FAQ: National Provider Identifier (NPI)
NPI News: As a result of the Health Insurance Portability and Accountability Act (HIPAA) of 1996, the federal Department of Health and Human Services mandated the use of the National Provider Identifier (NPI), which is a standard unique identifier for health care providers. More information and latest news about implementation.
General
1. What is the National Provider Identifier (NPI)?
The NPI is a unique 10-digit number for health care providers that can be used nationally which contains no "intelligence" about the provider and is issued for life. The NPI replaces all "legacy" provider numbers that are currently being used including:
- UPIN (Unique Physician/Practitioner Number)
- Medicaid Provider Number
- Medicare Provider Number
- Blue Cross and Blue Shield Numbers
2. What is the National Provider Identifier (NPI) Requirement?
As a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the federal Department of Health and Human Services has mandated the use of the National Provider Identifier (NPI). On January 23, 2004, CMS defined and published the Governing Rules for NPI. NPIs replace Provider Numbers assigned by Medicare, Medicaid, local carriers and other federal programs for HIPAA Transactions. The Final Rules placed responsibility on health plans, health care clearinghouses and covered health care providers to obtain an NPI number, rather than on the states to assign them.
3. What are the rules for obtaining a National Provider Identifier (NPI)?
Any All HIPAA covered health care providers, whether they are individuals or organizations must obtain an NPI for use to identify themselves in HIPAA standard transactions. Standard transactions are Electronic Data Interchange (EDI) transactions that transmit health care data in standard formats that were adopted by HHS by regulations. Examples of standard transactions are:
- Institutional, professional/dental, retail pharmacy drug claims;
- Payment and remittance advice;
- Eligibility inquiry or response;
- Claim status inquiry or response;
- Referral/prior authorization.
4. Do I need an NPI if I only bill on paper or via the Web?
All healthcare providers, regardless of the method of claims submission are required to register an NPI number with DHS – even providers who submit claims via the Web or on paper. This requirement supports the submission and exchange of HIPAA formatted claims with other payers. For example; if you submit a claim to DHS that also needs to be submitted to a third-party insurer, the third party insurer may need an NPI number to pay the claim. Additionally, another provider who conducts HIPAA standard transactions (such as pharmacies, hospitals, laboratories, and others) may need to identify you as a rendering, ordering, referring, prescribing, or another type of provider, in the claims they send to health plans. These providers would also need to have your NPI number on file to include in their claims submissions.
5. How do I apply for a National Provider Identifier (NPI)?
Providers can apply for an NPI online at the National Provider and Plan Enumeration System (NPPES) Web site at nppes.cms.hhs.gov or providers can complete the NPI paper application form and mail it to the Enumerator at the address below.
Fox Systems, Inc.
NPI Enumerator
P.O. Box 6059
Fargo, ND 58108-6059
The NPI Enumerator Call Center Telephone Number is 1-800-465-3203
Contingency Plan
1. Can I submit claims using only my legacy number until May 23, 2008?
No. Sometime prior to May 23, 2008, DHS will move into the NPI Dual Strategy phase. During this phase claims submitted with only the 13-digit PROMISe Provider ID (legacy number) will be denied. You should be using your registered and validated NPI number.
2. Why should I submit claims with both the legacy number and the NPI number at first?
DHS suggests that you use the Legacy Dual Strategy phase to test your NPI number to ensure that it is correctly associated with the 13-digit PROMISe Provider ID (legacy number) you intended. Remittance advices will contain Error Status Code (ESC) information if there are any problems during claims processing. Error Status Codes and detailed descriptions can be found at http://www.DHS.state.pa.us/Business/PROMISe/003673549.htm.
3. Does the contingency plan mean I do not have to use the new paper forms until later?
No. The UB04 was required starting May 23, 2007. The new CMS 1500 has been required since July 1, 2007.
Implementation Dates
1. When did the Department of Human Services transition to the NPI?
The Department of Human Services has implemented a contingency plan supporting a Dual Strategy approach. Information on the NPI Contingency Plan is contained in the NPI Contingency Plan presentation.
2. When will the Department of Human Services require NPI on Paper Claims?
The Department of Human Services is not requiring NPI on paper claims but we are requesting the NPI on paper claims.
3. When will the Department of Human Services begin returning NPIs only on the 835 Institutional and Professional?
DHS is switching to NPIs only no later than May 23, 2008, on 835 Institutional and Professional. Information on the NPI Contingency Plan is contained in the NPI Contingency Plan presentation.
