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National Provider Identifier

National Provider Identifier. The NPI is the standard unique health identifier for health care providers Presented by: Sheri Botts, PMP DIRM Projects Office January 20, 2005. NPI: Important Dates. Final Rule published on January 23, 2004

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National Provider Identifier

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  1. National Provider Identifier The NPI is the standard unique health identifier for health care providers Presented by: Sheri Botts, PMP DIRM Projects Office January 20, 2005 NPI Overview

  2. NPI: Important Dates • Final Rule published on January 23, 2004 • Covered providers can begin applying for NPIs May 23, 2005 • Compliancedate applicable to DHHS is May 23, 2007 • By this date, covered entities must use only the NPI to identify providers in standard electronic transactions. NPI Overview

  3. NPI: What it will and will not do • It will: • Replace the use of all legacy provider identifiers (e.g., UPIN, Medicaid Provider Number, Medicare Provider Number, Blue Cross and Blue Shield Numbers) in standard transactions as of the compliance date • Simplify transactions, including claims and COB, and save money in the long term • It will not: • Guarantee reimbursement by health plans • Enroll providers in health plans • Make providers covered entities • Require providers to conduct electronic transactions NPI Overview

  4. NPI: What does it look like? • 10 positions (9 plus the check-digit) • All numeric • Never changes • May be deactivated/reactivated • Does not itself convey information about the provider • Compatible with health insurance card issuer standard NPI Overview

  5. NPI: Who can have an NPI? • Any “health care provider” (160.103) • Both covered and noncovered providers • Individuals: Physicians, dentists, nurses, chiropractors, others • Organizations: Hospitals, ambulatory care facilities, laboratories, HMOs, group practices, others • Subparts of providers • Non-health care providers not eligible NPI Overview

  6. NPI: Who is required to obtain and use NPIs? • Covered providers MUST obtain NPIs and must use them in standard transactions by the 5/23/07 compliance date • Health plans MUST use the NPIs of any health care provider or subpart to identify the health care provider or subpart in standard transactions by the 5/23/07 compliance date NPI Overview

  7. NPI: What is a “subpart”? • A provider is a legal entity • Subpart is not a legal entity but it furnishes health care (e.g., Hospital unit, member of chain) • Is designated as such by the covered organization provider • Concept does not necessarily correlate to hybrid entity, health care component, or organized health care arrangement • Concept does not apply to individuals NPI Overview

  8. NPI: Covered Providers and “Subparts” • Covered provider responsible for determining subpart’s need for NPI • If need exists, covered provider responsible for subpart obtaining NPI • Covered provider responsible for enumerated subpart’s compliance with Final Rule NPI Overview

  9. NPI: How does a provider obtain an NPI? • Provider completes application form to apply for NPI • Can file electronically (Internet) or on paper • Application is processed by NPS • NPS uses data on application to ensure unique identification of provider • NPS detects incomplete, illogical, and duplicate applications • Provider receives notification of NPI • If application processing detects a problem, Enumerator communicates with provider NPI Overview

  10. NPI: Ensuring Unique Identification of a Provider • Information collected on application for NPI used for assignment of NPI • Minimum information necessary for unique identification and communication • Different information for individuals and organizations • Information is categorized as one of the following: • Required • Situational • Optional NPI Overview

  11. NPI: Information about Individuals • Required:name, gender, address/telephone, Taxonomy Code(s), date of birth, state/country of birth, contact person’s name/telephone • Situational:license number(s)/state(s) (required for certain Taxonomy Codes) • Optional:SSN/ITIN, name prefix/suffix, other name(s), credential(s), other identifiers NPI Overview

  12. NPI: Information about Organizations • Required:name, address/telephone, Taxonomy Code, authorized official’s name/telephone, contact person’s name/telephone • Situational:EIN (required if provider has one), license number(s)/state(s) (required for certain Taxonomy Codes) • Optional:other name(s), other identifiers NPI Overview

