The National Provider Identifier

NPI 101 NPI 101

An Information Resource Tool Developed by BCBS Nebraska and the BCBS Association

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What is the National Provider IdentifierWhat is the National Provider Identifier

• A HIPAA–mandated National Standard

• A new 10-digit, intelligence-free ID for Health Care Providers

• Issued by the Federal Government to Individual Providers as well as

small and large provider organizations

• One NPI per individual provider (Type 1); one or more NPIs to uniquely

identify an organization provider (Type 2) and its subparts

• Permanently assigned, and not expected to change

• Required to be used in HIPAA transactions (e.g.,

claims submission, electronic remittance advice, eligibility and claim

status)

• National Compliance Date: May 23, 2007

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Who is Subject to Comply with the NPI Who is Subject to Comply with the NPI

• All Covered Entities are required to comply with the NPI regulations– “Covered Entities” include health plans clearinghouses,

and health care providers that transmit administrative transactions electronically

• All health care providers are eligible to obtain an NPI

• Covered health care providers are required to obtain and use their NPIs

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Why is the NPI NeededWhy is the NPI Needed

• Eliminate all plan-specific provider identifiers used in

processing health care transactions

– All plan-specific identifiers on the transactions will be replaced by NPI

(such as Medicare’s UPIN, Medicaid provider IDs, BCBS and other

commercial legacy provider IDs)

• Simplify provider billing

• Facilitate conducting coordination of benefits

• NPI does NOT replace the Tax-ID

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Why You Need to Act NowWhy You Need to Act Now

• NPI implementation is complex; it will directly affect

processing of claims and payments to providers

• The process for planning and transitioning to the new NPI

involves several internal and external steps

• Delaying or waiting can result in inadequate testing,

payment delays, denials or incorrect allocation

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Actions You Need to Take:Actions You Need to Take:1. Assess NPI Needs and Obtain NPIs1. Assess NPI Needs and Obtain NPIs

• Evaluate your NPI needs• Become educated on the NPI and the information available• Develop an enumeration strategy for individual and

organizational Subpart NPIs• Determine how you should apply: Paper, Web-based, EFIO, etc.

• Assess your internal systems and processes• Contact vendors, billing systems, clearinghouses• Identify changes required

• Apply and Obtain your NPI(s)

Important: Retain and safeguard official NPI Notification from NPPES and login/password created (via web), to access the

NPI system in the future

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Subpart TriviaSubpart Trivia• A Subpart is a component of an organization provider that furnishes health care

and is not, by itself, a legal entity

• Examples of a subpart may include clinics, labs, pharmacies, home health or professional services departments

• A subpart must obtain an NPI if they conduct their own standard transactions and may obtain an NPI even if they do not

• A subpart cannot be a person and a person cannot have subparts

• A subpart might have the same or different addresses, provide the same or different services, and conduct the same or different transactions as the ‘Parent’ organization

• Subparts are needed so they can be uniquely identified in standard transactions

• Not all organization providers have or need subparts

• The organization providers are responsible for identifying, obtaining, and communication the subpart NPIs

• Health plans are prohibited from requiring Providers to obtain subpart NPIs

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• Contact all entities that will need your NPI (e.g., Health plans,

Clearinghouses, Referring Providers, Business Associates, Billing

Services)

• Identify methods to communicate your NPI (e.g., Within the HIPAA

transactions, spreadsheets, web-based systems, fax, email)

• Confirm that entities are ready to receive your NPI and include

information necessary to match with internal provider identifier

• Begin sharing your NPI with those entities

Actions You Need to Take:Actions You Need to Take:2. 2. SSHAREHARE Your NPIs Your NPIs

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• Check with health plans, clearinghouses when will they be ready to begin accepting NPI transactions

• Start by sending your NPI along with the corresponding plan-specific ID in the same transactions (Dual Use Strategy)

Actions You Need to Take:Actions You Need to Take:3. Begin Using NPIs in Transactions3. Begin Using NPIs in Transactions

Remember: Communication will be the key to your NPI implementation success to ensure that your payments from

Health Plans are not impacted

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Enumeration StatisticsEnumeration Statistics• As of November 13, 2006, the following number of Nebraska NPIs

have been assigned by the enumerator as reported by CMS:– Individual (Type 1) Providers Assigned: 7,346

– Organization (Type 2) Providers Assigned: 2,408

– Total Providers Assigned: 9,754

• This does not indicate the number of NPIs that have been communicated to the health plans, only the number obtained by Providers

• Over 1.4 million total NPIs have been assigned. Industry predictions range from 2.5 to 3.5 million total NPIs need to be assigned prior to May 23, 2007

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Remember…Remember…• The NPI is Yours:

– NPI is assigned to the provider– Individual NPI doesn’t belong to a health plan or the employer where the individual

works• The NPI is Unique:

– It identifies a provider uniquely, regardless of where provider practices or the type of practice

• The NPI will become the Only Identifier:– It will be the only provider identifier permitted to be used in HIPAA transactions (except

for TaxID)• The NPI must be Shared:

– Providers must share their NPI with other entities that need it in order to conduct business

• The NPI will Not . . . – Eliminate or replace the Provider enrollment processes conducted by health plans– Guarantee reimbursement by any health plan– Necessary eliminate the health plan legacy provider numbers, only the use of those

numbers for standard transactions• The NPI must be Used with All Payers:

– Provider must use their NPIs with all payers for all HIPAA transactions

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NPI ResourcesNPI Resources

• CMS Main NPI Website

– http://www.cms.hhs.gov/NationalProvIdentStand/

• NPI Enumerator Website

– https://nppes.cms.hhs.gov/NPPES/Welcome.do

• Main site to enter an NPI application

• WEDI NPI White Papers– http://www.wedi.org/snip/public/articles/dis_publicDisplay.cfm?docType=6&wptype=3

• WEDI NPI Outreach Initiative– http://www.wedi.org/npioi/index.shtml

• Contact me

– Tom Pusic

– 402-398-3740

– tom.pusic@bcbsne.com