National Provider Identifier (NPI)
May 7 is “Legacy Free” Day
An opportunity to check your NPI readiness!
CMS, in collaboration with the Healthcare Information and Management Systems Society (HIMSS), has requested clearinghouses that submit claims to FFS Medicare to participate in a one day NPI preparation exercise
. Specifically, on Wednesday, May 7, 2008, participating
clearinghouses should submit Medicare claims with NPI-only in all provider identifier fields for which a provider uses NPI/legacy pairs. On May 8th, participating
clearinghouses will revert back to sending Medicare NPI/legacy pairs as received from the providers.
Through its monthly NPI messages, CMS has been requesting providers to begin testing NPI-only by sending a group of claims with NPI alone in primary provider fields. This “exercise” will result in feedback from your Medicare contractor on your readiness as it pertains to your National Provider Identifiers.
On May 7, 2008, participating
clearinghouses will send Medicare claims with NPI-only in provider fields which originally contain NPI/legacy pairs from the provider. In other words, clearinghouses will strip the legacy identifiers when they are submitted as part of an NPI/legacy pair. Of course, fields already containing NPI-only will be sent to Medicare, as usual, and secondary provider identifier fields containing legacy-only will be sent to Medicare, as usual.
This exercise will help Medicare providers evaluate their NPI readiness prior to the May 23, 2008 deadline.
The outcomes of this exercise are described below:
- Claims are processed and paid by Medicare. Under this scenario, the provider can feel confident that their cash flow will not be affected by the May 23rd implementation date.
- Claims are rejected or suspended. Under this scenario, the provider will know in advance that there are problems that must be resolved prior to May 23rd. Resolution might include changes to the NPESS data or to the 855 enrollment record.
Again, on May 8, 2008, participating
clearinghouses will revert back to sending Medicare NPI/legacy pairs, if sent to them by the provider.
Participating clearinghouses will be soon notifying provider clients about details so pay close attention to Clearinghouse communications.
The NPI Compliance Deadline is Here!
At this point, any covered entity that is noncompliant, and has not implemented a contingency plan, is at risk for enforcement action. Please review the April 2, 2007 CMS "Guidance on Compliance with the HIPAA National Provider Identifier (NPI) Rule."
As this guidance pertains to claims transactions, it means that:
- Providers must have and use their NPI;
- Clearinghouses must accept and use NPIs; and
- Health plans must accept and send NPIs in claims transactions.
Providers should be:
- Aware of contingency plans for any health plans they bill. Contingency plans may differ by health plan.
- Aware that health plans may lift their contingency plans (and require an NPI on claims or other HIPAA transactions) any time before May 23, 2008.
- Working with vendors and clearinghouses with whomthey contract, to make sure the NPI is being passed to health plans.
- Paying close attention to how and when health plans will be testing implementation of the NPI.
- Aware that, for those health plans that did not establish a contingency plan, providers are required to use their NPIs now. This means that if you are not using your NPI, your claim may be rejected or denied.
Tip Sheet Available
A Tip sheet entitled What the "Guidance on Compliance with the HIPAA National Provider Identifier (NPI) Rule" Means for Health Care Providers
is now available at http://www.cms.hhs.gov/NationalProvIdentStand/Downloads/ContingencyTipSheet.pdf
This product provides helpful steps for providers based on the contingency guidance released on April 2, 2007. This guidance does not mean that providers have an extra year to get an NPI, so please view the Tip Sheet for additional information.
Reminder - Sharing NPIs
Once providers have received their NPIs, they should share them with other providers with whom they do business, and with health plans that request them. In fact, as outlined in current regulation, providers who are covered entities under HIPAA must share their NPIs with any entities that request them for use in standard transactions - including those who need to identify ordering or referring physicians/providers. Providers should also consider letting health plans, or institutions for whom they work (e.g. a large hospital system), share their NPIs for them.
When to Contact the NPI Enumerator for Assistance
Providers should remember that the NPI Enumerator can only answer/address the following types of questions/issues:
- Status of an NPI application, update, or deactivation
- Forgotten/lost NPI
- Lost NPI notification letter
- Trouble accessing NPPES
- Forgotten password/User ID
- Need to request a paper application
- Need clarification on information that is to be supplied in the NPI application
Providers needing this type of assistance may contact the enumerator at 1-800-465-3203, TTY 1-800-692-2326, or email the request to the NPI Enumerator at CustomerService@NPIenumerator.com
Resources for other kinds of questions can be found at the end of this document.
