NPI numbers are a key component of the provider enrollment, credentialing, or contacting process with the payors. Let's first understand what they are and why you need them.
The Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandated the adoption of standard unique identifiers for health care providers and health plans. The purpose of these provisions is to improve the efficiency and effectiveness of the electronic transmission of health information. The Centers for Medicare & Medicaid Services (CMS) has developed the National Plan and Provider Enumeration System (NPPES) to assign these unique identifiers.
The NPI number can be obtained online through the National Plan and Provider Enumeration System (NPPES) website. Turnaround time for obtaining a number is usually very expeditious, which is normally unusual for a medical credentialing operation. NPI numbers can be searched on the CMS website listed in external links National Plan and Provider Enumeration System information from CMS.
Health practitioners need to have this number in order to receive reimbursement from insurance companies and to prescribe medicines. This is also needed to refer patients to other practitioners who particiapte with the health plans.
There are two types of NPI numbers. Type 1, which is for the individual provider and Type 2, which is a number for the organization or business.
As outlined in the Federal Regulation, The Health Insurance Portability and Accountability Act of 1996 (HIPAA), covered providers must also share their NPI with other providers, health plans, clearinghouses, and any entity that may need it for billing purposes.
All individual HIPAA covered healthcare providers (physicians, physician assistants, nurse practitioners, dentists, chiropractors, physical therapists, etc.) or organizations (hospitals, home health care agencies, nursing homes, residential treatment centers, group practices, laboratories, pharmacies, medical equipment companies, etc.) must obtain an NPI for use in all HIPAA standard transactions, even if a billing agency prepares the transaction. Once assigned, a provider's NPI is permanent and remains with the provider regardless of job or location changes.
Other health industry workers, such as admissions and medical billing personnel, housekeeping staff, and orderlies, who provide support services but not health care, are not required to obtain the NPI.
The NPI must be used in connection with the electronic transactions identified in HIPAA. In addition, the NPI may be used in several other ways:
For health care providers to identify themselves in health care transactions identified in HIPAA or on related correspondence;
For health care providers to identify other health care providers in health care transactions or on related correspondence;
For health care providers who do prescriptions (however, the NPI will not replace requirements for the Drug Enforcement Administration number or State license number);
For health plans in their internal provider files to process transactions and communicate with health care providers;
For health plans to coordinate benefits with other health plans;
For health care clearinghouses in their internal files to create and process standard transactions and to communicate with health care providers and health plans;
For electronic patient record systems to identify treating health care providers in patient medical records;
For the Department of Health and Human Services to cross reference health care providers in fraud and abuse files and other program integrity files;
For any other lawful activity requiring individual identification
If you need assistance in obtaining an NPI number for provider enrollment and credentialing, please click here contact our offices today!
Brian Agnew is President of Supero Healthcare Solutions a leading practice management company focused on provider enrollment and credentialing services for physicians and other healthcare providers.