What is a National Provider Identifier (NPI) Number?

Written by: Shubham Grover
Expertise: Healthcare Researcher
Experience: 6 Years
I am a dedicated healthcare researcher and an enthusiast specializing in medical grants, medical education and research. Through my articles, I aim to empower healthcare professionals and researchers with valuable insights and resources to navigate these critical aspects effectively.
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Updated by: Andrea Morales G.
Expertise: Fact Checker / Validator
Experience: 12 Years
With an extensive background spanning over ten years as a validation manager in the demanding and precise field of Cybersecurity, Andrea has adeptly transitioned her skills to the healthcare sector. In her current role, she leverages her experience in rigorous data analysis and verification to enhance the accuracy and reliability of healthcare information. As a detail-oriented fact-checker, Andrea scrutinizes every claim in our healthcare articles, ensuring they are thoroughly vetted against the latest medical research and guidelines. Her commitment to clear, precise, and unambiguous communication is pivotal in our mission to deliver trustworthy and evidence-based health content to our audience. Andrea's unique blend of cybersecurity rigor and healthcare focus positions her as a key asset in upholding the highest standards of informational integrity in the health and wellness space.
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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 used by healthcare providers when submitting claims to health plans, including Medicare and Medicaid, and by health plans in their transactions with other health plans and with clearinghouses.

Under the HIPAA regulations, eligible healthcare providers must obtain an NPI for use in healthcare transactions.

The NPI numbers are ideal for this. Today, covered healthcare service providers, all health insurance carriers, and healthcare clearinghouses need to use NPI numbers for all administrative and financial transactions under HIPAA.

Importance of NPI Numbers

What is a National Provider Identifier

What is a National Provider Identifier – 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. Different health plan carriers often assign The exact identification number to multiple healthcare providers.

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 patient health information through electronic means or 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 provider as described in 45 CFR 160.103, makes transactions or uses health record systems, and falls under HIPAA regulations must obtain an NPI number.

Health plan carriers, healthcare providers, and health plan clearinghouses that transmit health information electronically and 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 healthcare provider conducting electronic transactions as HIPAA defines. If you want to enroll in Medicare, you also need to obtain an NPI number.

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 time may vary, and after submitting the NPI application, the timeframe to receive an NPI number can also vary and may not be strictly within 10 days.

To do this, you must first create an account by choosing a username and password through the Identity & Access Management System. You must then 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/

Health plan carriers may reject claims that do not include a valid NPI, as required for standard electronic transactions under HIPAA.

Searching an NPI

There are several ways to search an NPI 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 be downloaded or captured using an application programming interface.

Conclusion

The primary purpose of NPI numbers is to provide a standard identifier for healthcare providers in electronic transactions, not specifically to prevent Medicare fraud. The NPI number helps match the identity of the provider treating the patient and prescribing or ordering supplies and equipment.

An NPI number does not convey licensure status nor indicate whether a provider has faced exclusion or sanctions.

However, these identifying credentials combine to prevent healthcare fraud effectively.

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Current Version
July 2, 2022
Written By
Shubham Grover
March 21, 2024
Updated By
Andrea Morales G.

https://www.cms.gov/Outreach-and-Education/

https://www.magellanprovider.com/getting-paid/

https://www.techtarget.com/searchhealthit/definition/

 

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