Is It Time to Update Your NPI Information?

The National Provider Identifier, also known as NPI, is a standard of the Health Insurance Portability and Accountability Act (HIPAA) as of 2004. It is a distinctive 10-digit identification number given to health care providers, such as you, for improving efficiency in the electronic transmission of health information such as health care claims. All covered healthcare professionals and health plans must use NPIs in their financial and administrative transactions. In order to assign such unique identification numbers, the Centers for Medicare & Medicaid Services developed the National Plan and Provider Enumeration System (NPPES).

An NPI does not include information about you, such as who you are or what your area of specialization is, nor will it change your name, address, or taxonomy. Furthermore, it does not enroll you in a health plan, ensure you are licensed, or require you to conduct HIPAA transactions. In HIPAA standard transactions, an NPI is merely used to benefit transactions between parties for specific purposes (health care data) and create a one of a kind numeric identifier for health care providers.

NPI is an essential matter to consider and you may have a few questions as to whether you need it, how to apply, how to update your NPI information, and more. Below, you will find a few answers to your questions:

• Why are NPIs significant?

Apart from distinctively identifying health care providers within the healthcare industry, NPIs may also be used to identify healthcare professionals through prescriptions, patient health records, health plans, program integrity documents, and more. Moreover, NPIs help to reduce fraud and abuse among the health care system.

• Why do I require an NPI?

If you try to submit a claim without an NPI identification number, it will almost certainly be denied. The same goes for Medicare claims. The bottom line is that if you want to receive payment for your services, NPIs make submitting electronic claims much easier. HIPAA requires covered entities to use NPIs and so if you are covered, you can conduct electronic transactions within national health programs.

• Who may obtain an NPI?

All health care providers may obtain an NPI. A health care provider is defined as an individual or an organization that provides health-related services. This includes:
• Physicians and other healthcare professionals;
• Practitioner groups;
• Dental providers;
• Healthcare facilities such as hospitals;
• Nursing homes;
• Laboratories;
• Pharmacies or other medical supply companies

• Who MUST obtain an NPI?

All health care providers, whether individuals or organizations that are covered entities by the HIPAA, must obtain an NPI. Examples of HIPAA-covered entities include a health care clearing house, a health care provider who conducts electronic transactions, or a health plan.

• What are the two main NPI categories?

The two main NPI categories of health care providers are Entity Type 1 (individual) and Entity Type 2 (Organization). If you have a sole proprietorship, you should apply for Type 1, whereas if you are working within an organization, you should apply for Type 2.

• How can I apply for my NPI?

You can apply for an NPI identification number in three different ways:
1. You can apply online through the National Plan and Provider Enumeration System (NPPES) page found on the website for CMS. You should set up an account with an NPPES username and password.
2. You can complete and mail in a written application to the address that is listed on the form.
3. You can have an electronic file interchange organization (EFIO) apply on your behalf.

• Is there a cost associated with applying for an NPI?

There is no charge for applying for or obtaining an NPI.

• Will my NPI information be available to other individuals?

The Centers for Medicare & Medicaid Services have created an online NPI registry where you can look up NPI information. Only the information following the Freedom of Information Act is released. Other personal information, for instance your social security number, is not disclosed to the public.

• How can I update my NPI?

You should inform the enumerator of any changes made within 1 month. Most changes will not reflect upon your NPI identification number. This only occurs in rare instances, such as fraud or abuse. If you already have an account, you can simply log into your NPI file online and use the available NPI update form to make the necessary changes. You can also choose to contact the NPI enumerator and request an NPI update form via mail.

• Should I share my NPI with other individuals?

Yes, NPI identification numbers can be used by other physicians or providers who you have referred patients to and who need to submit claims for your referral services. The same is true for billing purposes.

• What is my taxonomy number?

Taxonomy codes are administrative codes used to identify you and your area of specialization. In the NPI application, you must report both primary and secondary taxonomy codes for the purpose of submitting claims once your application has been filed and you have received an NPI identification number.

• Is the NPI only for submitting Medicare claims?

Your NPI identification number will take the place of billing digits for all health insurance plans – private and public.

• What if my NPI information and my Medicare application information do not align?

Due to the fact that you can update your NPI application online, it is best to do so in a timely manner so that it matches your Medicare  application information.

• What if I have a sole proprietorship? Do I need both an individual NPI and a group NPI for my practice?

In this particular case, you and your practice should each have an NPI. You should apply for each NPI individually. For instance, in your individual application (Type 1) you should state your license number, whereas in your organization application (Type 2) you should include your tax identification number.

• If I am a part of a practice with a group NPI, do I need an individual NPI as well?

In this particular case, your practice will be submitting the claims so technically, you do not need your own NPI identification number. However, it is strongly recommended to obtain one because there are instances where a Type 1 NPI may be associated with a particular claim or health plan.

• Will I ever need a new NPI?

An NPI is meant to be a lasting identification number and it is expected to remain unchanged even in times when you may change your number, address, taxonomy, or other information from your original NPI application. However, there are particular circumstances where you may need to obtain a new NPI, such as if your original one has been used fraudulently. Another instance is if you work within a practice that has a group NPI and certain changes in ownership require applying for a new NPI.

• What is the NPI Registry?

The NPI Registry Public Search is an available listing lookup for all currently active NPI records. It is free to use and allows individuals to look up health care providers throughout the industry by means of identification numbers (National Provider Identifier records).

Your NPI is a single identification number that will be accepted and recognized by all health plans. Therefore, it eliminates the need to maintain, report, or keep track of countless provider identification numbers. An NPI does not disclose your personal information but rather allows you to be identified in a certain way. It is permanently associated with a specific individual or organization, regardless of any changes made within the specialty or address. With an NPI number, you can submit health-related claims and receive payment for your services. Most important, you can update your NPI information whenever you see fit. NPI is intended to increase competence and performance of healthcare professionals such as you, by improving the effectiveness of the overall health care system.