4. When will the Department of Human Services begin adjudicating claims based on the NPI?
The NPI will be required on the submission of all Health Insurance Portability and Accountability Act (HIPAA) regulated electronic transactions no later than May 23, 2008. Information on the NPI Contingency Plan is contained in the NPI Contingency Plan presentation.
Pharmacy
1. Do pharmacists and pharmacies need NPI numbers?
Yes. Whenever there is a need for an individual pharmacist to be identified in a transaction, the pharmacist should be identified using an NPI number. Each licensed pharmacy should obtain an NPI number. NCPDP recommends all pharmacies obtain an NPI number, even if HIPAA covered transactions are not used by the pharmacy.
2. If a payor requires that the prescriber be identified on a pharmacy transaction, what number should a pharmacy submit on a pharmacy transaction when a prescriber does not have an NPI?
The pharmacy should submit the state license number and related qualifier for the prescriber.
3. What am I permitted to submit in the billing provider segment?
The service provider ID field will allow either the NPI number or the legacy provider number to be submitted beginning June 1, 2007, through May 22, 2008. May 23, 2008, and forward, the provider will only be allowed to submit their NPI number. The claim will be denied if the legacy provider number is submitted. Please click on the attached link to view DHS' NPI Contingency Plan.
4. What am I permitted to submit in the prescriber segment?
The NCPDP Telecommunication Standard Version 5.1 allows for only one identifier to be submitted in the prescriber ID qualifier field. Beginning June 1, 2007, the prescriber can continue to submit either state license number or they may submit their NPI number in the prescriber id field. The commonwealth of Pennsylvania will continue to enforce format edits, check digit edits and edits related to out-of-state license numbers.
5. How do I validate the NPI number on a transaction?
Basic validation can be performed using the check digit algorithm. It should be pointed out that this is not the same as the DEA check digit validation algorithm. To determine if the NPI number is an active and assigned value, it will be necessary to perform a lookup against a health care provider database that is indexed by the NPI number. The NCPDP Pharmacy Database can be used to perform this validation for pharmacies.
(6) Can the NCPDP enumerate Pharmacies?
A. NCPDP was certified to submit records for enumeration on behalf of pharmacies with their authorization. NCPDP submitted hundreds of files and continued to enumerate pharmacies until Feb. 1, 2007. Pharmacies must now use the paper or on-line process to obtain NPI numbers.
(7) What numbers will be returned on the outbound 835 transaction?
A. If the billing provider submits an NPI number, both the NPI number and the legacy provider number will be returned on the 835 transaction. If the billing provider submits a legacy provider number, the legacy provider number and tax identification number will be returned on the 835 transaction.
(8) Will the prescribing field on an NCPDP transaction require an NPI number?
A: DHS will be accepting either the NPI number or the prescriber license number (not the DEA number) in the prescriber provider segment. Note: Prescribers do not have to be enrolled with PA Medical Assistance to prescribe drugs. DHS will not, as a rule, reject pharmacy claims, if the prescriber has not obtained or does not have an NPI number. We will only reject claims that are not submitted with a valid prescriber license number (meaning in the correct format AA/NNNNNN, AA/NNNNNN/A or AAA/NNNNNN with a valid alpha prefix) or claims that are not submitted with a valid prescriber NPI number. If the prescriber license number or the prescriber NPI number is submitted and valid, we will process the claim for payment consideration.
NPI Registration
(1) How can I register my NPI information with the PA Department of Human Services?
A: Please refer to Bulletin number 99-06-14, to obtain instructions for registering your NPI number to DHS.
(2) How will Medical Assistance want to receive the organizational taxonomy codes for each NPI subpart number?
A: The DHS NPI registration process, both paper and electronic, will require providers to specify the taxonomy(s) that are associated with each NPI number.
(3) Will providers who have secured NPI numbers through bulk enumeration be able to submit an NPPES file to DHS?
A: Please refer to Bulletin number 99-06-14, to obtain instructions for registering your NPI number to DHS.
(4) Will provider organizations that have a large number of providers be able to submit an Excel file to DHS for registration?
A: Yes, but arrangements must be made to accommodate an Excel file. Providers should send an email to the PROMISe mailbox at PROMISe@pa.gov. The subject line should contain the phrase "NPI: Excel file". Include your phone number and a contact name. You will be contacted to discuss the requirements. You will be asked to submit NPPES verification for all providers on your file.