Please Note: The NPI Enumerator's operation is closed on federal holidays. The federal holidays observed are: New Year's Day, Independence Day, Veteran's Day, Christmas Day, Martin Luther King's Birthday, Washington's Birthday, Memorial Day, Labor Day, Columbus Day, and Thanksgiving.
Important Information for Medicare Fee-For-Service (FFS) Providers
Testing Medicare Claims
To date, Medicare has encouraged providers to submit both an NPI and a legacy identifier on claims. Medicare is now asking that submitters send a small number of claims using only the NPI. If no claims are rejected, the submitter can gradually increase the volume. If any claim is rejected, the NPI should be verified to make sure it was entered correctly. If the NPI is correct, then data in either NPPES or Medicare provider files should be corrected. The following fields in your NPPES and/or 855 provider enrollment record should be validated:
- EIN (for organization providers)
- Other Provider Identification Numbers. This is where providers, when they apply for their NPIs, list the Medicare legacy identifier(s) that needs to be linked to the NPI.
- Practice Location Address
- Master Address (from provider enrollment records)
- Other Address (from provider enrollment records)
- Legal Name or Legal Business Name
Once this has been done, test again with a small number of claims. This process will help establish confidence that your claims will be paid. It is critical that you start testing with your NPI now.
While Medicare FFS has announced its contingency plan, it is committed to ending the contingency plan as soon as possible.
Reminder - Medicare FFS Contingency Plan Announced on April 24th
View the associated Change Request at http://www.cms.hhs.gov/transmittals/downloads/R1227CP.pdf
, as well as the related MLN Matters article at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5595.pdf
on the CMS website. These materials were recently revised; please be sure to visit the links above for the latest information.
Reminder - NPI MLN Matters Articles
There are many MLN Matters articles dealing with various topics of NPI relative to the Medicare program. These MLN articles are available at
As always, more information and education on the NPI can be found at the CMS NPI page www.cms.hhs.gov/NationalProvIdentStand
on the CMS website. Providers can apply for an NPI online at https://nppes.cms.hhs.gov
or can call the NPI enumerator to request a paper application at 1-800-465-3203.
Getting your NPI is the first step in the process of meeting the compliance date. Once you have your NPI, you may need to modify your existing business processes to accommodate use of the NPI. You will also need to share your NPI with other health care providers with whom you do business.
The implementation of the NPI is a complex process that will impact all business functions of your practice, office or institution including: billing, reporting and payment. This is why providers are urged to get, share, and use their NPI NOW to avoid a disruption in cash flow.
NPI at a Glance
- Replaces Social Security Numbers, Individual Tax IDs or other identifiers on standard electronic health care transactions.
- Optometrists will not have to maintain multiple identifiers required by different insurance plans.
- Electronic claims function more efficiently with the standardized NPI.
- The NPI contains no vital intelligence about the provider's name, location, patients or qualifications.
- The NPI does not replace enrollment as a Medicare provider
- The NPI does not replace the DEA number used for prescribing controlled substances.
- The NPI should put an end to optometrists' complaints of misuse of DEA numbers by the pharmacies and the insurance industry.
- The NPI does not replace state-issued licenses.
- Social Security Number, Individual Tax ID and Employer ID will still be used for tax purposes.
Key NPI Facts
The Centers for Medicare & Medicaid Services (CMS) along with the Workgroup for Electronic Data Interchange (WEDI) and other industry health plans would like to remind providers of the following key NPI facts:
- Every covered health care provider must get and use the NPI; and even if a health care provider is an individual and is not conducting electronic transactions and is, therefore, not a covered provider, he or she may be required by health plans or employers to obtain an NPI.
- The NPI is not just a number. It does affect internal and external business and systems operations and can affect the appropriate payment of claims in a timely manner.
- It is estimated that use of the NPI can require a transition period of no less than 120 days.
