QUESTION:   What is the new federal National Provider Identifier (NPI) Program and do I have to sign up with this program for a provider number?

ANSWER: In 1996, the US Congress passed the so-called “administrative simplification provisions” of the Health Insurance Portability and Accountability Act (HIPAA) of 1996 (P.L. 104-191) requiring the Secretary of Health and Human Services (HHS) to adopt a national standard identifier for health care providers for use in the health care industry.     The Centers for Medicare and Medicaid Services (CMS) adopted the National Provider Identifier (NPI) as the standard identifier.

HHS has published the final rules for this standard unique health identifier number program and this program became operative on May 23, 2005. Providers can apply for NPIs at any time, and all health care providers are eligible to be assigned NPIs. All HIPAA covered “entities” and professionals providing services in all federal programs, including Medicare and Medicaid, must eventually obtain and use an NPI number. All HIPAA covered entities will be expected to use NPIs by the initial compliance date of May 23, 2007, and “small health plans” by May 23, 2008. The Centers for Medicare & Medicaid Services (CMS) has developed the National Plan and Provider Enumeration System (NPPES) to assign these unique identifiers.

The NPI requirement is scheduled to supersede all other numbers for providers in terms of claims filings, though entities may elect to use other types of provider numbers for internal purposes. According to the HHS announcement:

“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 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.”

According to the U.S. Department of Health and Human Services, “The purpose of the National Provider Identifier (NPI) is to 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, in program integrity files, 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. 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.”

Once again, DCs may apply to obtain a unique provider number now, but it is not a requirement at present. However, according to the official CMS release, “Under the National Provider Identifier Regulation” (that was published in the Federal Register on January 23, 2004), 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 .”

You may apply online for the National Provider Identifier (NPI) number at: https://nppes.cms.hhs.gov/NPPES/StaticForward.do?forward=static.instructions

You can also access the paper application form for the National Provider Identifier (NPI), and submit by mail or online at:

http://www.cms.hhs.gov/forms/cms10114.pdf

HIPAA VIDEO STILL AVAILABLE

The official HHS instructional video entitled “ HIPAA 101 (Health Insurance Portability and Accountability Act of 1996): The Basics of HIPAA Administrative Simplification ” is still available from HHS for a fee of $13.00 from the National Technical Information Service in Springfield, Virginia 22161 by calling (703) 605-6000. Ask for Item No. AVA21211VNB1. This video was designed to inform the health care provider community about the administrative simplification provisions of the Health Insurance Portability and Accountability Act of 1996, or HIPAA. It will help you understand the history of HIPAA and its benefits, how to tell if you are a 'covered entity' under HIPAA, the standards that have been adopted for electronic transactions and code sets, why the Designated Standards Maintenance Organizations may be important to you, what you need to do to be compliant with the administrative simplification provisions of HIPAA, and how HIPAA's rules and deadlines will be enforced.

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