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NPI 101

The National Provider Identifier. NPI 101. An Information Resource Tool Developed by BCBS Nebraska and the BCBS Association. What is the National Provider Identifier. A HIPAA–mandated National Standard A new 10-digit, intelligence-free ID for Health Care Providers

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NPI 101

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  1. The National Provider Identifier NPI 101 An Information Resource Tool Developed by BCBS Nebraska and the BCBS Association

  2. What is the National Provider Identifier • A HIPAA–mandated National Standard • A new 10-digit, intelligence-free ID for Health Care Providers • Issued by the Federal Government to Individual Providers as well as small and large provider organizations • One NPI per individual provider (Type 1); one or more NPIs to uniquely identify an organization provider (Type 2) and its subparts • Permanently assigned, and not expected to change • Required to be used in HIPAA transactions (e.g., claims submission, electronic remittance advice, eligibility and claim status) • National Compliance Date: May 23, 2007

  3. Who is Subject to Comply with the NPI • All Covered Entities are required to comply with the NPI regulations • “Covered Entities” include health plans clearinghouses, and health care providers that transmit administrative transactions electronically • All health care providers are eligible to obtain an NPI • Covered health care providers are required to obtain and use their NPIs

  4. Why is the NPI Needed • Eliminate all plan-specific provider identifiers used in processing health care transactions • All plan-specific identifiers on the transactions will be replaced by NPI (such as Medicare’s UPIN, Medicaid provider IDs, BCBS and other commercial legacy provider IDs) • Simplify provider billing • Facilitate conducting coordination of benefits • NPI does NOT replace the Tax-ID

  5. Why You Need to Act Now • NPI implementation is complex; it will directly affect processing of claims and payments to providers • The process for planning and transitioning to the new NPI involves several internal and external steps • Delaying or waiting can result in inadequate testing, payment delays, denials or incorrect allocation

  6. Actions You Need to Take:1. Assess NPI Needs and Obtain NPIs • Evaluate your NPI needs • Become educated on the NPI and the information available • Develop an enumeration strategy for individual and organizational Subpart NPIs • Determine how you should apply: Paper, Web-based, EFIO, etc. • Assess your internal systems and processes • Contact vendors, billing systems, clearinghouses • Identify changes required • Apply and Obtain your NPI(s) Important: Retain and safeguard official NPI Notification from NPPES and login/password created (via web), to access the NPI system in the future

  7. Subpart Trivia • A Subpart is a component of an organization provider that furnishes health care and is not, by itself, a legal entity • Examples of a subpart may include clinics, labs, pharmacies, home health or professional services departments • A subpart must obtain an NPI if they conduct their own standard transactions and may obtain an NPI even if they do not • A subpart cannot be a person and a person cannot have subparts • A subpart might have the same or different addresses, provide the same or different services, and conduct the same or different transactions as the ‘Parent’ organization • Subparts are needed so they can be uniquely identified in standard transactions • Not all organization providers have or need subparts • The organization providers are responsible for identifying, obtaining, and communication the subpart NPIs • Health plans are prohibited from requiring Providers to obtain subpart NPIs

  8. Actions You Need to Take:2. SHARE Your NPIs • Contact all entities that will need your NPI (e.g., Health plans, Clearinghouses, Referring Providers, Business Associates, Billing Services) • Identify methods to communicate your NPI (e.g., Within the HIPAA transactions, spreadsheets, web-based systems, fax, email) • Confirm that entities are ready to receive your NPI and include information necessary to match with internal provider identifier • Begin sharing your NPI with those entities

  9. Actions You Need to Take:3. Begin Using NPIs in Transactions • Check with health plans, clearinghouses when will they be ready to begin accepting NPI transactions • Start by sending your NPI along with the corresponding plan-specific ID in the same transactions (Dual Use Strategy) Remember:Communication will be the key to your NPI implementation success to ensure that your payments from Health Plans are not impacted

  10. Enumeration Statistics • As of November 13, 2006, the following number of Nebraska NPIs have been assigned by the enumerator as reported by CMS: • Individual (Type 1) Providers Assigned: 7,346 • Organization (Type 2) Providers Assigned: 2,408 • Total Providers Assigned: 9,754 • This does not indicate the number of NPIs that have been communicated to the health plans, only the number obtained by Providers • Over 1.4 million total NPIs have been assigned. Industry predictions range from 2.5 to 3.5 million total NPIs need to be assigned prior to May 23, 2007

  11. Remember… • The NPI is Yours: • NPI is assigned to the provider • Individual NPI doesn’t belong to a health plan or the employer where the individual works • The NPI is Unique: • It identifies a provider uniquely, regardless of where provider practices or the type of practice • The NPI will become the Only Identifier: • It will be the only provider identifier permitted to be used in HIPAA transactions (except for TaxID) • The NPI must be Shared: • Providers must share their NPI with other entities that need it in order to conduct business • The NPI will Not . . . • Eliminate or replace the Provider enrollment processes conducted by health plans • Guarantee reimbursement by any health plan • Necessary eliminate the health plan legacy provider numbers, only the use of those numbers for standard transactions • The NPI must be Used with All Payers: • Provider must use their NPIs with all payers for all HIPAA transactions

  12. NPI Resources • CMS Main NPI Website • http://www.cms.hhs.gov/NationalProvIdentStand/ • NPI Enumerator Website • https://nppes.cms.hhs.gov/NPPES/Welcome.do • Main site to enter an NPI application • WEDI NPI White Papers • http://www.wedi.org/snip/public/articles/dis_publicDisplay.cfm?docType=6&wptype=3 • WEDI NPI Outreach Initiative • http://www.wedi.org/npioi/index.shtml • Contact me • Tom Pusic • 402-398-3740 • tom.pusic@bcbsne.com

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