National Provider Identifiers As The Deadline Approaches, Physicians, Groups, And Hospitals Must Know The Score

The deadline for health care providers to obtain their National Provider Identifier (NPI) is still 18 months away, but providers shouldn’t wait until the last minute.

Although the first deadline for insurance companies to require NPI use on claims isn’t until May 23, 2007 (May 23, 2008 for small health plans), they can require NPIs at any date prior to that. Non-compliance could mean rejection of claims.

The National Provider Identifier will be the single identifier replacing the numerous identifiers currently used for each health plan for which you do business.

This identifier which is a requirement of HIPAA must be used by most HIPAA covered entities including physicians, dentists, nurses, hospitals, nursing homes, durable medical equipment suppliers, pharmacies and pharmacists, clinical laboratories and group practices. Implementation of the NPI will eliminate the need for health care providers to use different identification numbers to identify themselves when conducting standard transactions with multiple health plans. All Medicare providers will be required to use the NPI for Medicare billing purposes regardless of whether or not the Medicare provider bills electronically.

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. The NPI will replace all previous identifiers such as the Unique Physician Identification Number (UPIN), Medicaid Provider Number, Medicare Provider Number, Blue Cross and Blue Shield Numbers, etc. NPIs can be obtained for each individual provider (will be used regardless of where practicing), each group, and for each subpart (i.e. a hospital with a home health agency or hospice program, etc.)

The Centers for Medicare and Medicaid Services (CMS) has developed the National Plan and Provider Enumeration System (NPPES) to collect identifying health care information and assign these unique identifiers. An entity, known as the enumerator, will be responsible for receiving applications and updates and assigning the NPIs. It will also be responsible for resolving problems and answering questions. The process of obtaining an NPI is an enumeration process only and not an enrollment process with any Medicare or Medicaid contractor or any third-party payor.

Providers will still have to be credentialed with each health plan for which they do business. (i.e. Medicare, Medicaid, Blue Cross, etc.)

Health Care providers will be assigned NPIs upon completion of an application either on paper or over the Internet.

Electronic File Interchange (EFI) is expected to be available at a later date. This was formerly known as Bulk Enumeration and will allow an organization to send NPI applications for many health care providers, to NPPES within a single electronic file. Once assigned a number, the provider must furnish updates to its data within 30 days of any changes including name, address, tax identification numbers, healthcare provider taxonomy code, state of licensure or state license number.

There is no fee charged to be assigned an NPI or to update data.

Each health plan may create its own transition plan for converting from existing provider numbers to NPIs. Medicare is preparing a crosswalk to link NPI and existing Medicare provider numbers exclusively for Medicare business which should enable Medicare to continue claims-processing activities without interruption. The Medicare NPI transition plan is as follows:

  • From May 23 2005 to Jan. 2, 2006: Continue to use existing Medicare provider numbers. Do not use your NPI.
  • Jan. 3, 2006 to Oct. 1, 2006: Medicare contractors will accept existing Medicare provider numbers or NPIs accompanied by existing Medicare provider numbers.
  • Oct. 2, 2006 to May 22, 2007: Medicare contractors will accept existing Medicare provider numbers only, or NPIs only, or both.
  • May 23, 2007 and thereafter: Medicare contractors will ONLY accept NPIs (unless a small health plan.)

To apply for your NPI online go to https://nppes.cms.hhs.gov/NPPES/. This address also contains a link for a paper application or you can go directly towww.cms.hhs.gov/hipaa/hipaa2/regulations/identifiers/default.asp

Remember, you only need to apply for one NPI. The same NPI is used for every health plan. Healthcare providers should not begin using the NPI before the compliance dates or until health plans issue specific instructions as to their procedure for accepting the NPI. Health plans may request use of the NPI prior to the compliance dates.

Additional information can be obtained at www.cms.hhs.gov/hipaa/ hipaa2. Halfway down the page is a very useful link ‘CMS National Provider Identifier (NPI) Viewlet.’

Lisa A. Patenaude, CPA, is manager of the Health Care Services Division of Meyers Brothers Kalicka, P.C. certified public accountants and Business Consultants in Holyoke; (413) 536-8510

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