As the standard, electronic claim formats (835i and 835p) have been implemented, it should come as no surprise that CMS has turned its attention to standardizing the data submitted in the electronic formats. One of the standardized data initiatives is to eliminate the current provider numbers, PIN's and UPIN's, and require a single, unique identification number. This new piece of data is called the Nation Provider Identifier or NPI.
The NPI is simply a ten digit number which is dubbed "intelligence free". This means the number is randomly selected, and not issued based on any pre-set sequence which would relate back to the type of service or specialty of the provider. Once you have obtained an NPI, it is yours for life. An NPI does not expire, and, if a provider gives up their NPI, it is not "recycled" and issued to another provider. Replacing an NPI will only be allowed under very rare and unique circumstances, so it is important that you keep all information attached to your NPI current. In fact, any changes to that information must be reported to the issuing authority within thirty (30) days of the change.
Any organization, partnership or individual provider who falls under the HIPAA guidelines must obtain an NPI. This includes Hospitals, Skilled Nursing Facilities, Independent Laboratories, Physician's and Physician practices, among others. The NPI structure divides all eligible providers into two groups: Type 1, which includes individual physicians, dentists and sole proprietors, or Type 2, which includes organizations, physician groups, hospitals, nursing homes, skilled nursing facilities and any corporation when an individual incorporates him/herself. If you are an individual who is a health care provider and who is incorporated or part of an incorporated practice, you may need to obtain an NPI for both yourself (as a Type 1 provider) and for your corporation (as a Type 2 provider). Hospitals and other larger organizations may also need to obtain multiple NPI's if they have subparts. For example, a hospital may need one NPI for the acute care facility, and a second NPI for its Home Health Agency. In this example, the HHA is a considered a subpart of the hospital. CMS and the NPI regulator has left the definition of what is and is not a subpart up to the providers. If you are not sure how to define it, a good rule of thumb is to obtain one NPI for each of the current Medicare provider numbers you or your organization uses.
NPI's can be obtained by applying on-line, or by submitting a paper application. The on-line site can be found at: https://NPPES.cms.hhs.gov. You can also print-off a paper application from this web site. The application requires about twelve piece of information, including the tax identification number (Tax ID) or Employer Identification Number (EIN) issued by the Internal Revenue Service (IRS), information about your license and a taxonomy code. Taxonomy codes relate to the type of service or specialty of the provider. A list of the codes can be found at : http://www.wpc-edi.com.
You can apply for an NPI number right now. CMS contractors (Fiscal Intermediaries or Carriers) must be able to accept an NPI starting January 3, 2007, although they will continue to require you also submit your Provider Number or PIN/UPIN as well. The official switch-over date for CMS to the NPI is May 23, 2007. By that date you must have your NPI, and be able to send it on your claim if you want to be paid by Medicare. Medi-Cal requires that you first register your NPI number with the Medi-Cal program. You must be registered by March 1, 2007, and use it as your submitting identification beginning May 23, 2007. To register with Medi-Cal, you can go to their web site at: www.medi-cal.ca.gov, or call 1-800-541-5555, press 11 and then 18 for more information.
It is imperative to you keep in mind that if you currently need the PIN/UPIN/Provider Number of another healthcare provider (i.e. admitting physician or the ordering physician), in order to submit a complete claim for your services, then on May 23, 2007, you will need to have that other providers NPI number in order to submit your claim to the payers. As of today, CMS does not have a mechanism to access a national data base of provider NPI numbers like they had available for UPIN numbers. We are all on our own to obtain the NPI number of other providers.
The commercial payers are required to accept the NPI data as of May 23, 2007, However, not even the Federal Government can dictate to a private company what they actually use to identify a provider. Considering the estimated costs to expand data bases to store two more digits to accommodate the date of "2000" at the turn of the century, there is no guarantee the insurance plans will want to spend the money to store another ten digits when they already use a unique number to identify payers (Tax ID's, EIN's or Social Security Numbers). It would be advisable, to ensure payment from any third party payer source, for all providers to continue to send those identifiers on their claims, along with the NPI. The bottom line for all providers still has not changed: he/she who matches the payers computer systems, gets paid.
Please include your provider name (either the individual or the organization), your NPI number and the name of the person/employee within the organization who is making the request along with a contact phone number and a return fax number.