Frequently Asked Questions: NPI

What is the NPI?

The National Provider Identifier (NPI) is a unique, 10-digit identification number used to identify a provider in Health Information Portability and Accountability Act (HIPAA) standard transactions. NPIs are intelligence-free, meaning they do not contain imbedded information about the provider such as practice location, type of service provided, etc.

Who assigns NPIs?

The Centers for Medicare and Medicaid Services (CMS) is responsible for oversight and management of the NPI system. CMS has contracted with Fox Systems to operate the National Plan and Provider Enumeration System (NPPES or “the Enumerator”), a computer system that will process applications and updates, ensure the uniqueness of the healthcare provider and generate NPIs.

Who is required to obtain an NPI?

All “covered entities” who engage in HIPAA standard transactions must obtain an NPI. Healthcare providers who bill Medicare for their services are required to apply for a national identifier as well. Entities who do not furnish healthcare services (e.g., taxi services, hotels, etc.) are not eligible for NPIs. These HIPAA definitions may offer more clarification:

1. Covered entities are defined as healthcare providers, health plans and healthcare clearinghouses that transmit any health data electronically in connection with a transaction for which the Secretary of Health and Human Services (HHS) has adopted a standard (i.e., HIPAA standard transactions).
2. Healthcare provider is defined in HIPAA regulations as a provider of medical or healthcare services (e.g., physician, qualified psychologist, certified nurse-midwife, hospital, skilled nursing facility, home health agency, etc.) and any other person or organization who furnishes, bills or is paid for healthcare in the normal course of business.
3. Standard transactions – such as those found on HHIN+ – include, but are not limited to: claims and encounter information (837 I/P/D), payment and remittance advice (835), eligibility (270/271) and claims status and inquiry (276).

Why was the use of NPI established?

The NPI was established by the Department of Health and Human Services ( HHS ) in 2004 as an Administrative Simplification mandate of HIPAA. The intent is to simplify billing, as providers will have one standard identification number, and speed up coordination of benefits (COB) payments by easing communication among payers.

Where can I get more information about NPI?

Use these resources to learn more about NPI:

1. CMS NPI website: www.cms.hhs.gov/NationalProvIdentStand/
2. NPPES (the Enumerator) website: https://nppes.cms.hhs.gov/NPPES/Welcome.do
3. NPPES phone: 1-800-465-3203; 1-800-692-2326 (TTY)

How can I obtain an NPI?

Providers can apply for a no-cost NPI three ways:

1. Complete the online application at the NPPES website: https://nppes.cms.hhs.gov/NPPES/StaticForward.do?forward=static.npistart.
2. Call 1-800-465-3203 or 1-800-692-2326 (TTY) to request a hard-copy application from NPPES (the Enumerator).
3. Permit an organization – known as an electronic file interchange organization (EFIO) – to obtain an NPI on his or her behalf through an electronic file interchange (EFI). Refer to www.cms.hhs.gov – National Provider Identifier (NPI) for more information about bulk enumeration.

How many NPIs may a healthcare provider obtain?

There are two types of healthcare providers in terms of NPIs:

1. Type 1 – Healthcare providers who are individuals , including physicians, dentists and all sole proprietors. An individual is eligible for only one NPI.*
2. Type 2 – Healthcare providers who are organizations , including physician groups, hospitals, nursing homes and the corporation formed when an individual incorporates him- or herself. Further, organizations must determine if they have “subparts” that require their own NPIs for unique identification in HIPAA standard transactions. A subpart is a component of an organization that furnishes healthcare and is not itself a separate entity. Refer to www.cms.hhs.gov/MLNMattersArticles/downloads/SE0608.pdf [PDF] for more information about subpart designation.

*Note: An individual healthcare provider who is incorporated may need to obtain an NPI for her- or himself (Type 1) and an NPI for his or her corporation or LLC (Type 2).