(5) How is DHS going to crosswalk our current 9 digit number with the 4 digit suffix's to the required NPI?
A: For health care providers who will be required to use their NPI number on HIPAA transactions, DHS' strategy is to bring in the provider's NPI number, Taxonomy Code and 9 digit zip and crosswalk that information to the provider's existing Medical Assistance number and service location. The Medical Assistance number will be used to do all processing internally. When the transaction is finalized, the outgoing communication of the provider number will reflect the NPI information.
(6) Will we need to obtain NPI's for each of our current Medical Assistance numbers and Service locations?
A: Once you have consolidated service locations by closing duplicate locations or locations that are no longer being used for billing, refer to Bulletin number 99-06-14 to obtain DHS' recommendations for subparts.
(7) What should a health care organization do if they are required by another payor to have an NPI # for subpart locations that are not enrolled in Medical Assistance?
A: For type 2 organizations, there must be an enrolled service location that corresponds to each unique NPI number. If an organizational provider has more NPI numbers than active service locations, they must submit a form to enroll the service location that matches the NPI numbers they wish to register for that service location.
(8) Do Private Duty/Homecare agencies need an NPI?
A: If these agencies provide health care services, either directly or through their providers, they must secure an NPI number and use it for billing HIPAA covered electronic transactions.
(9) Would you recommend that both groups and individuals obtain an NPI?
A: Each individual provider as well as the group, is required to obtain an NPI.
(10) Where can I find the Taxonomy Codes Crosswalk to DHS Provider Types and Specialties?
A: This information will be on the DHS Web site at National Provider Identifier (NPI) Information. Please check this site before registering your NPI number.
(11) What if I cannot find the appropriate Taxonomy Code when registering my NPI?
A: The selection of Taxonomy Codes you are given during the NPI registration process is based on the specialty code that is currently on file for your enrollment. If you do not have the appropriate code to select you should contact the enrollment area through the DHS Feedback Form or by phone using the Provider Hotline number 1-800-537-8862, to determine if your specialty needs to be corrected or updated.
(12) How can I close Service Locations that are duplicates or are no longer being used for billing?
A: Service Locations can be closed through an ePEAP update at thePROMISe Web site or by completing and mailing the PROMISe Service Location change request form. If you are uncertain of all your open service locations, send an email to the PROMISe mailbox at PROMISe@pa.gov requesting a report of your open service locations and addresses. The subject line should contain the phrase "NPI Service Location Request."
(13) I am unable to find taxonomy codes for all of my specialties on the DHS Provider Type/Provider Specialty to Taxonomy Crosswalk. Does this mean that services submitted on claims for those specialties will not pay?
A: No. Taxonomy codes are used to connect the NPI number to the service location that will be used for processing. When registering your NPI number with Medical Assistance (MA), you should select taxonomy codes that most closely correspond to the provider types and primary specialties that you currently have on record with MA. You can view your specialties that are on file through ePEAP. If these specialties need to be updated, you should contact the provider enrollment department with your updates. DHS is currently using taxonomy codes as one of three pieces of information to help link your NPI to the correct service location when claims are submitted. As long as you submit your claim using the same taxonomy code as you have registered with your NPI along with the NPI number and nine-digit zip codes, the claim should connect to the correct service location. Once a match has been established, the claim will process as it does today.
Claims
(1) Are your new Billing and Companion Guides available?
A: Updated billing and companion guides are available by clicking below to access appropriate provider handbooks, billing guides and companion guides for all provider types:
(2) Are you using our inbound NPI data to populate your system?
A: No.
(3) If no, how do you plan on populating NPIs into your system?
A: Providers will need to register their NPI information with the Department of Human Services with confirmations from the CMS enumerator. (See enrollment FAQs for details)
(4) When will the Department of Human Services begin adjudication of claims based on the NPI?
A:The NPI will be required on the submission of all Health Insurance Portability and Accountability Act (HIPAA) regulated transactions no later than May 23, 2008. Information on the NPI Contingency Plan is contained in the NPI Contingency Plan presentation.
(5) Are providers required to submit their 13-digit PROMISe Provider ID number and an NPI for a transition period?
A: Providers are not required to submit both identifiers but are permitted to do so under the NPI Contingency Plan
(6) Will the Department of Human Services require Taxonomy Codes on the claim form?
