3 This presentation was current at the time it was printed or downloaded. This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services. The Centers for Medicare & Medicaid Services (CMS) employees, agents, and staff make no representation, warranty, or guarantee that this compilation of information is error-free and will bear no responsibility or liability for the results or consequences of the use of this presentation. This publication is a general summary that explains certain aspects of NPI implementation, but is not a legal document. Disclaimers
4 The Medicare Learning Network (MLN) is the brand name for official CMS educational products and information for Medicare fee-for-service providers. For additional information visit the Medicare Learning Network's web page at www.cms.hhs.gov/MLNGenInfo www.cms.hhs.gov/MLNGenInfo on the CMS website.
5 NPI Background CMS developed the National Plan and Provider Enumeration System (NPPES) on authority delegated by the Secretary of HHS The NPI is a Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification Standard The NPI Enumerator assists providers in applying for NPIs and resolves problems with NPI applications
6 Purpose of the NPI Simplify Billing Single ID replaces multiple legacy provider identifiers Speed up COB Payments National Provider Identifier
7 Facts About NPI Required for all providers (individuals and organizations) who are “covered providers” under HIPAA Permanent and is not expected to change Organizations may obtain NPIs for subparts One NPI will be assigned per provider or provider subpart
8 Facts About NPI 10 position numeric identifier Intelligence-free Check-digit in last position
9 NPI Timeline January 23, 2004 NPI Final Rule published 2004 2007 2008 May 23, 2007 All HIPAA covered entities, except small health plans, must use NPIs by May 23, 2007 May 23, 2008 Small health plans must use NPIs by May 23, 2008 1996 July 21, 1996 HIPAA signed in to law 2005 May 23, 2005 Health care providers began applying for NPIs
10 Affected Entities Health Care Providers Health Care Clearinghouses Health Plans NPI
11 Health Care Providers Health care providers do not need to be “covered entities” to apply for NPIs Entities that never render “health care” are not eligible for NPIs
12 Subparts and NPIs Subparts may need to be uniquely identified in standard transactions If subparts conduct their own standard transactions, they must obtain NPIs Not all organization providers have subparts
13 The NPI Enumerator: Processes paper NPI Application/Update Forms (CMS – 10114) Provides NPI application forms to providers upon request Maintains a call center to assist providers with questions or problems regarding the processing of their application or NPI updates Handles error resolution including resolving pending applications Processes deactivation requests
14 The National Plan and Provider Enumeration System (NPPES): Sets up and maintains records Creates reports and output files Enumerates providers and health plans
15 Applying for an NPI Electronic File Interchange (EFI) – With the permission of the health care provider, an organization may submit multiple health care providers’ applications in an electronic file 2. 3. Three ways to apply. Choose only one: Apply through a web-based application process at https://nppes.cms.hhs.gov https://nppes.cms.hhs.gov Call the NPI Enumerator and request a blank application form at 1-800-465-3203 or TTY 1-800-692-2326 1.
16 NPI Assignment All applications go to National Plan and Provider Enumeration System (NPPES) Data on applications is used to ensure uniqueness NPI Enumerator resolves problem applications Applications are rejected if provider or subpart already has an NPI or approved if an NPI has not been assigned and the application is complete and accepted Notifies provider of the NPI
17 NPI Notifications Keep NPI notification in a safe place Share copies of your NPI notification with those who need it NPPES Provider NPPES notifies Contact Person of NPI assignment Contact Person shares NPI notification with provider Contact Person
18 When to Change NPI Data Update your NPI data in the NPPES when you have a change to your: Name Address Licensing Or any other data furnished in your application (except SSN) Notify the NPPES of changes to NPI data within 30 calendar days.
19 How to Change NPI Data Three ways to change data. Choose only one: Over the web https://nppes.cms.hhs.govhttps://nppes.cms.hhs.gov Paper NPI Application/Update Form (CMS-10114) and mail to the NPI Enumerator. Request a form by calling 1-800-465-3203 or TTY 1-800-692-2326. EFIO, with your permission Regardless of how you applied, you can make changes over the web. 1. 2. 3.
20 Deactivating NPIs Provider retires, goes out of business, dies, or evidence of fraud exists Must use paper NPI Application/Update Form (CMS-10114) NPI deactivation is not the same as disenrollment by a health plan, sanction, or revocation
21 NPPES The NPPES will not: Link subparts to the covered organization provider Capture memberships in groups Capture multiple practice location addresses Know whether or not a health care provider is a covered entity
22 NPI Having an NPI will not: Eliminate or replace the provider enrollment processes of health plans Guarantee reimbursement by health plans Convey covered entity status Assure licensure or credentials Require a health care provider or a subpart to conduct standard transactions
23 Health Plans Health plans: –Will need to know subpart designations and NPIs –Must develop links or crosswalks of legacy identifiers and NPIs –Are not prohibited from requiring their enrolled health care providers to obtain and use NPIs (in accordance with the Final Rule)
24 CMS Roles Establishes regulatory policy Manages activities delegated by the Secretary for HIPAA (regulations, enumeration, enforcement) NPI implementation within Medicare Provides guidance / outreach materials to the industry Oversees NPI implementation by the Medicaid State agencies
25 Provider Implementation Check for collaborative organizations Watch for instructions Review laws and regulations Share
27 NPI Enumerator For questions from health care providers about NPI applications, updates, and deactivations –Phone: 1-800-465-3203 1-800-692-2326 (TTY) –E-mail: Customerservice@npienumerator.com –Mail: NPI Enumerator P.O. Box 6059 Fargo, ND 58108-6059
28 Frequently Asked Questions Question: After the compliance date for the NPI, can a covered health care provider continue to use other numbers, such as legacy or proprietary identifiers, in addition to its NPI to identify itself as a health care provider in standard transactions? Answer: No. After May 23, 2007 for standard transactions to or from large health plans and clearinghouses, and after May 23, 2008 for standard transactions to or from small health plans, a covered health care provider may use only its NPI to identify itself as a healthcare provider.
29 Frequently Asked Questions Question: Does my NPI replace my Tax Identification Number (TIN)? Answer: No. The NPI does not replace the TIN when the TIN is required to identify the health care provider as a taxpayer. A TIN that is used to identify a health care provider as a health care provider is replaced by the NPI.
30 Frequently Asked Questions Question: How long will it take to get an NPI? Answer: The amount of time it will take to obtain a National Provider Identifier (NPI) cannot be predicted. It is dependent on the quality of the application, SSN verification (for an individual), and uniqueness. Providers should follow up with the Enumerator if no NPI is communicated in 15 days.
31 Frequently Asked Questions Question: Is there a cost for getting an NPI? Answer: No. Getting an NPI is absolutely free, there is no charge to get an NPI.
32 Other Questions? Getting an NPI is free – not having one can be costly.