National Provider Identifier

Background The Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandated that the Secretary of Health and Human Services adopt a standard unique health identifier for health care providers. On January 23, 2004, the Secretary published a Final Rule that adopted the National Provider Identifier (NPI) as this identifier. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandated that the Secretary of Health and Human Services adopt a standard unique health identifier for health care providers. On January 23, 2004, the Secretary published a Final Rule that adopted the National Provider Identifier (NPI) as this identifier. The NPI must be used by covered entities under HIPAA. The NPI must be used by covered entities under HIPAA. The NPI will identify healthcare providers in electronic transactions for which the Secretary has adopted standards (the standard transactions) after the compliance dates. These transactions include claims, eligibility inquiries and responses, claim status inquiries and responses, referrals, and remittance advices. The NPI will identify healthcare providers in electronic transactions for which the Secretary has adopted standards (the standard transactions) after the compliance dates. These transactions include claims, eligibility inquiries and responses, claim status inquiries and responses, referrals, and remittance advices.

Background, continued The NPI will replace health care provider identifiers that are in use today in standard transactions. The NPI will replace health care provider identifiers that are in use today in standard transactions. Implementation of the NPI will eliminate the need for health care providers to use different identification numbers to identify themselves when conducting HIPAA standard transactions with multiple health plans. Implementation of the NPI will eliminate the need for health care providers to use different identification numbers to identify themselves when conducting HIPAA standard transactions with multiple health plans. All health plans (including Medicare, Medicaid, and private health plans) and all health care clearinghouses must accept and use NPIs in standard transactions by May 23, 2007 (small health plans have until May 23, 2008). All health plans (including Medicare, Medicaid, and private health plans) and all health care clearinghouses must accept and use NPIs in standard transactions by May 23, 2007 (small health plans have until May 23, 2008). After those compliance dates, health care providers will use only their NPIs to identify themselves in standard transactions, where the NPI is required. After those compliance dates, health care providers will use only their NPIs to identify themselves in standard transactions, where the NPI is required.

NPI Principles NPI is not a credentialing program NPI is not a credentialing program NPIs are not tied together in the database NPIs are not tied together in the database NPI is required on standard transactions, optional elsewhere NPI is required on standard transactions, optional elsewhere HIPAA does not govern internal systems HIPAA does not govern internal systems NPI may be used for any lawful purpose NPI may be used for any lawful purpose Identifies health care providers or subparts as health care providers in standard transactions Identifies health care providers or subparts as health care providers in standard transactions Replaces the use of proprietary and legacy provider identifiers in standard transactions for health care providers and subparts who have been assigned NPIs Replaces the use of proprietary and legacy provider identifiers in standard transactions for health care providers and subparts who have been assigned NPIs

Structure of NPI NPI is 10 digits: C NPI is 10 digits: C PlanID is also 10 digits PlanID is also 10 digits C = Check digit C = Check digit First digit distinguishes between NPI & PlanID First digit distinguishes between NPI & PlanID First Digit Capacity Used By 1,2 200 million NPI million PlanID 0,3,4,5,6,7,9 700 million Reserve

Eligibility for an NPI All healthcare providers as defined in 45 CFR , are eligible to obtain an NPI All healthcare providers as defined in 45 CFR , are eligible to obtain an NPI Covered healthcare providers (submitting electronic HIPAA transactions) are required to obtain an NPI Covered healthcare providers (submitting electronic HIPAA transactions) are required to obtain an NPI Subparts of covered organization health care providers (that conduct any of the standard transactions) are required to obtain an NPI Subparts of covered organization health care providers (that conduct any of the standard transactions) are required to obtain an NPI Eligible providers include: physicians, hospitals, dentists, nurses, physician assistants, licensed social workers, DME suppliers, suppliers related to health care such as prosthetics, pharmacies, pharmacists, group practices, medical students who provide care. Eligible providers include: physicians, hospitals, dentists, nurses, physician assistants, licensed social workers, DME suppliers, suppliers related to health care such as prosthetics, pharmacies, pharmacists, group practices, medical students who provide care. Providers not eligible include: atypical service providers such as taxis, home & vehicle modifiers, administrative agents for providers such as billing services, clearinghouses, repricers. Providers not eligible include: atypical service providers such as taxis, home & vehicle modifiers, administrative agents for providers such as billing services, clearinghouses, repricers.

