National Provider Identifier

General Information

NPI: Get It. Share It. Use It.

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Presented By…

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This presentation was current at the time it was printed or downloaded. This presentation was prepared as a tool to assist providers and is not

intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the

information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance

advice lies with the provider of services.

The Centers for Medicare & Medicaid Services (CMS) employees, agents, and staff make no representation, warranty, or guarantee that

this compilation of information is error-free and will bear no responsibility or liability for the results or consequences of the use

of this presentation. This publication is a general summary that explains certain aspects of NPI implementation, but is not a legal document.

Disclaimers

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Disclaimers

The Medicare Learning Network (MLN) is the brand name for official CMS educational products and information for

Medicare fee-for-service providers. For additional information visit the Medicare Learning Network's web page at

www.cms.hhs.gov/MLNGenInfoon the CMS website.

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NPI Background• CMS developed the National Plan

and Provider Enumeration System (NPPES) on authority delegated by the Secretary of HHS

• The NPI is a Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification Standard

• The NPI Enumerator assists providers in applying for NPIs and resolves problems with NPI applications

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Purpose of the NPI

Simplify Billing

Single ID replaces multiple legacy provider identifiers

Speed up COB Payments

National Provider Identifier

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Facts About NPI

• Required for all providers (individuals and organizations)

who are “covered providers” under HIPAA

• Permanent and is not expected to change

• Organizations may obtain NPIs for subparts

• One NPI will be assigned per provider or provider subpart

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Facts About NPI

• 10 position numeric identifier

• Intelligence-free

• Check-digit in last position

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NPI Timeline

January 23, 2004NPI Final Rule published

2004 2007 2008

May 23, 2007All HIPAA covered entities, except small health plans, must use NPIs by May 23, 2007

May 23, 2008Small health plans must use NPIs by May 23, 2008

1996

July 21, 1996HIPAA signed in to law

2005

May 23, 2005Health care providers began applying for NPIs

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Affected Entities

Health Care Providers

Health C

are

Clearinghouses

Hea

lth

Plan

s

NPI

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Health Care Providers

• Health care providers do not need to be “covered entities” to apply for NPIs

• Entities that never render “health care” are not eligible for NPIs

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Subparts and NPIs

• Subparts may need to be uniquely identified in standard transactions

• If subparts conduct their own standard transactions, they must obtain NPIs

• Not all organization providers have subparts

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The NPI Enumerator:Processes paper NPI Application/Update Forms (CMS – 10114) Provides NPI application forms to providers upon requestMaintains a call center to assist providers withquestions or problems regarding the processing of their application or NPI updatesHandles error resolution including resolving pending applicationsProcesses deactivation requests

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The National Plan and Provider Enumeration System (NPPES):

Sets up and maintains records

Creates reports and output files

Enumerates providers and health plans

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Applying for an NPI

Electronic File Interchange (EFI) – With the permission of the health care provider, an organization may submit multiple health careproviders’ applications in an electronic file

2.2.

3.3.

Three ways to apply. Choose only one:Apply through a web-based application process at https://nppes.cms.hhs.gov

Call the NPI Enumerator and request a blank application form at 1-800-465-3203 or TTY 1-800-692-2326

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NPI Assignment

All applications go to National Plan and Provider Enumeration System (NPPES)

Data on applications is used to ensure uniqueness

NPI Enumerator resolves problem applications

Applications are rejected if provider or subpart already has an NPI or approved if an NPI has not been assigned and the application is complete and accepted

Notifies provider of the NPI

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NPI Notifications

Keep NPI notification in a safe place

Share copies of your NPI notification with those who need it

NPPES

Provider

NPPES notifies Contact Person of NPI assignment

Contact Person shares NPI notification with provider

Contact Person

Contact Person

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When to Change NPI DataUpdate your NPI data in the NPPES when you have a change to your:

Name

Address

LicensingOr any other data furnished in your application (except SSN)

Notify the NPPES of changes to NPI data within 30 calendar days.

