In less than a year, National Provider Identifiers (NPIs) will be used to identify healthcare providers in standard healthcare transactions. Outlined below is a series of questions and answers summarizing recent guidance prepared by the Centers for Medicare & Medicaid Services (CMS) on NPIs and the NPI application process. Why is the NPI Needed? Currently, healthcare providers find themselves having to keep track of different identifiers for multiple health plans with which they do business. The NPI will replace these numbers and act as the single provider identifier. According to CMS, the use of the NPI will improve the effectiveness of the healthcare industry by simplifying the administration of the healthcare system and by enabling the efficient electronic transmission of health information. What is an NPI? The NPI is a 10-position, intelligence free numeric identifier (10-digit number). "Intelligence free" means that the number does not include embedded information about the provider and the provider's identity, such as the state in which he/she lives or his/her medical specialty. How Was the NPI Standard Developed? In 1993, CMS (then known as HCFA) undertook a project to develop a healthcare provider identification system to meet the needs of the Medicare and Medicaid programs, as well as the call for a national provider identification system. Findings from the project were later incorporated into the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) which mandated, among other things, that the Department of Health and Human Services (HHS) establish standard unique identifiers for healthcare providers. In January 2004, HHS published a Final Rule announcing the adoption of a National Provider Identifier as the standard unique identifier. Who is Eligible to Receive an NPI? All persons and entities who meet the definition of a "healthcare provider" (i.e., a provider of medical or health services and any person or organization that furnishes, bills, or is paid for healthcare in the normal course of business) are eligible to receive NPIs. However, healthcare providers who are HIPAA "covered entities" (i.e., persons or entities that transmit any health information in electronic form in connection with a standard transaction) are required to obtain and use NPIs. How Does a Healthcare Provider Obtain an NPI? To obtain an NPI, a healthcare provider must submit an application. Providers can do this: (1) by using the Web-based National Plan and Provider Enumeration Process System (NPPES), which can be accessed at: https://nppes.cms.hhs.gov/NPPES/StaticForward.do?forward=static.npistart; (2) by filling out a paper application form (which can be accessed at: http://www.cms.hhs.gov/NationalProvIdentStand/Downloads/NPIapplication.pdf) and mailing it to the NPI Enumerator (the CMS contractor responsible for processing NPI applications); or (3) by using an Electronic File Interchange Organization (EFIO) which is authorized to submit applications on behalf of providers. Once a provider's NPI application is processed, the provider will be sent an NPI notification by NPPES. (It is important that providers maintain and safeguard this notification — as a copy may need to be provided as proof of NPI receipt.) Are There Instances Where an Organization Will Need More Than One NPI? Yes. In the case of individuals (e.g., physicians, dentists, etc.), only one NPI is generally needed per individual regardless of the number of practice locations, contracts, and similar factors. (Note: If an individual is billing through a business entity, such as a P.C., an NPI may be needed for that entity.) In the case of organizations (e.g., hospitals, nursing facilities, DME suppliers, etc.), there may be circumstances in which an NPI is required for both the organization as a whole and one or more if its subparts. (A "subpart" is a component of an organization that furnishes healthcare and is not itself a legal entity. For example, a hospital may have subparts such as a hospice, home health agency, excluded units, etc., which bill for their services separately.) To assist providers with understanding subpart classification and when and what circumstances subpart NPIs are needed, CMS has published the following resources: · June 2006 Subparts PowerPoint Presentation: http://www.cms.hhs.gov/NationalProvIdentStand/Downloads/powerpoint_npi.pdf · March 2006 CMS Subparts Fact Sheet: http://www.cms.hhs.gov/NationalProvIdentStand/downloads/npi_fs_subparts_032106.pdf · January 2006 Subparts White Paper: http://www.cms.hhs.gov/NationalProvIdentStand/Downloads/Medsubparts01252006.pdf. When Can a Provider Apply for an NPI? Healthcare providers can (and should) apply for NPIs now. (May 23, 2005, was the start date of the application process.) Indeed, according to CMS guidance, providers should obtain NPIs as soon as it is practicable for them to do so in order to allow ample time to share NPIs with their healthcare partners, including payers, clearinghouses, vendors, and other healthcare providers. This will allow partners to integrate the NPIs into their systems and processes, as well as engage in transaction testing. This will also decrease the possibility of any interruption in claims payment. Are there Any Fees Associated with Obtaining NPIs? There are no fees or processing charges associated with the NPI application and assignment process. However, healthcare providers themselves may incur costs with the implementation of NPIs — such as software costs and training costs. Is There a Compliance Deadline? Yes. Beginning May 23, 2007, (May 23, 2008, for small health plans), NPIs must be used and accepted for identification purposes in standard transactions. Legacy provider identifiers, such as PINs, UPINs, NSC numbers, OSCAR numbers, etc., may not be used. (Note – this will not affect the use of EINs, TINs, and SSNs.) Is an NPI Permanent? Yes. Generally, once a healthcare provider has been assigned an NPI, it will be permanent and the provider will never need another one. (There may be exceptions, however, such as situations where an NPI is used fraudulently by another and the provider requires a replacement NPI.) Accordingly, providers should exercise care to safeguard their NPIs and share them only as required. Can Providers Receive Assistance with NPI Applications? Yes. CMS has contracted with Fox Systems, Inc., to serve as the NPI Enumerator. As the NPI Enumerator, the company employs staff members who are available to provide assistance with questions regarding the processing of NPI applications. Providers can reach NPI Enumerator staff by telephone at 1-800-465-3203 and by E-mail at customerservice@npienumerator.com. Where Can Providers Locate Guidance on NPIs? For more information about NPIs, including guidance on submitting an application, providers can go to the CMS NPI Web site at: http://www.cms.hhs.gov/apps/npi/01_overview.asp. The Web site contains a number of NPI educational resources including: NPI Fact Sheets, Tip Sheets, Implementation Timetables, MedLearn Articles, PowerPoint Presentations, and Frequently Asked Questions and Answers. Providers can also find helpful information on the BlueCross BlueShield of Alabama Web site at: https://www.bcbsal.org/providers/edNpi.cfm (including copies of the BCBSA publication "NPI Countdown"), as well as on the Alabama Medicaid Web site at: http://www.medicaid.alabama.gov/billing/NPI.aspx?tab=6. Jennifer L. Griffin is a member of the Burr & Forman LLP Health Law Practice Group.