To prevent fraud in healthcare and ensure quality care, the Centers for Medicare and Medicaid (CMS) introduced the NPI number. It validates the credentials of the provider or healthcare professional who treats the patients, prescribes medicines, or orders supplies and equipment.
Being a healthcare provider, you’ve probably heard about NPI numbers. But are you still wondering whether you need an NPI or not? Is it really important to get one?
The answer is ‘Yes.’ You need an NPI ASAP!
If you don’t clearly understand NPI and how to apply for your NPI number, you don’t have to worry anymore. We’ve got you covered.
This guide provides all the important information you’ll need about the NPI, its requirements, and registration, including NPI lookup and related details.
NPI means National Provider Identifier. It is a special 10-digit numerical identifier allocated to healthcare professionals and organizations.
The NPI was established as the Administrative Simplification Standard in 2004 and thereby became a legal requirement according to the Health Insurance Portability and Accountability Act (HIPAA).
The Centers for Medicare and Medicaid (CMS) assigns the National Provider Identifier (NPI) number to healthcare providers via National Plan and Provider Enumeration System (NPPES) registry.
What is the NPI Number Purpose?
All the individuals and organizations who meet the criterion for healthcare providers working under HIPAA can get their unique NPI number. This will remain with the healthcare professionals for the entire period they practice under the act.
Even if healthcare professionals’ location, roles, and duties change, the NPI number remains the same. As it is an intelligence-free numeric identifier, NPI doesn’t carry any information about the healthcare providers.
This number was introduced for administrative and billing purposes only. The NPI must be used for all HIPAA standard electronic transactions. It offers a more convenient way of filling out the prescription forms, claim forms, status inquiries, dealings with healthcare plans, medical records identifying the previous healthcare providers of the patients, and general HIPAA correspondence.
Thus, National Provider Identifier (NPI) number helps in improving the effectiveness and efficiency of electronic transmission of health information by preventing fraud.
NPI vs. UPIN
Prior to the National Provider Identifier (NPI) number, the usage of Unique Physician Identification Number (UPIN) was made by the Centers for Medicare and Medicaid Services (CMS) to recognize physicians and non-physician practitioners.
UPIN was a 6-character alpha-numeric identifier. But it was discontinued in 2007. Now, NPI has replaced UPIN. NPI ensures quality services and prevents fraud more effectively as the new provider identification number.
However, it’s important to note that an NPI number doesn’t necessarily guarantee that the healthcare professional is fully licensed.
Also, remember that the National Provider Identifier (NPI) number only replaces the identification numbers providers use in healthcare under HIPAA. All other identification numbers, such as Social Security Number, the license number, as well as the taxpayer identification number (TIM) and/or Drug Enforcement Administration registration, can’t be replaced by the NPI number.
Am I Eligible for an NPI Number?
Any individual or organization that meets the criteria of a healthcare provider in 45 CFR 160.103 is qualified for National Provider Identifier (NPI) number. So, if you’re a healthcare provider who provides healthcare services and submits HIPAA transactions, you can obtain your NPI number via the NPPES registry.
All individuals and organizations under HIPAA and related to CMS need to have an NPI number. You can’t submit any information electronically or carry out any transaction and communication without an NPI number. Also, claims submitted without NPI numbers are mostly denied.
The following are some examples of individuals who need an NPI number:
- Nurse practitioners
- Occupational therapists
Some of the organizations eligible for NPI numbers include:
- Residential care facilities
- Medical equipment providers
- Nursing homes
Types of NPI Providers
There are two types of National Provider Identifier (NPI) providers: Type 1 NPI Providers and Type 2 NPI Providers. These providers are explained as under:
1. Type 1 NPI Providers
The Type 1 NPI Providers include individual healthcare providers. A provider under this category is assigned only one NPI number. The Type 1 NPI Providers are the people who include dentists, physicians, and all sole proprietors, who provide healthcare services as a single entity.
