NPI frequently asked questions
General information
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).
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 HIPAA standard transaction in electronic form, is required to obtain an NPI.
HIPAA requires the adoption of a standard unique identifier for health care providers.
NPIs allow for simpler electronic transmission of HIPAA standard transactions.
The NPI is 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.
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 NPI 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.
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, visit the Centers for Medicare & Medicaid Services website.
Registering your NPI with Independence is easy. Once you have obtained your NPI, you may register online by completing and submitting one of our NPI Provider Registration Forms.
Different online registration forms are available for all types of providers (participating and nonparticipating).
Contact your network coordinator with questions regarding the online provider registration forms.
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.
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.
Registering your NPI with Independence is easy. Once you have obtained your NPIs, 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 NPIs 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.
The Centers for Medicare & Medicaid Services website is an excellent resource for detailed information on the NPI.
Enumeration
While keeping NPI enumeration requirements in mind, Independence strongly encourages providers to enumerate with NPIs in the same configuration as they are now enumerated with Independence using Corporate Provider IDs.
Claims/billing
Billing information can be found in our claims submission toolkit for proper electronic and paper claims submissions as well as in our companion guides. Additional information can be found in our online newsletter, Partners in Health UpdateSM, as well as in the current Provider Manual for Participating Professional Providers.
An NPI is required by HIPAA regulations. If a claim is submitted without a valid, registered NPI, the claim will reject.
In accordance with the CMS mandate, providers must use the NPI as the primary identifier on the claim, and Independence will reject claims with invalid NPIs.
For purposes of processing a claim, you must submit your registered NPI. In accordance with the reimbursement terms of your provider contract, you may continue to provide your 10-digit legacy number. Only a valid NPI will be accepted by us as the primary identifier on the claim.
Yes. Paper claims must be submitted with an NPI as the primary identifier.
Yes. Tax ID is required for all claims.
Some of these providers may not have an NPI, and others we may not be able to obtain. Independence requires NPI identifiers in the following four provider fields:
- Billing provider
- Rendering provider
- Service facility provider
- Referring provider
The nine-digit ZIP code is currently not required.
No, Independence will not require enrollment of all subparts. However, Independence will not accept health care transactions using these NPIs if they are not registered with Independence.
Payer readiness
While keeping NPI enumeration requirements in mind, Independence strongly encourages providers to enumerate with NPIs in the same configuration in which they are now enumerated with Independence using corporate provider IDs. Otherwise, issues may occur with your claim payments and internal business and reporting procedures. Independence recommends that you take a close look at your current provider number configuration and plan wisely when obtaining your NPIs.
Registering your NPIs with Independence is easy. Once you have obtained your NPIs, 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.
Independence 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 NPIs to Independence so that your NPIs can be registered.
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.
Independence does not currently plan to publish provider’s NPIs in its provider directory.
Because the IVR system is not covered under the CMS mandate, providers are permitted to use either an NPI or 10-digit legacy ID number and tax ID to access the IVR.
