National Provider Identifier (NPI)

Frequently asked questions

General NPI information

What is a National Provider Identifier (NPI)?

Is a health care provider required to obtain an NPI?

Why do health care providers need NPIs?

How can health care providers obtain an NPI?

How many NPIs do health care providers need?

What is my Primary Provider Taxonomy Code?

How long will it take to receive an NPI?

How can health care providers report NPIs to Independence Blue Cross (IBC)?

Where can I obtain additional information on the National Provider Identifier?

Enumeration

How do I enumerate?

Claims/Billing

What are the significant dates associated with applying for and using an NPIs on electronic and paper claims?

Where are the IBC billing instructions and companion guides?

What happens if a claim comes in without an NPI?

Will IBC allow providers to bill legacy and/or NPI after May 23, 2008?

Will IBC require NPIs on paper claims after May 23, 2008?

Will IBC require Tax ID in addition to NPI on paper claims?

If IBC is requiring NPI for all provider fields, will claims be denied/rejected if the NPI is not provided for ordering and/or referring providers? Some of these providers may not have an NPI, and others we may not be able to obtain.

Is IBC planning on requiring a nine-digit zip code on the claim form?

If providers choose to enumerate their subparts further than they currently have today with payer legacy numbers, will IBC require enrollment of their additional subparts?

Payer Readiness

Does IBC currently require different NPIs when there are different provider numbers?

When will IBC start processing standard transactions with NPIs?

How can hospitals notify IBC of their NPIs?

Does IBC plan to validate [meet CMS NPI formula] and verify [Dr. Smith’s NPI is truly Dr. Smith’s] provider NPI?

What happens in IBC’s system if an invalid NPI is received in any provider field?

Does IBC plan to give providers access to their NPI(s) in provider directories?

Are NPIs required when using the interactive voice response (IVR) system?

General NPI information

What is a National Provider Identifier (NPI)?
An NPI is a unique, ten-digit, intelligence-free, numeric identifier. Intelligence-free means that the numbers do not carry information about health care providers, such as the state in which they practice, their provider type, or their specialization.

NPIs replace health care provider identifiers used for standard transactions under the Health Insurance Portability and Accountability Act (HIPAA). Those numbers included payer-specific IDs and Medicare legacy IDs (e.g., UPIN, OSCAR, PIN, and National Supplier Clearinghouse).

A provider’s NPI will not change. It will remain with the provider regardless of job or location change(s).

Is a health care provider required to obtain an NPI?
Yes. Under the National Provider Identifier Regulation (published in the Federal Register on January 23, 2004), a health care provider who is a covered entity, as defined in 45 C.F.R. § 160.103, and who transmits any health information in connection with a HIPPA standard transaction in electronic form, is required to obtain an NPI.

Why do health care providers need NPIs?
HIPAA requires the adoption of a standard unique identifier for health care providers.

NPIs allow for simpler electronic transmission of HIPAA standard transactions.

After May 23, 2008, the NPI will be the only health care provider identifier that can be used for identification purposes in standard transactions by covered entities. Covered entities include health plans, health care clearinghouses, and those health care providers who transmit any health information in electronic form in connection with a transaction for which the Secretary of Health and Human Services has adopted a standard.

NPIs are being used to identify health care providers on prescriptions and in internal files to link proprietary provider identification numbers and other information, coordination of benefits between health plans, patient medical record systems, program integrity files, and other ways as well.

How can health care providers obtain an NPI?
Providers who have not yet obtained their NPI may apply in one of the following ways:

• through an easy, web-based application process that takes approximately 20 minutes to complete online;
• by calling the National Provider Identifier enumerator call center at 1-800-465-3203 to request a paper application;
• through an electronic file submitted by an organization. You must have the permission of the health care provider to apply for an NPI by using this method.

How many NPIs do health care providers need?
An individual is eligible for a single NPI. An individual cannot have subparts and cannot designate subparts. In terms of NPI assignment, an individual is an Entity Type 1.

A sole proprietor/sole proprietorship is eligible for a single NPI. A sole proprietor/sole proprietorship cannot have subparts and cannot designate subparts. In terms of NPI assignment, a sole proprietor/sole proprietorship is an Entity Type 1 (Individual).

Organizations must also apply for a single NPI. In terms of NPI assignment, organization health care providers who are covered entities under HIPAA must apply for NPIs as Entity Type 2 (organization). Organization health care providers are corporations/partnerships or other types of businesses that are considered separate from an individual by the state in which they exist. Subparts of such organization health care providers who apply for NPIs are also Entity Type 2.

• A subpart must have its own NPI if it conducts any of the HIPAA standard transactions separately from the covered organization health care provider of which it is a part. If your organization has subparts, please ensure that they have their own NPIs.
• Example: A hospital owns ten home health agencies that all operate under the Tax Identification Number of the hospital. Because the hospital and each of the ten home health agencies is separately surveyed and enters into its own provider agreement with Medicare, 11 different NPIs should be obtained in total — one by the hospital and one by each of the ten home health agencies.
• For further clarification regarding entity types and subparts click here, or visit the Centers for Medicare & Medicaid Services website.

What is my Primary Provider Taxonomy Code?
The Provider Taxonomy is an alphanumeric code, ten characters in length, that allows a single provider (individual, group, or institution) to identify its specialty category. Information on Provider Taxonomy Codes is available through the Washington Publishing Company.

How long will it take to receive an NPI?
The Centers for Medicare & Medicaid Services (CMS) cannot predict the amount of time it will take to obtain an NPI. There are several reasons for that. Such factors CMS considers include:

• volume of applications being processed at a given time;
• whether the application is submitted electronically or on paper;
• whether the application is complete and free of errors. When gathering information for the application, be sure that all provider information, such as social security number and federal employer identification number, are correct.