A: We will be using the NPI number, the taxonomy, and the five- or nine-digit zip code whenever possible to make an accurate one-to-one connection from the NPI number to the existing 13-digit PROMISe Provider ID and are therefore requesting that taxonomy codes be provided whenever possible.
(7) Will the 835 (Electronic Remittance Advice) contain the NPI that is sent to the Department of Human Services on an incoming claim?
A: If the NPI is sent in on the incoming transaction and registered with the Department of Human Services, then it will appear on the 835.
(8) Will you strictly use the NPI, or 13-digit PROMISe Provider ID number, via "back end mapping" to determine how to pay claims and to whom?
A: We will be using a crosswalk system to connect the NPI to the existing PROMISe Provider ID numbers. Claims processing will continue to use the PROMISe ID numbers to complete internal processes. The PROMISe Provider ID number will then be crosswalked or connected back to the NPI number for outgoing communication.
(9) Will different fields be used on claims to determine how to pay claims (i.e., location, group, taxonomy, bill type etc.)? If so, what fields/data elements will you use?
A: A combination of, NPI, taxonomy and zip code will be used to determine a one-to-one match with the provider's current 13-digit PROMISe Provider ID. Once the NPI, taxonomy and zip code is connected to the PROMISe ID the claim is processed as it is today.
(10) Which fields will be used for those NPIs? Will taxonomies be required on claims?
A: Please click below to access the appropriate provider handbooks, companion guides and billing guides for all provider types.
(11) Currently, some forms require license number (Prior authorizations, Program exceptions). Will it remain that way? How are Durable Medical Equipment (DME) handled?
A: The NPI will replace the license number in the 837 transaction. DMEs are not atypical and will be required to obtain an NPI if they conduct HIPAA covered electronic transactions. Please click below to access the appropriate provider handbooks, billing guides and companion guides for all provider types.
(12) Will NPI take the place of license number?
A: NPI will take the place of license number on the 837 electronic transactions
(13) Will the Department of Human Services still be using the PROMISe Provider ID number and the new NPI's used to identify providers and sub-parts?
A: Department of Human Services will be using the NPI, taxonomy, five- or nine-digit zip code that is submitted on the 837 electronic transaction which is then crosswalk or connected to the PROMISe Provider's ID. Once the PROMISe Provider ID number is found, the claim will be processed as it is currently processed today.
(14) Which fields on the claim submission will be used for NPIs?
A: Please click below to access the appropriate provider handbooks and billing guides for all provider types.
(15) Will the referring and billing provider NPIs be required?
A: Yes. Please click below to access the appropriate provider handbooks and billing guides for all provider types.
(16) Do you allow testing for NPI?
A: Although the formal testing period has ended, the implementation of the NPI Contingency Plan provides an opportunity for providers to conduct testing. Beginning June 1, 2007 providers who submit a legacy number (13-digit PROMISe Provider ID) and an NPI number on claims will be able to conduct their own tests. Submitting both a legacy number (13-digit PROMISe Provider ID) and an NPI number on claims will allow providers to verify that the NPI number they are using matches the legacy number as intended.
(17) Will the paper remittance advice (RA) contain the NPI number?
A: An NPI number will display on both the paper and electronic RAs if one is submitted on the claim.
(18) How are payments being handled for claims with new NPI numbers?
A: Payments will be handled as they are being handled today. The crosswalk will allow the existing internal processing to continue to make use of PROMISe Provider ID numbers and therefore continue to process claims as they are processed today.
Subparts
(1) What is a Subpart?
A: A Subpart is a component of an organization that provides health care but is not a legal entity. Only Organizational providers are permitted to create subparts. Individual providers are permitted one NPI number which should be associated to a home office where they see patients.
(2) What are the Department of Human Services's recommendations for Subparts?
A: The Department of Human Services's (DHSs) subpart recommendations for the following provider types are:
- Acute Care Hospitals (Provider Type 01) secure separate NPIs for the following areas:
- Short Procedure Units which must have a separate service location from the hospital;
- Specialized units of the hospital such as the psychiatric unit or inpatient rehabilitation units;
- Hospital based clinics that are enrolled as Primary Care Physicians for ACCESS Plus.