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How to Change NPI Data

Three ways to change data. Choose only one:

Over the web https://nppes.cms.hhs.gov

Paper NPI Application/Update Form (CMS-10114) and mail to the NPI Enumerator. Request a form by calling1-800-465-3203 or TTY 1-800-692-2326.

EFIO, with your permission

Regardless of how you applied, you can make changes over the web.

1.1.

2.2.

3.3.

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Deactivating NPIs

•Provider retires, goes out of business, dies, or evidence of fraud exists

•Must use paper NPI Application/Update Form (CMS-10114)

•NPI deactivation is not the same as disenrollment by a health plan, sanction, or revocation

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NPPESThe NPPES will not:

Link subparts to the covered

organization provider

Capture memberships in groups

Capture multiple practice location

addresses

Know whether or not a health care

provider is a covered entity

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NPIHaving an NPI will not:Eliminate or replace the providerenrollment processes of health plansGuarantee reimbursement by health plansConvey covered entity statusAssure licensure or credentialsRequire a health care provider or a subpart to conduct standard transactions

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Health Plans

• Health plans:– Will need to know subpart designations

and NPIs– Must develop links or crosswalks of

legacy identifiers and NPIs– Are not prohibited from requiring their

enrolled health care providers to obtain and use NPIs (in accordance with the Final Rule)

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CMS Roles

• Establishes regulatory policy• Manages activities delegated by the

Secretary for HIPAA (regulations, enumeration, enforcement)

• NPI implementation within Medicare • Provides guidance / outreach

materials to the industry• Oversees NPI implementation by the

Medicaid State agencies

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Provider Implementation

Check for collaborative organizations

Watch for instructions

Review laws and regulations

Share

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CMS Resources

• CMS NPI web pagewww.cms.hhs.gov/NationalProvIdentStand/– Fact Sheets– Frequently Asked Questions (FAQs)

• NPI Final Rule www.cms.hhs.gov/NationalProvIdentStand/Downloads/NPIfinalrule.pdf

• CMS Medicare Learning Network (MLN) www.cms.hhs.gov/MLNGenInfo/

• NPI Viewletwww.cms.hhs.gov/apps/npi/npiviewlet.asp

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NPI Enumerator• For questions from health care providers about

NPI applications, updates, and deactivations– Phone:

• 1-800-465-3203• 1-800-692-2326 (TTY)

– E-mail:• Customerservice@npienumerator.com

– Mail:NPI Enumerator

P.O. Box 6059

Fargo, ND 58108-6059

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Frequently Asked Questions

Question: After the compliance date for the NPI, can a

covered health care provider continue to use other numbers, such as legacy or proprietary identifiers, in addition to its NPI to identify itself as a health care provider in standard transactions?

Answer: No. After May 23, 2007 for standard transactions

to or from large health plans and clearinghouses, and after May 23, 2008 for standard transactions to or from small health plans, a covered health care provider may use only its NPI to identify itself as a healthcare provider.

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Frequently Asked Questions

Question: Does my NPI replace my Tax Identification Number (TIN)?

Answer: No. The NPI does not replace the TIN

when the TIN is required to identify the health care provider as a taxpayer. A TIN that is used to identify a health care provider as a health care provider is replaced by the NPI.

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Frequently Asked Questions

Question: How long will it take to get an NPI?

Answer: The amount of time it will take to obtain a National

Provider Identifier (NPI) cannot be predicted. It is dependent on the quality of the application, SSN verification (for an individual), and uniqueness. Providers should follow up with the Enumerator if no NPI is communicated in 15 days.

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Frequently Asked Questions

Question:

Is there a cost for getting an NPI?

Answer:No. Getting an NPI is absolutely free, there is no charge to get an NPI.

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Other Questions?

Getting an NPI is free – not having one can be costly.