CMS estimates that, in general, a health care provider who submits a properly completed, electronic application could have an NPI within ten days.

How can health care providers report NPIs to Independence Blue Cross (IBC)?
Registering your NPI with IBC is easy. Once you have obtained your NPI(s), you may register online using our NPI Provider Registration web form. All providers (participating and nonparticipating) may register using the appropriate online form.

Participating providers may also register their NPI(s) with us by mailing their completed custom NPI submission form. This form has been included in mailings to participating provider offices.

Contact your Network Coordinator with questions regarding the new Provider Registration web form or your custom NPI submission form.

Where can I obtain additional information on the National Provider Identifier?
The Centers for Medicare & Medicaid Services website is an excellent resource for detailed information on the National Provider Identifier.

Enumeration

How do I enumerate?
While keeping NPI enumeration requirements in mind, IBC strongly encourages providers to enumerate with NPIs in the same configuration as they are now enumerated with IBC using Corporate Provider IDs.

Claims/Billing

What are the significant dates associated with applying for and using an NPI on electronic and paper claims?

Electronic Claims

837(I) and 837(P) Electronic Claim Forms:

IBC began accepting NPIs along with your legacy IDs on January 1, 2007. Beginning May 23, 2008, IBC will only accept your claims using your NPI(s).

CMS-1500, UB-04, UB-92 Paper Claim Forms:

The professional and institutional paper claim forms (CMS-1500 and UB-92) have been revised to allow NPIs to be included. As of April 2007, CMS requires all health care providers to obtain and use their NPIs, regardless of the submission method.

IBC no longer accepts paper claims submitted on forms CMS-1500 (12/90) and UB-92. All paper claims must be submitted on revised forms CMS-1500 (08/05) and UB-04. Paper claims submitted on forms CMS-1500 (12/90) and UB-92 will reject.

Where are the IBC billing instructions and companion guides?
Billing information can be found in our NPI toolkit as well as in our companion guides. Additional information can be found in issues of Partners in Health Update as well as in the current Provider Manual for Professional Providers (10/07).

What happens if a claim comes in without an NPI?
As of May 23, 2008, an NPI is required by HIPAA regulations. If a claim is submitted without a valid, registered NPI, the claim will reject.

Will IBC allow providers to bill legacy and/or NPI after May 23, 2008?
As of May 23, 2008, in accordance with the CMS mandate, providers must use the NPI as the primary identifier on the claim, and IBC will reject claims with invalid NPIs on or after this date.

For purposes of processing a claim in accordance with the reimbursement terms of your IBC provider contract, you may continue to provide your ten-digit legacy ID number in addition to your valid, registered NPI. The sole purpose for providing the ten-digit legacy ID number is to facilitate accurate claims payment — not to identify the claim for acceptance into IBC’s system. Only a valid NPI will be accepted by IBC as the primary identifier on the claim.

Will IBC require NPIs on paper claims after May 23, 2008?
Yes, beginning May 23, 2008, paper claims must be submitted with an NPI as the primary identifier.

Will IBC require Tax ID in addition to NPI on paper claims?
Yes. Tax ID is required for all claims.

If IBC is requiring NPI on all provider fields, will claims be denied/rejected if an NPI is not provided for ordering and/or referring providers? Some of these providers may not have an NPI, and others we may not be able to obtain.
IBC requires NPI identifiers in the following four provider fields:

1. Billing provider
2. Rendering provider
3. Service Facility provider
4. Referring provider

Is IBC planning on requiring a nine-digit zip code on the claim form?
The nine-digit zip code is currently not required.

If providers choose to enumerate their subparts further than they currently have today with payer legacy ID numbers, will IBC require enrollment of their additional subparts?
No, IBC will not require enrollment of all subparts. However, IBC will not accept health care transactions using these NPIs if they are not registered with IBC.

Payer Readiness

Does IBC require different NPIs when there are currently different provider numbers?
While keeping NPI enumeration requirements in mind, IBC strongly encourages providers to enumerate with NPIs in the same configuration in which they are now enumerated with IBC using corporate provider IDs. Otherwise, issues may occur with your claim payments and internal business and reporting procedures. IBC recommends that you take a close look at your current provider number configuration and plan wisely when obtaining your NPI(s).

When will IBC start processing standard transactions with NPIs?
IBC began accepting claims submitted with NPIs on January 1, 2007.

How can hospitals notify IBC of their NPIs?
Registering your NPI(s) with IBC is easy. Once you have obtained your NPI(s), you may register online using our NPI Provider Registration web form. All providers (participating and nonparticipating) may register using the appropriate online form.

Contact your Network Coordinator with questions regarding the new Provider Registration Web Form.

Does IBC plan to validate [meet CMS NPI formula] and verify [Dr. Smith’s NPI is truly Dr. Smith’s] provider NPI(s)?
IBC validates provider NPIs through the NPPES database provided by CMS. However, unless we are 100 percent sure of a provider match, we will not enter that NPI into our systems. Therefore, it is important to submit your NPI(s) to IBC so that your NPI(s) can be registered.

What happens in IBC’s system if an invalid NPI is received in any provider field?
Each claim must pass an NPI check-digit validation to ensure that it has a valid NPI. To date, many claims are not passing this check-digit validation. The most common reasons why claims are not passing the NPI check-digit validation are:

• the wrong provider identifier is entered in an NPI field;
• the NPI is entered incorrectly;
• the number entered is not a valid NPI.

Does IBC plan to give providers access to NPIs in provider directories?
IBC does not currently plan to publish provider’s NPIs in its provider directory.

Are NPIs required when using the interactive voice response (IVR) system?
Because the IVR system is not covered under the CMS mandate, providers are permitted to submit either an NPI or ten-digit legacy ID number.

Important information about links to other sites