Fact sheet




Background: One of the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA, Title II) required the Department of Health and Human Services (HHS) to adopt a national standard for uniquely identifying health care providers.  The purpose of these provisions is to improve the efficiency and effectiveness of the electronic transmission of administrative health care transactions.  The final rule adopting the NPI as the standard unique health identifier for providers was published January 23, 2004, and became effective on May 23, 2005.  All HIPAA-covered entities had to be in compliance with the NPI provisions by May 23, 2007, except for small health plans, which were given an extra year.


In April 2007, in response to industry concerns about NPI-readiness, HHS and the Centers for Medicare & Medicaid Services (CMS) issued “Guidance on Compliance with the HIPAA NPI Rule.”   This guidance set forth a “Good Faith Policy” whereby, for a period of 12 months after the May 23, 2007, compliance date, CMS would not impose penalties on covered entities that established contingency plans and made reasonable and diligent efforts to become NPI-compliant.  In effect, an additional year was allowed for covered entities to come into compliance and, to the best of our knowledge, all covered entities used the full 12 months.  We are not aware of any health plan that mandated full NPI compliance prior to May 23, 2008.


May 23, 2008, Is Almost Here


Significant progress towards full implementation of the NPI has been made across the health care industry, including the Medicare Fee-For-Service (FFS) Program.  For Medicare FFS, 99 percent of claims are coming in with NPIs (NPI-only or NPI/legacy number pairs).  Medicare, like many other health plans, deployed a dual-use strategy of accepting NPI/legacy pairs on its transactions, to allow providers and suppliers time to gain experience in using their new number.  Medicare is also experiencing regular increases in the percentage of Medicare claims coming in with NPI-only.  Medicare is quickly moving towards high rates of compliance for all transactions which use the NPI – the claim, the remittance advice, the beneficiary eligibility inquiry, and the claim status inquiry.  On May 23, all HIPAA-covered transactions to/from Medicare will be NPI-only.


Medicare Communications Have Been Exhaustive


Over the past several years, CMS has deployed an aggressive communications strategy for reaching and informing Medicare FFS providers, suppliers, State Medicaid Agencies, and others about NPI requirements.  This effort has accelerated in recent weeks in response to the approaching deadline and industry comments.  Examples of our activities include:  regular messages via listservs, MLN Matters articles, and website postings; regular calls with provider associations and clearinghouse groups; messages and announcements at the CMS Provider Open Door Forums; NPI “roundtables” which support nationwide call-ins for questions and answers; messages associated with individual claim submissions; communications with the State Medicaid Agencies to understand their readiness since many Medicare beneficiaries are dual eligibles; press interviews; and more.


Industry has praised our communication efforts.


Testing, Testing, and More Testing


Over the past many months, upon achieving a high rate of NPI usage, Medicare has continually encouraged providers and suppliers to begin testing claims with only NPIs, thus preparing them for what may happen on May 23, 2008, the final date for full NPI implementation. 


·        Medicare estimates that 60-80 percent of its FFS claims come in via a clearinghouse or billing service.

·        To facilitate provider/supplier testing and to gain further insight as to what may be expected on May 23, CMS collaborated with the clearinghouse industry where for one day only (May 7) the clearinghouses which had the capability would accept NPI/legacy claims from their provider/supplier clients and strip off the legacy number and pass the NPI-only claim on to Medicare.  The results were very positive.  As expected, the rate of NPI-only claims increased dramatically and very few claims were returned (i.e., rejected) back to the provider/supplier.  Medicare’s approach of using a crosswalk to take an incoming NPI, crosswalk it to a legacy number in its internal systems, process the claim, and crosswalk the legacy number back to the NPI is working.  Some claims were suspended because the crosswalk could not precisely match the incoming NPI with an exact legacy number, but the volume was manageable.

·        Similarly, State Medicaid agencies have gone to extensive lengths to upgrade their claims processing systems, communicate with their providers regarding the need to obtain and use NPIs, as well as develop contingencies plans should unanticipated issues arise.


Other Actions CMS Has Implemented To Assist Readiness


·        NPI Coordination Teams were established at each Medicare contractor, to identify and resolve provider/supplier enrollment and NPI claims processing issues.

·      Medicare enrollment procedures have been streamlined to expedite processing enrollment applications while ensuring only qualified providers and suppliers are enrolled.

·        Medicare contractors are triaging provider enrollment issues to ensure top priority is given to providers and suppliers experiencing difficulties in getting their enrollment information corrected so that their claims may be properly processed and paid.

