization (EFIO) submit the application data on behalf of the health care provider (i.e., through a bulk enumeration process). If a health care provider agrees to permit an EFIO to apply for the NPI, the EFIO will provide instructions regarding the information that is required to complete the process. 3. Fill out and mail a paper application form to the NPI Enumerator. Health care providers may wish to obtain a copy of the paper NPI Application/Update Form (CMS-10114) and mail the completed, signed application to the NPI Enumerator located in Fargo, ND, whereby staff at the NPI Enumerator will enter the application data into NPPES. This form is now available for download from the CMS website (http://www.cms.gov/cmsforms/downloads/CMS10114.pdf) or by request from the NPI Enumerator. Health care providers who wish to obtain a copy of this form from the NPI Enumerator may do so in any of these ways: Phone -- 1-800-465-3203 or TTY 1-800-692-2326 E-mail -- customerservice@npienumerator.com  Mail: NPI Enumerator P.O. Box 6059 Fargo, ND 58108-6059.

 

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