The NPI is intended to identify the provider throughout his or her career. Organization NPIs also are intended to be permanent except in rare situations (e.g., a healthcare provider does not wish to continue an association with a previously used NPI, a provider’s NPI has been used fraudulently, etc.).

By what date am I required to have an NPI?

The NPI implementation date is May 23, 2007. At that time, HIPAA covered healthcare providers must transmit standard EDI transactions using NPI, and health plans and clearinghouses must be able to accept EDI transactions with NPI. Small health plans have until May 23, 2008, to comply.

Although the NPI implementation date is several months away, HMSA encourages providers to apply for their NPI now. As more providers wait to get their NPI at a later date, it is anticipated the volume of applications NPPES (the Enumerator) receives will increase and the length of time it takes to process NPI requests also will increase. Providers who wait until the last minute may not have their NPIs in time to file claims on May 23, 2007.

Providers should also ensure that their software is able to accommodate the NPI. This may require contacting the vendor.

Do I need to share my NPI with HMSA?

Yes! It is essential for HMSA to have all provider NPIs as soon as possible to ensure HIPAA standard transactions process correctly by the implementation date.

HMSA has begun contacting providers to acquire NPI information. If you have not received a communication requesting your NPI or an HMSA representative has not contacted you to obtain your NPI, contact your Field Representative. If you need assistance contacting your representative, call 808-948-5190 on Oahu or 1-800-603-4672, ext. 5190 from the Neighbor Islands.

What if I receive more than one communication from HMSA requesting my NPI?

If you receive more than one request to provide your NPI to HMSA, do not assume it is an error. HMSA has organized the mailing into groups (e.g., providers who direct payment to themselves, providers who direct payments to groups or clinics, providers who have more than one specialty, etc.). Some providers fall into more than one of these groups; therefore, the provider may receive more than one communication.

If you receive multiple communications from HMSA, carefully review the message and submit the requested information. Do not assume you have received a duplicate communication.

Why has HMSA not yet contacted me for my NPI?

If you have not received a request to provide your NPI to HMSA, please contact your Field Representative. For assistance contacting your representative, call 808-948-5190 on Oahu or 1-800-603-4672, ext. 5190 from the Neighbor Islands.

What will HMSA do with my NPI?

HMSA will use provider NPIs to update its records and systems, which will enable HMSA to process EDI transactions by the implementation deadline: May 23, 2007. HMSA will collect, use and disclose NPI only in accordance with applicable laws and regulations.

When does HMSA want me to begin using my NPI?

As soon as possible. Please contact HMSA EDI Support at 808-948-6355 on Oahu or 1-800-377-4672 from the Neighbor Islands to arrange to use your NPI in electronic transactions. The NPI must be used in all HIPAA-standard electronic transactions no later than May 23, 2008.

Will I still need to use my HMSA provider identification number(s)?

The HMSA provider identification number is required on all hard copy claims. EDI transactions may contain both the NPI and the HMSA provider identification number until May 23, 2008. However, beginning May 23, 2008, all EDI transactions must contain only the NPI and cannot contain the HMSA provider identification number.

What if I use my NPI before HMSA has notified me to do so?

EDI claims submitted with the NPI in place of the HMSA provider identification number may encounter processing delays or errors if HMSA has not been made aware prior to submission. Please contact HMSA EDI Support as soon as possible at 808-948-6355 on Oahu or 1-800-377-4672 from the Neighbor Islands to arrange to use your NPI in electronic transactions.

What if I submit hard-copy claims?

Covered healthcare providers who file hard-copy claim forms (CMS 1500, UB-92, ADA) can obtain an NPI, although the NPI mandate applies only to HIPAA standard transactions (e.g., electronic claims). HMSA encourages all providers to obtain an NPI, whether they file hard-copy or electronic claims.

The CMS 1500 hard-copy claim form was updated to accommodate NPI and became available October 1, 2006. HMSA automated its acceptance of the updated CMS 1500 claim form effective January 1, 2007. Providers may submit CMS 1500 claims using the new version of the form.

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