What is a National Provider Identifier (NPI)?
An NPI is a unique 10-digit numeric identifier assigned to those health care providers and organizations defined as covered entities under HIPAA. The NPI will be a permanent identifier, assigned for life.

What are the significant dates associated with applying for and using an NPI?

• May 23, 2007: All health care providers who utilize HIPAA standard electronic transactions must have an NPI by this date. Providers who do not utilize HIPAA standard electronic transactions may have an NPI.
• May 23, 2007: All large health plans and payers must have the capability to use the NPI to identify providers in standard electronic transactions by this date.

Who should obtain an NPI?
Any health care provider or organization defined as a covered entity under HIPAA is required to obtain an NPI. Providers who transmit health care information via HIPAA standard electronic transactions are covered entities under HIPAA, whether they transmit the transactions themselves or use a vendor to transmit them.

Even if you don't send electronic transactions from your practice, an NPI may be needed to identify you in other situations; such as when another provider wants to refer a patient to you, a pharmacy needs to bill for drugs you prescribed, a hospital needs to bill for a patient you treated or admitted, or a lab needs to bill for services you ordered. You will also need an NPI if you bill Medicare on paper forms.

What is the difference between a covered entity and a non-covered entity?
Health care providers who transmit standard electronic transactions (for example, claims submissions, referrals, etc.) are covered entities and are required by the HIPAA NPI regulations to apply for and receive an NPI prior to the May 23, 2007, compliance date. Acquiring an NPI is optional for non-covered entities (providers who do not submit standard electronic transactions).

What will an NPI do?
As of May 23, 2007, an NPI will:

• Replace all other provider identifiers previously used by health care providers (for example, UPIN, Medicare/Medicaid numbers, etc.).
• Establish a national standard and unique identifier for all health care providers.
• Simplify health care system administration and encourage the electronic transmission of health care information.
• Be needed on all prescriptions to identify the provider separate from the DEA number requirement for narcotic prescriptions.

What will an NPI not do?
As of May 23, 2007, an NPI will not:

• Replace the tax identification number (TIN), which is an IRS requirement.
• Convey information about the provider (for example, provider type, service location, etc.).
• Guarantee reimbursement by health plans.
• Enroll providers in health plans.
• Replace use of your DEA, CLIA and Mammography Certification number when required by regulations.

Who can apply for an NPI?

• Individual health care providers, such as physicians, dentists and pharmacists.
• Organizational health care providers, such as hospitals, pharmacies, group practices, laboratories, ambulatory care facilities and nursing homes.

What's the difference between Individual Providers and 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 is assigned for an individual
• The organizational health care provider would receive a Type II-Organizational NPI
  • Defined subpart(s) may receive organizational NPI(s)
  • Subpart(s) may function independently of the covered organization, may have their own billing numbers, licensure and or physical location, i.e. clinics, departments, pharmacies, DME suppliers and nursing homes.

How can a health care provider apply for an NPI?
The Centers for Medicare & Medicaid Services (CMS) has contracted with a vendor to administer the assignment of NPIs and deal with health plans and providers on issues concerning unique identification.

There are only three ways a health care provider can apply for an NPI:

• Complete the application online at https://nppes.cms.hhs.gov. Estimated time to complete the NPI application is 20 minutes.
• Complete a paper copy by downloading it from https://nppes.cms.hhs.gov, or by calling 1-800-465-3203 to request a copy.
• With the provider's permission, an organization may submit the application in an electronic file on behalf of the provider.

Where can additional information about HIPAA NPI regulations be found?

• See the CMS website: www.cms.hhs.gov/hipaa/hipaa2/regulations/identifiers/.
• CMS has also consulted with the Workgroup for Electronic Data Interchange (WEDI) in the development of standards and for comments on data dissemination and other issues. WEDI has formed several workgroups consisting of representatives from all areas of the health care industry. See published "white papers" on various topics and other information on the WEDI website: www.wedi.org.