Medicare Part B 101 Manual

Medicare Part B 101 Manual

National Provider Identifier

Table of Contents

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National Provider Identifier

On 5/23/2007, the NPI changed the health care industry (small health plans that have less than five million dollars in annual revenues have an additional year to comply). Physicians, facilities, dentists, vision care providers, behavioral health professionals, and other health care professionals must begin using this unique, all numeric, ten-position intelligence-free identifier (intelligence-free means that the numbers do not carry information about health care providers, e.g., the state in which they practice or their provider type or specialization) when requesting reimbursement for health care services. The CMS extended the implementation of the NPI with a contingency plan that enforces the usage of the NPI to no later than 5/23/2008.

The transition to NPI directly affects claims processing and payments for providers and impacts electronic transactions and paper claim transactions.

The NPI replaces health care provider identifiers in use today in HIPAA standard transactions. Those numbers include Medicare legacy IDs (i.e., UPINs, OSCAR, PIN).

Note: The provider’s NPI will not change and will remain with the provider regardless of job or location changes.

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Background

The HIPAA of 1996 requires the adoption of a standard unique identifier for health care providers. The NPI Final Rule issued 1/23/2004, adopted the NPI as the standard.

A HIPAA-covered health care provider is a health care provider who transmits any health information in electronic form in connection with a transaction for which the secretary of the HHS has adopted a standard, even if the health care provider uses a business associate to do so.

The NPI will ensure:

  • simpler electronic transmission of HIPAA standard transactions;
  • standard unique health identifiers for health care providers; and
  • more efficient coordination of benefits transactions.

Having an NPI does not:

  • ensure a provider is licensed or credentialed;
  • guarantee payment by a health plan;
  • enroll a provider in a health plan;
  • turn a provider into a covered provider; and
  • require a provider to conduct HIPAA transactions.

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Application Process

All Medicare providers currently enrolled in the Medicare Program are required to obtain an NPI. Providers may apply for their NPI in one of three ways:

  1. Apply through an easy-to-use web-based application process at National Plan & Provider Enumeration System.
  2. Complete a paper application and send it to the Enumerator. A copy of the application, including the NPPES mailing address (where you will send it) is available at NPPES.
  3. With the provider’s permission, an organization may submit the provider’s application in an electronic file. This could mean a professional association, or perhaps a health care provider who is the provider’s employer, could submit an electronic file containing their information and the information of other health care providers.

When gathering information for the application, be sure that all of the information, such as your Social Security Number and the federal employer identification number, are correct. Communicate any changes to required data elements to the NPPES within 30 calendar days.

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Sharing Your NPI

Once providers have their NPIs, they should protect them. Covered providers must share their NPI with any entity that would need to identify the provider in a standard transaction. For example, a referring physician must share their NPI with the provider that is billing for the service. Other entities the provider should consider sharing their NPI with are:

  • Any provider with which they do business (e.g., pharmacies)
  • Health plans with which they conduct business and
  • Organizations where they have staff privileges

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NPI Contractor

Fox Systems Inc.
800-465-3203 (NPI toll free)
800-692-2326 (NPI TTY)

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Mailing Address

NPI Enumerator
7125 Ambassador Rd. Ste 100
Windsor Mill, MD 21244

Email: customerservice@npienumerator.com

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NPI Registry

The NPI registry enables you to search for a provider’s NPPES information. All information produced by NPI Registry is provided in accordance with the NPPES Data Dissemination notice. You may run simple queries to retrieve the read-only data. For example, users may search for a provider by the NPI or legal business name. There is no charge to use the registry. To perform a registry search, you can access the NPPES.

Revised 10/14/2024