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National Provider Identifier (NPI) FAQS


What is the National Provider Identifier (NPI)?

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?

Are any providers exempt from submitting claims using their NPI number?

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.

 

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

Please note: TRICARE network providers are required to submit their claims electronically; therefore, all network providers must submit claims with NPI numbers.

 

Is NPI required on paper transactions?

The NPI is required in electronic HIPAA transactions. However, the NPI mandate allows TRICARE the ability to require the use of the NPI on all transactions, including paper, to improve processing efficiency.

 

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.

 

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.

 

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).

 

How can providers an NPI number?

Providers can get an NPI number by contacting the NPI Enumerator or you can go to the Web and apply. The NPI Enumerator can be contacted by:

  • Call 1- 800-465-3203
  • Postal Mail: NPI Enumerator
                      PO Box 6059
                      Fargo, ND 58108-6059  

 

 

What happens if a doctorchanges 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.

 

How can I learn more about NPI?

To learn more about NPI from CMS, visit the  CMS Web site. To ask general questions about NPI, please call:

North Region Providers  1-877-334-2524

South Region Providers (800)-403-3950 -follow the options for Provider File Maintenance.

West Region Providers 1-877-988-9378

 

When are providers required to submit their claims with NPI?

All healthcare providers and clearinghouses are required to use the NPI in all HIPAA transactions by May 23, 2008.

 

Are any providers exempt from submitting claims using their NPI number?

Atypical and Foreign providers are exempt from submitting claims with an NPI number. Atypical providers are usually not health care providers, e.g., non-emergency transport van, adult day care provider, etc.  Atypical providers do not usually provide TRICARE benefits.  Foreign providers who are certified-authorized TRICARE providers are not required to obtain an NPI.

 

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.
  • Hospitals (nursing facilities, etc.): One NPI or some/all subparts may also need to have NPIs. Hospitals should obtain separate NPIs for each Medicare A number. (For example HHAs, hospice, emergency room, mental health, rehab, etc.)Obtain separate NPI for each unique reimbursement or contract methodology. (For example low volume psych, high volume psych, or teaching differential.)
  • 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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