·        CMS has engaged the clearinghouse industry to elicit its support, on behalf of Medicare providers and suppliers.  Though CMS has no standing with clearinghouses (their relationship is with their clients—the providers and suppliers), those clearinghouses that are capable will strip legacy numbers from provider/supplier claims before the claims are sent to Medicare.

·        CMS has engaged our coordination of benefits trading partners (e.g., commercial insurers who handle Medigap claims and the Medicaid State Agencies) to make sure they understand that, beginning May 23, 2008, claims electronically crossed over to them from Medicare will contain only an NPI.  Thus, they need to be prepared.  We are pleased that most of our trading partners report they will be ready (See “Coordination of Benefits,” below).


CMS Expectations for May 23, 2008


·        We expect the majority of Medicare claims coming in on that day will be NPI-only claims and will be processed successfully.  We also expect the majority of Medicaid claims processed by the State Agencies to be NPI-compliant and to be processed successfully based on the information States have provided us.

·        Providers/suppliers who do not bill with NPI-only will have their claims returned to them as soon as the claim hits Medicare’s front door.  We expect the volume will be small since, as stated, 99 percent of Medicare claims have NPIs and, in most cases, clearinghouses will strip legacy numbers before forwarding the claim to Medicare.

·        There may be a small volume of claims returned to providers and suppliers due to their NPIs not being found on the Medicare NPI crosswalk.  (The crosswalk links NPIs to Medicare legacy identifiers in the claims processing systems.)  Our experience is that these types of rejections will be small, around 1 percent of claims submitted with NPIs.

·        Call volumes may increase as providers continue to need assistance with provider enrollment corrections as well as explanations for returned claims.


CMS Expectations for the Week of May 26, 2008


·        Following the 3-day holiday weekend, we expect increases in the volume of NPI-only claims.  Again, we expect most claims will be processed successfully.

·        The volume of claim rejections will increase as will the calls for assistance.  But, we still expect the percentage of claims returned to the providers to be small in comparison to the percentage of claims processed successfully.

·        The larger concern may be with those claims that start suspending for development because the incoming claim’s NPI could not find a precise legacy match on the Medicare NPI crosswalk.  Percentage-wise this may be small, but the volume will require providers/suppliers and contractors to make corrections to enrollment data and/or claims processing information.

·        Based on the information received by CMS from the State Medicaid Agencies, we believe that while the majority of States will be able to process NPI-only claims, some States (see below) are in the midst of transitioning from old claims processing systems to new ones.  During this transition period, they will not be able to process NPI-only claims.  They have, however, informed their providers of this situation and have developed contingencies to ensure the least disruption of payments as possible. 

CMS Expectations for the Weeks Following May 31, 2008


·        These next weeks will be informative as we expect a continuation of claims being processed successfully and, hopefully, a diminishing number of claim rejections and suspensions as issues get resolved.

·        Call volumes will likely continue at a higher-than-normal level as these issues are discussed with providers.


What Providers/Suppliers Might Expect


·        Providers and suppliers which have not obtained an NPI or which continue to show legacy numbers on their claims will experience claim rejections.

·        Providers and suppliers which have not updated their Medicare enrollment information may experience claims processing disruptions.

·        Providers and suppliers which have multiple legacy numbers for one NPI may experience a claims processing disruption if their contractor is unable to determine the appropriate legacy number to associate with their NPI.


Coordination of Benefits


Medicare has entered into trading partner agreements where we crossover Medicare claims to commercial insurers who pay secondary to Medicare.  A similar arrangement exists for State Medicaid Agencies where a Medicare beneficiary is also eligible for Medicaid.  To be fully HIPAA-compliant, Medicare will send NPI-only crossover transactions to these other payers.  Legacy numbers will not be passed.  Our trading partners report that almost all will be ready for these NPI-only crossover claims.  We understand only one commercial payer will not be ready: the Maryland Kidney Disease Program.  Further, eight State Medicaid Agencies report they will not be fully ready and will operate under their own contingency plans (Alaska, Indiana, North Carolina, New Hampshire, New Jersey, Ohio, Washington, and Wisconsin).


(NOTE:  A separate paper from CMSO has been prepared on Medicaid State readiness).


Medicare Risk Mitigation


·        CMS and the Medicare contractors are taking aggressive steps to ensure that providers and suppliers will be paid for treating Medicare beneficiaries on/after May 23, 2008.

