What is a National Provider Identifier – Overview
The National Provider Identifier (NPI) number is a 10-digit number that identifies a specific provider or a healthcare organization.
NPI numbers are shared with other employers, providers, health plan providers, and payers for billing purposes.
As per the HIPAA Act of 1996, each healthcare provider must adopt this standard of identification.
The NPI numbers are ideal for this. Today, all covered healthcare service providers, all health insurance carriers, and healthcare clearing-houses need to use NPI numbers for all administrative and financial transactions under HIPAA.
Importance of NPI Numbers
Before the NPI numbers were implemented, health plan carriers and federal payers assigned identification numbers to healthcare providers and suppliers.
These identification numbers were not industry-standard which caused a single provider to use multiple identification numbers issued to it by the various health plan providers with whom they worked.
This made the provider’s claim submission process extremely complicated and confusing. Often, the same identification number was assigned to multiple healthcare providers by different health plan carriers.
The NPI Final Rule was introduced to establish a standard for unique health identifiers for healthcare service providers to use in the healthcare systems. This nationwide standard has simplified the claims reimbursement process and lowered the administrative burden on healthcare providers.
Healthcare providers need to use their NPI whenever transmitting any patient health information through electronic means, whenever concerning a transaction.
As per the NPI Final Rule, “the use of the NPI will improve the Medicare and Medicaid programs, and other federal health programs and private health programs, and the effectiveness and efficiency of the healthcare industry in general, by simplifying the administration of the healthcare system and enabling the efficient electric transmission of certain health information”.
Obtaining an NPI
Every individual and organization that fulfills the definition of healthcare providers as described in 45 CFR 160.103 that make transactions or use health record systems, and fall under HIPAA regulations are required to obtain an NPI number.
Health plan carriers, healthcare providers, and health plan clearing-houses that transmit health information using electronic means, along with healthcare organizations that transmit protected private patient health information to covered entities with access, are required to obtain an NPI.
You need an NPI number if you are a HIPAA-covered healthcare provider or supplier who bills federally-funded programs for your services. If a healthcare provider wants to enroll in Medicare, then they also need to obtain NPI numbers.
Getting an NPI
The quickest way for a healthcare provider or organization to get an NPI number is to apply through the NPPES (National Plan and Provider Enumeration System).
The application process for this usually takes around 20 minutes to complete. After you complete the NPI application process, you can expect to receive a unique NPI number within 10 days.
To do this, you will need to first create an account by choosing a username and password through the Identity & Access Management System. You will then need to log in to NPPES using the username and password.
Healthcare providers can also apply for an NPI number via a paper form through an organization on their behalf. You can find the complete set of instructions on this process at the official CMS website at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/
If you do not have a valid and registered NPI, then health plan carriers can reject your claims, as per HIPAA regulations.
Searching an NPI
There are several different ways to perform an NPI search for an organization or provider.
The official website of the NPPES NPI registry is available at https://npiregistry.cms.hhs.gov/. This is a free service and can be used by anyone with internet access.
To search for information related to specific NPI numbers, you can start by their name or NPI number.
The search results will show details of the NPI holder, such as first and last name, the type of NPI with icons, phone numbers, primary practice address, and primary taxonomy.
These results appear in the search result window and can also be downloaded or captured using an application programming interface.
NPI numbers are aimed at preventing fraud in Medicare. The NPI number helps in matching the identity of the provider treating the patient and prescribing or ordering supplies and equipment.
Having a valid NPI number does not imply that the provider is licensed, or has been previously excluded or sanctioned.
However, these identifying credentials combine to prevent healthcare fraud effectively.