Anyone working as a sole proprietor will be assigned a single NPI number. If you’re under the Type 1 NPI Provider category, it implies that you’ll not get the NPI numbers for your employees, if any.
2. Type 2 NPI Providers
The Type 2 NPI Providers include organizational providers. The term organizational provider encompasses organizations like hospitals and nursing homes and the individuals who have formed corporations.
Thus, the Type 2 NPI Numbers are assigned to incorporated practitioners. Under this category, the incorporated individuals/organizations can get NPI numbers for their employees as well. So, instead of one NPI number, the organizations get several NPI numbers.
Organizations greatly benefit from the Type 2 NPI Numbers as there are several departments within the organizations. These departments are also known as ‘subparts.’ But remember that subparts refer to those departments within the healthcare organization which offer services different from each other.
When each subpart has been assigned a unique NPI number, it can conveniently conduct HIPAA transactions, billing, etc.
Furthermore, incorporated practitioners get one NPI number for themselves and one for their corporation.
How do I apply for an NPI?
CMS assigns the NPI numbers through the NPPES registry. But before applying for the NPI number, you have to decide whether you’re a Type 1 NPI Provider or a Type 2 NPI Provider. If you’re a Type 2 NPI Provider, be sure to apply on behalf of your subparts.
The subparts can also apply on their own, but the subparts are required to work in accordance with the NPI Final Rule.
Once you’ve identified your NPI Provider category, you can apply for your NPI number.
Whether you’re an individual or organization, you can get the NPI number in the following three ways:
- The first option is to visit the NPPES website and get your NPI number via the web-based application process. Firstly, you’ll have to create your account. By using your username and password, you can log in to NPPES, and within 10 minutes, you’ll be assigned a unique NPI number.
- The second option is to visit the CMS website and download the paper form. After that, you’ll have to print out the form, fill it out, and then mail it to the address listed on the form. Or you can also send the form via email. Once the CMS receives your mail or email, you’ll be assigned your NPI number.
- The third option is to get the Electronic File Interchange Organization (EFIO) to apply for your NPI number. This organization will provide your NPI number through a bulk process.
The NPI Lookup
Once you’re assigned your NPI number, it’ll be stored on the NPPES registry. Any patient can look up your NPI on the NPI search database by entering your name/surname, state, or organization name. The accuracy of the search results depends on how much information the patient has added.
NPI Lookup provides the following search results:
- NPI Number: The NPI lookup provides the unique, 10-digit National Provider Identifier (NPI) number that is assigned to the healthcare provider.
- NPI Provider Type: As mentioned above, there are two types of NPI numbers. The NPI lookup also lists whether the provider is a Type 1 NPI Provider (individual provider) or a Type 2 NPIs (organizational provider).
- Enumeration Date: The date on which the NPI number was assigned to the provider is called the enumeration date. It is also listed on the database.
- Status: The term status represents whether the NPI of the provider is active or deactivated.
- Address: The primary address, secondary address, and/or the provider’s mailing address are also mentioned in the NPI lookup results.
- Taxonomy: The healthcare provider can select one or more taxonomy codes that categorize their specialization, type, or classification. However, at least one code must be chosen as the primary taxonomy. The NPI lookup results will provide the taxonomy of the provider, along with their license number and state code.
- Other Identifiers: The NPI of the provider is also matched with their Medicare and Medicaid insurers.
- Endpoint Information: The endpoint information may include the affiliation of the provider and other related information. It also provides information about how the patient can contact the healthcare provider.
If you’re providing healthcare services under HIPAA, you need to have your unique National Provider Identifier (NPI) number. The NPI will verify your credentials as a healthcare provider and ensure quality care for the patients. This also protects the patients and prevents fraud in healthcare. The process of obtaining the NPI is pretty simple. So, make sure you get your NPI number ASAP! When you have an NPI number, your patients can look up your name or your organization’s name in the NPI search database and decide whether you’re the right provider for them or not.