The National Provider Identifier is a 10-digit numeric identifier that must be used on claim forms submitted to payors by individual and organization health care providers who meet the definition of a "covered entity" under the Health Insurance Portability and Accountability Act (HIPAA), beginning May 23, 2008. The application process began in May of 2005.
In April 2007, CMS released information regarding the establishment of contingency plans that would allow providers additional time to apply for NPIs and allow providers and insurers additional time to make adjustments necessary to accept NPIs on claim forms. During this period (May 23, 2007-May 23, 2008), CMS will not take action against entities that violate HIPAA as it relates to NPI as long as they have a contingency plan in place. All contingency plans must end by May 23, 2008. After this time, CMS will take action against those who are not in compliance with the HIPAA NPI regulations.
During the May 2005 to May 2008 transition, CMS is suggesting that providers continue to use both their regular identifiers, along with the NPI, once they receive it, until they hear differently from their individual payers. This practice is referred to as "dual identifier use." For additional information on the timeline and transition period, visit CMS' Web site at: http://www.cms.hhs.gov/NationalProvIdentStand/.
To complete the application online, go to the National Plan and Provider Enumeration system Web site.
To request a paper application, call 800/465-3203.
Why do I need the NPI?
In order to be paid, the NPI must be used on claims forms by all health care providers who meet the definition of "covered entity" after May 23, 2008. As one of the Health Insurance Portability and Accountability Act mandates, its use will further streamline electronic claims processes already in place. It should also simplify claims submission for providers, given that separate insurer-specific numbers will no longer be necessary. CMS has stated that use of the NPI will reduce costs and improve efficiency.
Is the NPI for Medicare Claims only?
No. The NPI will ultimately replace all legacy or billing numbers for all health insurance plans; both public and private.
During the transition period, I used both my NPI and my legacy billing number on my claims forms. On May 23, 2008 I started using my NPI only and now my claims are rejecting. Why is this happening?
There are a couple of reasons your claims might be rejecting. First, you should look at the codes on the remittance advice you receive. The Medicare program has released guidance on some of the most common remittance advice codes you may receive for Medicare claims and an explanation for what these codes mean.
Secondly, you should make sure that the information you included on your Medicare enrollment application (e.g. 855i and 855B forms) matches with the information you submitted with your NPI application. If there are any differences between the two applications, your claims may reject as they can not be appropriately matched through the NPI crosswalk. For instance, if you listed your address as 1500 Maple Rd. on your Medicare enrollment application and 1500 Maple Road on your NPI application, there is a possibility that the crosswalk will not match and your claims may reject.
What should I do if my Medicare enrollment information and my NPI information do not match?
Because you can complete updates on your NPI application online and in a relatively timely fashion, it may be best to update the NPI information to match with your Medicare enrollment application.
I work in a group practice. Will the group practice also be required to apply for an NPI?
Yes, the group practice, in addition to the individual physical therapists working in the practice, will each be required to obtain an NPI.
I have a solo practice, but have incorporated my practice. Do I need both the individual NPI and an NPI for the practice?
In this case, the corporation and the individual therapist should each have an NPI. Your state physical therapy license number should appear on the individual application. The corporate application should include the number associated with the corporate entity, such as the tax identification number. It is not necessary to include your state license number on the application for the corporate NPI. You must apply for each NPI separately, and you will be asked to create a profile for each type of application on the NPPES Web site.
I am a physical therapist who works in a skilled nursing facility and therefore do not bill separately for my services. Is it mandatory for me to apply for an NPI?
According to CMS, all health care practitioners are eligible to apply for an NPI, even if your services, as the rendering practitioner, are billed by the facility and not individually. Settings such as nursing facilities and hospitals may want you to obtain your NPI for administrative purposes, but it is not mandatory for health care providers who are not "covered entities" under HIPAA. "Covered entity" is defined in the regulations as a health care provider who transmits any health information in electronic form, such as submitting a claim. APTA encourages all physical therapists to apply for an NPI.
As a physical therapist assistant am I required to apply for an NPI?
Physical therapist assistants are also eligible to apply for an NPI. Once again, your facility's administration may want you to obtain your NPI for tracking purposes, but it is not mandatory for health care providers who are not "covered entities" under HIPAA.
How will I know it is time to use only the NPI?
Effective May 23, 2008 you may only use the NPI on the claim form.
I want to apply for a Medicare supplier number and notice that the application now requires me to have an NPI. How long does the application process take?
Once you have assembled the required documents, such as your social security number and state license information, the online process takes 20-30 minutes. If you are applying by mail, factor in turnaround time for processing and mailing.
Where can I find information about the claim forms that accommodate the NPI?
Information on the new claim forms for use after May 23, 2007, is available at the CMS Web site.
The claim form fields clearly identify where the NPIs are to be entered for both the billing and rendering providers.
Does CMS provide outreach to providers on the NPI?
Visit the CMS Web site for more information. This resource now includes a training package, a power point presentation, and numerous frequently asked questions. In addition, you may call the NPPES directly, at: 800/465-3203.