  13. NPI: The National Provider System (NPS) • Developed under contract with HHS • Will process NPI applications and assign NPIs • Will store information about enumerated providers and apply providers’ updates • Will generate reports and statistics • System of Records Notice (July 28, 1998) NPI Overview

  14. NPI: The Enumerator • Will operate under one HHS contract • Will receive applications and updates • Will resolve errors, help with problems, and answer questions • Will handle data requests • Will utilize the NPS NPI Overview

  15. NPI: Enumerating Existing Providers • Providers do not have to take any action at this time • May 23, 2005: Covered providers may begin applying for NPIs • Extremely heavy initial demand • Covered providers must begin using NPIs in standard transactions within 2 years (by May 23, 2007) • Does not replace enrollment process NPI Overview

  16. NPI: Enumerating Existing Providers (cont.) • Noncovered providers may apply for NPIs • Being assigned NPIs does not make providers covered entities • There is no requirement for noncovered providers to obtain or use NPIs • NPIs can be used on paper transactions NPI Overview

  17. NPI: Disseminating Data • 3 levels of users: • 1-HHS/enumerator • 2-Health industry • 3-The public • NPS System of Records Notice • Protect confidentiality of data • Heavy initial demand for data • Strategy to be published NPI Overview

  18. NPI: Covered Provider Requirements • Obtain an NPI for itself and/or subpart(s) • Use NPI to identify the provider on standard transactions • Disclose its NPI when requested • Furnish updates to NPS (30 days) • Require BAs to use all NPIs appropriately • Comply with requirements for subpart(s) NPIs NPI Overview

  19. NPI: Requirements for Health Plans & Clearinghouses • Health plans: • must use NPIs to identify providers on standard transactions and • may not require enumerated providers to obtain additional NPIs • Health care clearinghouses must use NPIs to identify providers on standard transactions NPI Overview

  20. NPI: What should covered entities be doing at this time? • Become informed about the NPI and its implementation • Identify processes/systems that are affected by provider identifiers • Develop implementation plans (internal, external with trading partners and others) • Educate staff NPI Overview

  21. NPI: Its Effect on Providers • Provides the ability to bill all health plans uniformly - no longer necessary to use different identifiers for different health plans, contracts, locations • Billing will be simplified • COB payments will come sooner NPI Overview

  22. NPI: Its Effect on Individual Providers • Individuals are assigned only one NPI • “Incorporated” individual = an organization • Organization and individual eligible for NPIs • The single NPI identifies the individual no matter where the services are rendered • Individuals cannot be considered “subparts” NPI Overview

  23. NPI: Its Effect on Health Plans • No need to use or maintain existing provider enumeration systems • Will still need to use health plan enrollment process • Will need to collect enrollment data • Memberships in groups • Multiple practice locations • Will need to validate enrollment data • COB will be simplified • UR will be facilitated NPI Overview

  24. NPI: Some Things To Keep in Mind • Health plans will continue their provider enrollment processes • Health plans cannot require an enumerated health care provider or subpart to obtain an additional NPI • Health plans are not prohibited from requiring their enrolled providers to obtain/use NPIs (if eligible) NPI Overview

  25. NPI: Its Effect on X12 IGs • NPI must be used as the provider’s Primary--and only--Identifier • Legacy identifiers (secondary identifiers) cannot be used after 5/23/07 • EIN (issued by IRS) may be used for tax purposes per the IGs (Pay-to, Billing Providers) • Final Rule does not require NPI to replace ETINs NPI Overview

  26. NPI: X12N 837 IG Data Elements Impacted by NPI • Billing Provider ID • Pay-to Provider ID • Rendering (Attending) Provider ID • Referring Provider ID • Supervising Provider ID • Purchasing Provider ID • Service Location ID NPI Overview

  27. NPI: Sources of Information • www.cms.hhs.gov/hipaa/hipaa2 • Overview of NPRM • Analysis of public comments • Link to Final Rule • Frequently Asked Questions • HIPAA Roundtables • Professional organizations NPI Overview

  28. Questions / Discussion NPI Overview

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