NPI Specifics 10-position identifier (9 plus a check digit in the 10th position). The ISO standard check digit will detect keying and data entry errors. 10-position identifier (9 plus a check digit in the 10th position). The ISO standard check digit will detect keying and data entry errors. All numeric. The numeric NPI will facilitate telephone keypad entry-required for telephone base recognition software. For example, some health plans have established telephone key pad verification software to check on a patient’s eligibility for a particular health care service. All numeric. The numeric NPI will facilitate telephone keypad entry-required for telephone base recognition software. For example, some health plans have established telephone key pad verification software to check on a patient’s eligibility for a particular health care service. Intelligence free NPI. NPI will not contain intelligence about the health care provider’s organization. For example, if an individual health care provider changes their specialty the NPI is not affected and this ensures the lasting nature of the NPI. Intelligence free NPI. NPI will not contain intelligence about the health care provider’s organization. For example, if an individual health care provider changes their specialty the NPI is not affected and this ensures the lasting nature of the NPI.

Specifics, continued Permanent identifier. The NPI is a permanent identifier for the health care provider, except in certain situations, such as a health care provider who does not wish to continue an association with a previously used NPI which has been used fraudulently. Permanent identifier. The NPI is a permanent identifier for the health care provider, except in certain situations, such as a health care provider who does not wish to continue an association with a previously used NPI which has been used fraudulently. Unique identifier. Safeguards will be established to guard against assigning the same NPI to more than one health care provider or more than one NPI to the same health care provider. Unique identifier. Safeguards will be established to guard against assigning the same NPI to more than one health care provider or more than one NPI to the same health care provider. Individual health care provider: Each individual health care provider may receive and use only one NPI. Individual health care provider: Each individual health care provider may receive and use only one NPI. Death of a Health Care Provider: An NPI is deactivated upon death or dissolution of a health care provider. Safeguards will be established to ensure a deceased health care provider’s NPI is never reissued. Death of a Health Care Provider: An NPI is deactivated upon death or dissolution of a health care provider. Safeguards will be established to ensure a deceased health care provider’s NPI is never reissued.

An NPI will not… Be assigned to entities that do not meet “health care provider” definition in regulation Be assigned to entities that do not meet “health care provider” definition in regulation Eliminate or replace the provider enrollment processes conducted by health plans Eliminate or replace the provider enrollment processes conducted by health plans Guarantee reimbursement by any health plan Guarantee reimbursement by any health plan Convey covered entity status Convey covered entity status Assure licensure or credentials Assure licensure or credentials Require a health care provider or a subpart to conduct standard transactions Require a health care provider or a subpart to conduct standard transactions

The NPI Timeline Health care providers began applying for NPIs on May 23, 2005 Health care providers began applying for NPIs on May 23, 2005 important to apply for NPI before the compliance date of May 2007 because health plans may require you to use your NPI before that date important to apply for NPI before the compliance date of May 2007 because health plans may require you to use your NPI before that date NPI Implementation deadline is 5/23/07 NPI Implementation deadline is 5/23/07 Small health plans have until 5/23/08 to comply Small health plans have until 5/23/08 to comply

NPI Application Methods Methods include Methods include Apply by paper (via mail) Apply by paper (via mail) Available 2005 Available 2005 Apply via web Apply via web Available May 23, 2005 Available May 23, 2005 Apply using the Electronic File Interchange (EFI) Apply using the Electronic File Interchange (EFI) Future development Future development

Individual Providers vs. Group Practices An individual who is a covered health care provider and is a member of an organizational health care provider is not considered to be a subpart of the organizational health care provider An individual who is a covered health care provider and is a member of an organizational health care provider is not considered to be a subpart of the organizational health care provider The individual would receive a Type I-Individual NPI The individual would receive a Type I-Individual NPI Only one NPI assigned for an individual Only one NPI assigned for an individual The organizational health care provider would receive a Type II-Organizational NPI The organizational health care provider would receive a Type II-Organizational NPI Defined subpart(s) may receive organizational NPI(s) Defined subpart(s) may receive organizational NPI(s)

NPI Enumerator Fox Systems, Inc. Fox Systems, Inc. Responsible for provider enumeration process using the National Provider and Plan Enumeration System (NPPES) Responsible for provider enumeration process using the National Provider and Plan Enumeration System (NPPES) Handles NPI applications/update forms Handles NPI applications/update forms The NPPES will not The NPPES will not Link subparts to covered organization health care providers or vice versa Link subparts to covered organization health care providers or vice versa Capture memberships in groups or multiple practice location addresses Capture memberships in groups or multiple practice location addresses Know whether or not a health care provider is a covered entity Know whether or not a health care provider is a covered entity

