National Provider Identifier (NPI) an Overview

1. National Provider Identifier(NPI) an Overview Janet Hill June 20, 2006

2. What is an NPI? • It is the new HIPAA regulated National Provider Identifier. • It will replace the current Horizon Legacy ID used in all HIPAA standard electronic transactions to identify a Health Care Professional. • It is a 10 position numeric data-element • Assigned by National Plan and Provider Enumeration System (NPPES) • It does not convey information about the provider or SUBPARTS it defines. -The 10th position on the right is a check digit based on Luhn Formula Algorithm 2

3. An NPI will not • Guarantee reimbursement by health plans • Enroll professionals in health plans • Make health care professionals covered entities • Require health care professionals to conduct electronic transactions • Replace Employer Identification Number (EIN) • Replace Social Security Number (SSN) • Replace State License Number 3

4. Who is an Entity Type 1 and who is an Entity Type 2 Provider? • A health care provider - individual human – must apply for an Entity Type 1 NPI. This includes, but is not limited to physicians, dentists and chiropractors • An organization, such as a hospital, must apply for an Entity Type 2 NPI. The definition of an organization includes, but is not limited to hospitals, residential treatment centers, laboratories, and group practices • Group -A business entity under which one or more individuals practice. A group does not require multiple professional providers. A single provider group is a valid group and would be identified by the business entity name, for instance - John Doe, PC. 4

5. What is Taxonomy • This is a 10 digit alphanumeric data element that indicates Specialty. • This data-element carries no identifying information about the Specialty. • A Type 1 Entity may have many Taxonomies for specialties. • A Type 2 Entity Will have a Taxonomy indicating Multi-Specialty. • The Taxonomy of the Type 1 Entity from within the multi specialty group will be used to indicate what Specialty was being performed . 5

6. Provider Communication Strategy • Develop and implement provider communication plans to support NPI awareness, identify NPI transition processes/schedules and set expectations in a proactive manner. • Meet with providers who have complex contracting frameworks to determine strategies that will meet both provider and health plan needs. • Coordinate with clearinghouses and direct connect providers • Take the lead in communicating with providers. • Provider bulletins, newsletters, websites, etc., will be used to educate about NPI, the health plan’s timeframe for accepting NPIs, and using the NPI. 6

7. Examples Option 1 Option 2 Current Numbering ABC HOSPITAL NPI Enumeration at Subpart Level NPI Enumeration at Facility Level TAX-ID 123456789 Medicare UPIN (legacy id) Acute Care - 320029 Skilled Nursing - 313025 Sub-Acute - 312025 Transactions submitted With TAX-ID 123456789 Unique NPI by Subpart Hospitals NPI 3012345670 -A unique NPI for each Subpart NPI 3123456780 or 3223456780 or 3323456780 or Transactions submitted with TAX ID - 123456789 NPI – 3012345670 Unique Taxonomy by Subpart Hospitals NPI 3012345670 -A unique Taxonomy for each Subpart 282N00000X 313M00000X 261QR0200X 7

8. Examples Option 1 Option 2 Current Numbering Dr. Smith NPI Enumeration at Location Level Taxonomy / Zip Code +4 TAX ID 234567891 Smith Pediatric PCPs 1st Street Legacy # 2345678910 JCODE - J1012 2ND Street Legacy # 234567891A JCODE - J1014 234567891 2222444466 Location 1 3333555566 Location 2 234567891 NPI = 22222444466 2080A0000X 07981-2000 2080A0000X 07981-2300 8

9. QUESTIONS? 9