National Provider Identifier

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National Provider Identifier
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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 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.

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Background, continued

• 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.
• 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.

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NPI Principles

• NPI is not a credentialing program
• NPIs are not tied together in the database
• NPI is required on standard transactions,
  optional elsewhere
• HIPAA does not govern internal systems
• NPI may be used for any lawful purpose
• 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

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Structure of NPI

• NPI is 10 digits 123456789C
• PlanID is also 10 digits
• C Check digit
• First digit distinguishes between NPI PlanID

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Eligibility for an NPI

• All healthcare providers as defined in 45 CFR
  160.103, are eligible 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
• 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.

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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.
• 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 patients
  eligibility for a particular health care service.
• Intelligence free NPI. NPI will not contain
  intelligence about the health care providers
  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.

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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.
• 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.
• 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 providers NPI is
  never reissued.

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An NPI will not

• 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
• Guarantee reimbursement by any health plan
• Convey covered entity status
• Assure licensure or credentials
• Require a health care provider or a subpart to
  conduct standard transactions

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The NPI Timeline

• 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
• NPI Implementation deadline is 5/23/07
• Small health plans have until 5/23/08 to comply

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NPI Application Methods

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

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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
• The individual would receive a Type I-Individual
  NPI
• Only one NPI assigned for an individual
• The organizational health care provider would
  receive a Type II-Organizational NPI
• Defined subpart(s) may receive organizational
  NPI(s)

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NPI Enumerator

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

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The National Plan and Provider Enumeration System
(NPPES)

• National Provider System (NPS) is synonymous with
  NPPES
• Developed under CMS contract
• 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
• Creates reports and output files

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The NPPES will not

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

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What information must be furnished to obtain an
NPI?

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

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Obtaining NPIs (cont.)

• NPPES uses data on application or in EFI to
  ensure unique identification
• SSN validation, address verification, duplicate
  check
• Edits to detect incomplete and illogical data
• 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

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Use of the Taxpayer Identification Number (TIN)

• 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
• 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

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Use of DEA, CLIA and Mammography Certification
Numbers

• Not considered to be healthcare provider
  identification numbers
• 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

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Options for Obtaining NPI Information

• Four different sources (maybe more)
• NPPES
• Provider to Plan/Clearinghouse
• Provider to Provider
• Plan/Clearinghouse to Plan/Clearinghouse

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What should you be doing now?

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

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Implementation Activities

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

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NPI Resources

• WEDI www.wedi.org
• Named in HIPAA as consulting organization
• NPI PAG, SNIP NPI listserv, white papers
• DSMOs
• NCPDP, X12, HL7, NUCC, NUBC, DeCC
• Other professional organizations and associations
• www.nppes.cms.hhs.gov
• NPI Enumerator Call Center
• 800-465-3203

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CMS NPI Resources

• www.cms.hhs.gov
• regulations
• FAQs
• Regulations and Outreach Listservs
• Outreach materials, announcements
• HIPAA Hotline [phone]
• AskHIPAA_at_cms.hhs.gov
• CMS NPI Web site now available