- Ambulatory Surgery Centers (Provider Type 02) secure an NPI for each licensed site;
- Durable Medical Equipment Suppliers (Provider Type 25) secure an NPI for each physical site licensed by the Department of Health;
- Group Practices (a group of individual practitioners of the same provider type such as Provider Type 31 – Physicians or Provider Type 14 – Podiatrist) secure an NPI for the service location from which they do their HIPPA billing. It is also recommended that provider groups consolidate their service locations on PROMISeTM to as few as possible;
- Pharmacy (Provider Type 24) secure an NPI for each licensed site;
- Organizations that have secured multiple NPIs to accommodate Medicare ensure that they have a single corresponding service location for each NPI acquired for Medicare;
- Case Management Organization (Provider Type 21) secure an NPI for each service location.
(3) If we choose to enumerate our Subparts further than we currently have today with payer legacy numbers, are you going to require enrollment of our additional subparts?
A: If you are ever going to use one of those NPI numbers in a claims submission process it is recommended that you register it with DHS. If a claim is submitted with an NPI that is not connected to a known provider DHS will not be able to determine to whom it should pay the claim.
Taxonomy Codes
(1) What are Taxonomy Codes?
A: Taxonomy codes are a 10-digit federally established number which health care professionals use to identify their unique specialty areas. They are a combination of Provider Type and Provider Specialty that are self-declared by health care providers during the National Provider Identifier (NPI) enrollment process. The Health Care Provider Taxonomy code set is developed by CMS and is published twice a year in July and January. The July publication is effective for use on October 1 and the January publication is effective for use on April 1. The taxonomy code set is available at www.wpc-edi.com/taxonomy.
(2) Is the Department of Human Services planning on requiring Taxonomy Codes on claim forms?
A: We will be using the NPI number, the taxonomy, and the five- or nine-digit zip code whenever possible to make an accurate one-to-one connection from the NPI number to the exiting 13-digit PROMISeTM Provider ID. The Department of Human Services is not requiring the NPI on paper claim forms but the NPI is requested.
(3) I am unable to find taxonomy codes for all of my specialties on the DHS Provider Type/Provider Specialty to Taxonomy Crosswalk. Does this mean that services submitted on claims for those specialties will not pay?
A: No. Taxonomy codes are used to connect the NPI number to the service location that will be used for processing. When registering your NPI number with Medical Assistance (MA), you should select taxonomy codes that most closely correspond to the provider types and primary specialties that you currently have on record with MA. You can view your specialties that are on file through ePEAP. If these specialties need to be updated, you should contact the provider enrollment department with your updates. DHS is currently using taxonomy codes as one of three pieces of information to help link your NPI to the correct service location when claims are submitted. As long as you submit your claim using the same taxonomy code as you have registered with your NPI along with the NPI number and nine-digit zip codes, the claim should connect to the correct service location. Once a match has been established, the claim will process as it does today.
Additional Resources
(1) Where can I find NPI information on the Department of Human Services's Web site?
A: The Department of Human Services Web site includes an NPI Information Section. Watch for updates and additional resources on this page of the DHS Web site… Medical Assistance Bulletins, Remittance Advice Banner Pages, Provider QuickTips and more.
(2) Where can I learn more about the NPI?
A: You can learn more about NPI and how to apply by visiting the CMS Web site: www.cms.hhs.gov
(3) What is the National Plan and Provider Enumeration System (NPPES)?
A: The National Plan and Provider Enumeration System (NPPES) was developed by the Centers for Medicare and Medicaid Services (CMS) to assign the NPI to eligible health care providers. The NPPES will also store the information about enumerated providers. Providers may apply through a web-based application process at NPPES. nppes.cms.hhs.gov/NPPES/Welcome.do
(4) What is FOX Systems Inc.?
A: CMS contracted with FOX Systems, Inc. to be the NPI enumerator. As the enumerator, FOX Systems, Inc. is responsible for processing NPI applications and updates and maintaining a helpdesk to assist with the NPI application, including the Enumerator's mailing address is available at NPPES.
(5) Does FOX Systems have recommendations regarding subparts?
A: In July 2006 FOX Systems published a document entitled "Decision Tree for Determination of Organizational NPI Subparts" containing information and recommendations for Type 2 organizations with regards to subparting.
6. What is the Workgroup for Electronic Data Interchange (WEDI)?
The Workgroup for Electronic Data Interchange (WEDI) is a health care industry group that has a formal consultative role under the HIPAA legislation. WEDI also sponsors SNIP. SNIP (Strategic National Implementation Process) is a WEDI program for helping the health care industry to identify and resolve HIPAA implementation issues. For more information, visit the WEDI Web site: www.wedi.org