Olympic Online NPI Provider Reference

The National Provider Identifier (NPI) Overview and Fact Sheet


Why NPI?

  • The Health Insurance Portability and Accountability Act (HIPAA) of 1996 mandated the adoption of a standard unique identifier for healthcare providers.
  • On January 23, 2004, HHS published the Final Rule that adopts the National Provider Identifier (NPI) as this standard.


What is an NPI?

  • The NPI is a 10-digit, intelligence-free number that uniquely identifies a healthcare provider.
  • Intelligence-free means there is no embedded information that conveys specifics about the provider, such as the state where they live or their medical specialty.
  • Making the number 10 digits long enables enough unique NPI’s to last for 200 years at the current rate of healthcare provider growth.
  • When the NPI is fully implemented, covered entities will use only the NPI to identify healthcare providers in all standard EDI transactions, including claims.
  • Legacy identifiers (e.g., UPIN, 6-digit Medicare#, 10-digit ASC#, DME supplier#) will not be permitted.
  • TIN will continue to be required for tax purposes.


Who can apply for an NPI?

  • All healthcare providers (as defined in 45 CFR 160.103) are eligible to receive NPI’s.
  • Healthcare providers who transmit health information in electronic form (on their own behalf or through a business associate) are required to obtain and use NPI’s.
  • Healthcare providers are divided into two categories for purposes of obtaining NPI’s:

      • Individual Providers:

    • Physicians
    • Nurses
    • Chiropractors
    • Pharmacists
    • Physical Therapists
    • Dentists
    • Etc.

      Organization Providers:

    • Hospitals
    • Home Health Agencies
    • Clinics
    • Nursing Homes
    • Laboratories
    • Ambulance Companies
    • Suppliers of DME
    • Pharmacies
    • Etc.


Organization Healthcare Provider “Subparts”

  • Organization healthcare providers (e.g., hospitals, suppliers, pharmacies) may be made up of components or have separate physical locations that furnish healthcare, but are not themselves legal entities.
  • These separate components or separate physical locations are called “subparts” and may require their own NPI’s to bill a Federal health plan such as Medicare.
  • For example: A hospital offers general acute care services, psychiatric services, and rehabilitation services. Each of these “units” may require its own NPI in order to bill Medicare.
  • Organization healthcare providers need to determine if they have subparts for purposes of obtaining NPI’s.
  • The subpart concept does not pertain to individual healthcare providers.


Who is not eligible for an NPI?

  • Any entity that does not meet the definition of a “healthcare provider” is not eligible for an NPI.
  • Examples of entities that are not eligible for NPI’s include billing services, healthcare clearinghouses, and atypical service providers, such as taxi and other transportation services.


NPI Application Process

  • Healthcare providers will be assigned NPI’s upon successful completion of the NPI Application/ Update form.
  • The form can be submitted on paper or over the Internet.
  • Providers are required to submit updates for required data elements within 30 calendar days of the changes.
  • Applications are available online at: https://nppes.cms.hhs.gov.


Is an NPI Permanent?

  • For the most part, once an NPI has been assigned, it will be permanent and will not change.
  • Exception: A healthcare provider is eligible for a new NPI if they find their NPI has been used fraudulently.


The National Plan and Provider Enumeration System (NPPES)

  • The information submitted by healthcare providers will be entered into a database called the National Plan and Provider Enumeration System (NPPES).
  • The NPPES will process the applications and updates, ensure the uniqueness of the healthcare provider, and generate the NPI’s.
  • CMS awarded a contract to Fox Systems, Inc. to operate the NPPES, assist providers with completing applications, resolve problems, and notify providers of their NPI’s.
  • Health plans will be provided with a mechanism to access data contained in the NPPES. This will enable health plans to validate submitted NPI’s.


NPI Implementation Dates

  • Healthcare providers were able to apply for NPI’s as of May 23, 2005. A number of articles have been issued by CMS since this time to educate and remind providers on the NPI application process.
  • Providers and health plans must use only the NPI to identify providers in standard EDI transactions (including claims) by May 23, 2007 (unless classified as a small entity).


Will the NPI replace the Medicare certification or enrollment process?

  • No! The NPI will not change or replace the current Medicare enrollment or certification process.


NPI and Paper Claim Forms

  • HIPAA regulations apply to electronic transactions – not paper.
  • This does not prevent health plans from requiring NPI’s on paper transactions such as claims.
  • There is no NPI capability on UB92 or CMS-1500 claim forms; therefore, new forms are being released.

    UB04 Implementation Timeline – National Uniform Billing Committee (NUBC) Proposed Recommendation:
    • March 1, 2007: Health plans and clearinghouses need to be ready/able to accept new UB04.
    • March 1 to May 22, 2007: Providers can use either the UB04 or UB92.
    • May 23, 2007: The UB92 is discontinued; only the UB04 form should be used. This includes corrected claims.

    Revised CMS-1500 Implementation Timeline – National Uniform Claim Committee (NUCC) proposed recommendation:

    • Jan. 1, 2007: Health plans and clearinghouses need to be ready/able to accept new CMS-1500.
    • Jan. 1, 2007 to Apr. 2, 2007: Providers can use either current or proposed CMS-1500 claim form.
    • Apr. 2, 2007: The current CMS1500 is discontinued; only the proposed CMS-1500 should be used. This includes corrected claims.