What is the National Provider Identifier (NPI)?

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandated that the Secretary of Health and Human Services adopt a standard unique health identifier for health care providers. On January 23, 2004, the Secretary published a Final Rule that adopted the National Provider Identifier (NPI) as this identifier. 

The NPI is a 10-position numeric identifier which contains no embedded intelligence; that is, it contains no information about the health care provider such as the type of health care provider or State where the health care provider is located. There is a Type 1 or individual NPI and a Type 2 or Organizational NPI.


What is the purpose of the NPI? Who must use it, and when?

Today, health plans assign identification numbers to health care providers -- individuals, groups, or organizations that provide medical or other health services or supplies. This means that providers who do business with multiple health plans often have multiple identification numbers. The NPI is a unique identification number for health care providers that will be used by all health plans. Health care providers and all health plans and health care clearinghouses will use the NPIs in the administrative and financial transactions specified by HIPAA.

The National Provider Identifier (NPI) will uniquely identify a health care provider in standard transactions, such as health care claims. NPIs may also be used to identify health care providers on prescriptions, in internal files to link proprietary provider identification numbers and other information, in coordination of benefits between health plans, in patient medical record systems, and in other ways. HIPAA requires that covered entities (i.e., 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) use NPIs in standard transactions by the compliance dates.


What are the compliance dates for NPI?

The compliance date for all covered entities except small health plans is May 23, 2007; the compliance date for small health plans is May 23, 2008. As of the compliance dates, the NPI will be the only health care provider identifier that can be used for identification purposes in standard transactions by covered entities.


Who is eligible to receive an NPI?

All health care providers, defined under the regulation to include dentists, are ELIGIBLE to obtain an NPI.


Is a health care provider required to obtain an NPI?

A health care provider who is a covered entity, as defined at 45 C.F.R. § 160.103, is REQUIRED to obtain a National Provider Identifier (NPI) by May 23, 2007.


Can I apply for and use an NPI even if I am not required to obtain and use and NPI under HIPAA?

Yes.


Should I apply for an NPI even if I am not required to use one under HIPAA

YES! DenteMax is strongly encouraging all of our participating providers to apply for and then provide us with a copy of their NPI. While CMS, under HIPAA, is only requiring that NPI be used by covered entities for electronic transactions, CMS has left it up to each health plan to decide if it wants to require NPI for all transactions including paper claims. There will be some health plans that require NPI be used for all transactions and therefore, obtaining an NPI now will ensure you are ready for this when it happens. Additionally, there may be some states which require all transactions to use NPI.


How will a health care provider obtain an NPI?

A health care provider will obtain a National Provider Identifier (NPI) by submitting an application for an NPI to the NPI Enumerator, selected by CMS. Applications may be submitted by mail or electronically via the enumerator’s website. Please see the section of site called NPI Links to access the enumerator’s website.


When can a health care provider apply for an NPI?

Health care providers could apply for National Provider Identifiers (NPIs) beginning on the effective date of the final rule, which was May 23, 2005.


How long will it take to get an NPI?

While there is no guarantee, according to the NPPES, electronic submission may take 1 to 5 business days while submission by mail may take up to 20 days for processing.


Who is the enumerator and what does the enumerator do?

Fox Systems, Inc. has been selected as the enumerator for NPI. The enumerator carries out a number of functions, which include entering identifying information about a health care provider into the system, performing data validation (for example, confirming the State license number), notifying a health care provider of its NPI, and updating information about a health care provider when notified by the health care provider that an update is necessary.


What does NPPES stand for?

National Plan and Provider Enumeration System.


Will a health care provider have to pay for an NPI?

No.


Will a health care provider continue to use other numbers besides the NPI
to identify itself in standard transactions after the compliance date?

Upon the compliance dates, only the National Provider Identifier (NPI) may be used for identification purposes for a health care provider in standard transactions; legacy identifiers (such as the Unique Physician Identification Number (UPIN), Medicaid Provider Number, Medicare Provider Number, and others) may not be used. Where a health care provider must be identified in standard transactions for tax purposes, it would use its Taxpayer Identifying Number (TIN) as required by the implementation specifications. Health care provider identification numbers other than the NPI may continue to be used in the internal processes and files of health plans or health care clearinghouses if they wish to continue to use those identification numbers in those internal processes and files.


Will a health care provider’s NPI ever change?

The National Provider Identifier (NPI) is meant to be a lifetime identifier and would not change based on changes in a health care provider’s name, address, ownership, membership in health plans, or Healthcare Provider Taxonomy classification. There may be situations where use of an NPI for fraudulent purposes results in a health care provider requesting a different NPI; such situations will be investigated and a different NPI may be assigned to the requesting health care provider.

Note: If you work for a large group practice, the practice may apply for a Type 2 or organizational NPI. If your organization does obtain a Type 2 or organizational NPI, DenteMax will request that both your Type 1 or individual AND your Type 2 or organizational NPI be submitted to us.


How will I know to begin using my NPI?

Each health plan will be required to notify you when they are ready to begin accepting NPI. Additionally, as we are given updates by our client partners, we will post them on this website and will include information in our quarterly provider newsletter, The DenteMax Digest.

Again, applying for your NPI now and submitting your NPI information to DenteMax now will ensure you are ready when the health plans are.


How do I submit my NPI information to DenteMax?

Please submit your NPI information to DenteMax as soon as you receive it. This will ensure that once our administrative partners begin to use NPI, your claims will be processed correctly.

To submit your NPI information to DenteMax, click on Submit NPI Now to complete the submission form. Once your form is received at DenteMax, you will be contacted by a member of our provider relations staff. We will then ask you to provide a copy of your official notification from the NPPES to keep on file.