·        Medicare contractors are enhancing their toll-free phone lines by expanding the number of people available to answer calls and provide program support.

·        Daily calls with the fiscal intermediaries, carriers, A/B Medicare Administrative Contractors (MACs), and DME MACs are scheduled to monitor the status of successful and rejected/suspended claims, inquiries, enrollment application workloads, and other relevant information.

·        As previously indicated, each contractor has established an NPI Coordination Team to quickly identify and resolve enrollment and claims processing issues related to the submission of the NPI.

·        Should a significant problem arise that is widespread in a contractor’s jurisdiction, with CMS’ approval each contractor has the ability to revert back to pre-May 23 conditions of receiving NPI-only or NPI/legacy pairs.


What You Can Do To Help Providers


·        With approximately 1.5 million providers and suppliers serving the Medicare program, there will be some who experience difficulties with the NPI mandate and they may contact sources other than the Medicare contractors, in search of assistance.  The Medicare contractors should always be the first point of contact for providers/suppliers as the contractors maintain all of the information that is specific to their providers/suppliers.  Moreover, they are in the best position to troubleshoot and provide guidance, whether it’s systemic or claim-specific.  Contact information for the Medicare contractors can be found at under “Downloads.” The file is named, “Provider Call Center Toll-Free Numbers Directory.”  Medicare contractors expect to be able to handle all incoming calls, but some callers may experience extended hold times.  CMS is urging providers and suppliers to be patient – their issues will be addressed.


·        We believe there may be some providers/suppliers who have not yet obtained an NPI.  If that is the situation, the process for enumeration is easy and quick.  To confirm whether a provider/supplier has an NPI, there is a web-based NPI Registry at:


If a provider or supplier has not obtained an NPI, the provider/supplier may do so by:


  1. Going to the web at and submitting the application on line.
  2. Obtaining the paper application form CMS-10114, and mailing it to the NPI Enumerator. This form can be found at or by calling the NPI Enumerator at 1-800-465-3203 and requesting it.


·        Providers and suppliers should verify that that their NPI record contains the correct legal business name and employer identification number for their business.


In addition, Medicare encourages providers and suppliers to include their Medicare legacy identifier in the other provider identifier section of the NPI application.  If a provider or supplier has included its Medicare legacy identifier in its NPI record, the provider or supplier should verify that the information is correct and was reported in the appropriate field.


o       If the provider or supplier has not obtained an NPI, the provider or supplier will need to do so before he or she can bill the Medicare program.


o       If the provider or supplier submits a change to their NPI record, the provider or supplier will need to wait about one week before resubmitting their claims to Medicare to enable the information to be reflected in the Medicare NPI crosswalk.


o       If the provider or supplier has verified that their NPI record is correct, request that the provider or supplier notify the Medicare contractor of the claims processing disruption. 


The provider or supplier should be prepared to submit a Medicare enrollment application to correct changes in legal business name, employer identification number, and/or practice locations that have not previously been reported. 


Providers and suppliers will need to submit a complete enrollment application (CMS-855) and the appropriate supporting documentation, including the Electronic Funds Transfer Authorization Agreement (CMS-588).   For additional information regarding tips to facilitate the enrollment process, please see download titled, “Tips to Facilitate the Medicare Enrollment Process.”  This download can be found at

·        In terms of the State Medicaid Agencies, because the States administer the claims processing systems themselves locally, Medicaid NPI issues should be sent directly to the respective State Medicaid Agency’s Director’s attention.  A listing of the current State Medicaid Directors and their phone numbers can be found at:

HIPAA Enforcement


CMS is responsible for enforcement of all the HIPAA rules except privacy.  CMS uses a complaint driven approach for enforcement.  If CMS receives a complaint about an NPI issue, we will contact each complainant and "filed against entity" by phone to expedite communication and resolution.  If technical assistance is needed by either party, CMS will facilitate such assistance by connecting the parties to appropriate resources.  Our objective is to ensure that covered health care providers, clearinghouses, and health plans can successfully exchange the HIPAA transactions such that neither patient care nor provider/supplier payment are negatively impacted.  While the contingency period ends on May 23, 2008, covered entities are expected to work together to ensure that business operations continue unimpeded.  We understand that some flexibility will be required between trading partners. 


If a corrective action plan is necessary, CMS will monitor that plan to ensure it has been executed, and that the complaining party is satisfied with the results.  The website for filing complaints is:   Information about how to file a complaint, and a link to the website is already available on the CMS website.