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The HIPAA-mandated standard unique health identifier for health care
providers, National Provider Identifier (NPI), will be required to
appear in all HIPAA mandated electronic transactions as of May 23, 2007.
That means if you don't have one and start using it on your claim forms
by that date, you won't be reimbursed.
The NPI will be used to identify the physician in all standard electronic
transactions across all payers. Physicians will be assigned only one NPI
and that NPI will not change over time. It will eventually replace Medicare
UPINs and other "legacy" identifiers that may now be required by payers.
A unique identifier has already been issued for employers and a unique
identifier for each health plan will also be issued.
What is the National Provider Identifier (NPI)?
Who is required to use an NPI number?
Is an NPI required on a paper transaction?
What if a provider has several health plan IDs, will each plan require an NPI?
What does NPI look like?
How are NPI numbers generated?
How can providers get an NPI number?
What happens if a doctor changes practices, specialties or moves?
How can I learn more about NPI?
When are providers required to submit their claims with NPI?
Can providers choose to have more than one NPI?
What is the National Provider Identifier (NPI)?
The National Provider Identifier (NPI) is a 10-digit identification number
that the federal government assigns to healthcare providers. It is one of
the simplifications of the Health Insurance Portability and Accountability
Act of 1996 (HIPAA) intended to reduce fraud and improve the efficiency of
the healthcare system.
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Who is required to use an NPI number?
All providers who complete electronic transactions must obtain an NPI to
identify themselves in HIPAA standard transactions. These providers include:
- Physicians and other practitioners, including, but not limited to, dentists,
physician assistants, chiropractors, nurses, licensed social workers,
physical therapists, and clinical psychologists
- Hospitals, nursing homes and other institutional providers
- Suppliers of durable medical equipment (DME)
- Pharmacies, including online pharmacies, and pharmacists
- Medical groups
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Is NPI required on paper transactions?
The NPI is required in electronic HIPAA transactions. However, the NPI
mandate allows us the ability to require the use of the NPI on all
transactions, including paper, to improve processing efficiency.
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What if a provider has several health plan IDs, will each plan require an NPI?
The NPI number is the sole identifier for each provider and should replace
each health plan identifier. Providers only need to apply for an NPI once.
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What does NPI look like?
The NPI is a 10-digit numeric field that includes one check digit in
the tenth position to ensure accuracy. This format permits 200 billion
unique identifiers to be issued without re-using the same values. The NPI
contains no logic, so you are not able to determine a provider’s state,
region, specialty, etc.
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How are NPI numbers generated?
NPI numbers are generated by a system called the National Plan and
Provider Enumeration System (NPPES) and issued by the U.S. Department
of Health and Human Services (HHS) through the Centers for Medicare
and Medicaid Services (CMS).
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How can providers get an NPI number?
Providers can get an NPI number by contacting the NPI Enumerator
or you can go to the Web and apply electronically. The NPI Enumerator can be contacted by:
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What happens if a doctor changes practices, specialties or moves?
If a provider changes specialty, practices or moves, he/she retains
the same NPI number. The NPI number is meant to identify the provider
throughout his/her career.
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How can I learn more about NPI?
The CMS NPI page, located at http://www.cms.hhs.gov/NationalProvIdentStand/,
is the only source for official CMS education and information on the
NPI initiative; all products located on this site are free of charge.
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When are providers required to submit their claims with NPI?
All healthcare providers are required to use
the NPI in all HIPAA transactions by May 23, 2007.
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Can providers choose to have more than one NPI?
To determine how many NPI numbers to request, please consider the
following tips provided by Centers for Medicare & Medicaid Services (CMS):
- Individuals (doctors, nurses):
One NPI per provider regardless of numbers of practice locations, contracts, etc.
- Clinics (group practices, etc.):
Clinics should obtain separate NPIs per Pay-To/Mailing Address.
- DME Suppliers: DME suppliers must obtain one NPI per location.
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