The National Plan and Provider Enumeration System (NPPES) National Provider System (NPS) is synonymous with NPPES National Provider System (NPS) is synonymous with NPPES Developed under CMS contract Developed under CMS contract Uniquely identifies health care providers and subparts and assigns them NPIs Uniquely identifies health care providers and subparts and assigns them NPIs Sets up and maintains a record for every enumerated health care provider and subpart Sets up and maintains a record for every enumerated health care provider and subpart Creates reports and output files Creates reports and output files

The NPPES will not… Link subparts to covered organization health care providers or vice versa Link subparts to covered organization health care providers or vice versa Capture memberships in groups Capture memberships in groups Capture multiple practice location addresses Capture multiple practice location addresses Know whether or not a health care provider is a covered entity Know whether or not a health care provider is a covered entity

What information must be furnished to obtain an NPI? The minimum data needed to ensure unique identification The minimum data needed to ensure unique identification Basic and identifying information, certification statement, signatures, contact person Basic and identifying information, certification statement, signatures, contact person More information will be required if necessary to establish uniqueness More information will be required if necessary to establish uniqueness Federal Register contains list of data elements Federal Register contains list of data elements

Obtaining NPIs (cont.) NPPES uses data on application or in EFI to ensure unique identification NPPES uses data on application or in EFI to ensure unique identification SSN validation, address verification, duplicate check SSN validation, address verification, duplicate check Edits to detect incomplete and illogical data Edits to detect incomplete and illogical data If application is OK, health care provider or subpart is notified of NPI If application is OK, health care provider or subpart is notified of NPI If application is not OK, Enumerator communicates with health care provider or subpart If application is not OK, Enumerator communicates with health care provider or subpart

Use of the Taxpayer Identification Number (TIN) TIN established by regulation to identify a taxpayer (SSN, EIN or ITIN) TIN established by regulation to identify a taxpayer (SSN, EIN or ITIN) Required in many standard transactions to identify entities (including health care providers or subparts) as taxpayers Required in many standard transactions to identify entities (including health care providers or subparts) as taxpayers When TIN is to be reported in standard transactions for its regulatory purpose, it must be used. When TIN is to be reported in standard transactions for its regulatory purpose, it must be used. NPI cannot be used as a substitute for a TIN

Use of DEA, CLIA and Mammography Certification Numbers Not considered to be healthcare provider identification numbers Not considered to be healthcare provider identification numbers When Number is to be reported for its regulatory purpose, it must be used. When Number is to be reported for its regulatory purpose, it must be used. NPI cannot be used as a substitute for a DEA, CLIA or Mammography Certification Number

Options for Obtaining NPI Information Four different sources (maybe more…) Four different sources (maybe more…) NPPES NPPES Provider to Plan/Clearinghouse Provider to Plan/Clearinghouse Provider to Provider Provider to Provider Plan/Clearinghouse to Plan/Clearinghouse Plan/Clearinghouse to Plan/Clearinghouse

What should you be doing now? Become informed about the NPI, the enumeration process and its implementation Become informed about the NPI, the enumeration process and its implementation Identify processes/systems that are affected by provider identifiers Identify processes/systems that are affected by provider identifiers Develop enumeration strategy and submit NPI applications Develop enumeration strategy and submit NPI applications Develop implementation plans (internal, external with trading partners and others) Develop implementation plans (internal, external with trading partners and others) Educate staff Educate staff

Implementation Activities Check CMS website for updates Check CMS website for updates Watch/ask for instructions/communications from CMS, vendors, health plans and trading partners Watch/ask for instructions/communications from CMS, vendors, health plans and trading partners Determine impact of NPI on contracts, systems, processes, files Determine impact of NPI on contracts, systems, processes, files Identify/resolve issues early Identify/resolve issues early

NPI Resources WEDI WEDI Named in HIPAA as consulting organization Named in HIPAA as consulting organization NPI PAG, SNIP NPI listserv, white papers NPI PAG, SNIP NPI listserv, white papers DSMO’s DSMO’s NCPDP, X12, HL7, NUCC, NUBC, DeCC NCPDP, X12, HL7, NUCC, NUBC, DeCC Other professional organizations and associations Other professional organizations and associations NPI Enumerator Call Center NPI Enumerator Call Center

CMS NPI Resources regulations regulations FAQs FAQs Regulations and Outreach Listservs Regulations and Outreach Listservs Outreach materials, announcements Outreach materials, announcements HIPAA Hotline HIPAA Hotline CMS “NPI” Web site now available CMS “NPI” Web site now available