- Providers should begin to test and use their NPIs in electronic health care transactions no later than January 31, 2007.
- May 23, 2007 is not when the process starts, but when the process must be completed.
- Providers may be requested to communicate their NPIs to health plans, clearinghouses, and other providers well before the compliance date.
- A health care provider who is a sole proprietor is considered an individual and can only have ONE NPI.
Learn more about NPI and how to apply by visiting http://www.cms.hhs.gov/apps/npi/01_overview.asp
on the CMS website. This page also contains a section for Medicare Fee-For-Service (FFS) providers with helpful information on the Medicare NPI implementation. A Countdown Clock is now available on this page to remind health care providers of the number of days left before the compliance date; bookmark this page as new information and resources will continue to be posted.
A press release on this topic is posted at http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=1870
on the CMS website.
Optometrists should apply now for their NPI number, according to the AOA Advocacy Group. The new standardized identification numbers are a key part of a government plan to encourage greater administrative efficiency in the nation's health care system and, effective May 23, 2007, will be required on claim forms for most public and private health plans.
Required under the Health Insurance Portability and Accountability Act (HIPAA) of 1996, the National Provider Identifiers (NPIs) are 10-digit numeric identifiers (with nine numbers and a "check digit" in the tenth place) designed to replace the myriad identification numbers now assigned to health care providers by various public and private health insurers for use on their claim forms. The NPIs are specifically designed for use in a new standardized electronic claims format, known as the "standard transaction" which health plans and providers will be required to adopt under HIPAA.
Under federal law, any provider who transmits health information electronically in connection with any of the standard transactions is required to obtain an NPI, even if the provider uses a business associate, such as billing agency, to prepare transactions. Although required by the government only for electronic transactions, NPIs will essentially become the standard form of identification for health care providers on paper claims as well, meaning even health care providers who do not file claims electronically will probably have to obtain NPIs, the AOA Advocacy Group notes.
"Health care providers" specifically includes individual health care practitioners such as medical doctors, dentists and optometrists, as well as hospitals and larger health care providers, under the final rule issued by the U.S. Centers for Medicare and Medicaid Services (CMS) to implement the NPI program.
CMS, through a subcontractor, began accepting applications for NPIs on May 23, 2005. Major health plans, including Medicare, Medicaid, and most private health insurance issuers, as well as all health care clearinghouses, will be required to accept and use NPIs in standard transactions by May 23, 2007. Small health plans will have until May 23, 2008. "After those compliance dates, health care providers may use only their NPIs to identify themselves in standard transactions, where the NPI is called for," CMS emphasized.
Medicare actually began the process of phasing-in the use of NPI numbers on its claim forms early this year. Since January 3, NPI numbers have been accepted as a means of identifying health care providers on Medicare fee-for-service claim forms-although providers, through most of this year, will have to continue to include their Medicare numbers-or "legacy identifiers"-on the claim forms as an additional form of identification. "Medicare systems will accept claims with an NPI, but an existing legacy Medicare number must also be on the claim," CMS emphasized in a recent Medlearn Matters article. "Note that CMS claims processing systems will reject as unprocessable any claim that includes only an NPI."
Beginning October 2 2006, CMS systems will accept an existing legacy Medicare billing number and/or an NPI on claims. The Medicare billing system, by that time, will be capable of using the NPI as the primary identifier for providers with the legacy Medicare number used as a backup. (However, providers will "strongly" be encouraged to continue using Medicare numbers on their claims at that time, according to CMS. Providers who do not use both identifiers could still risk nonpayment.) By May 23, 2007, however, Medicare, and most other public and private health plans, will be accepting only NPIs as a form of identification on claims. A new, modified CMS 1500 claim form has already been developed to accept the NPI.
The NPI should greatly simplify health care administration for everyone involved, including health care providers, according to CMS. "In order to administer its programs, health plans-including federal programs like Medicare, state-administered programs like Medicaid and private health plans-assign identification numbers to their providers of health care services and their suppliers," CMS noted. "However, those identifiers frequently are not standardized within a single health plan or across health plans, which results in a single health care provider having different identification number for each health plan, and often having multiple billing numbers issued within the same health plan. This complicates the health care provider's claims submission processes and may result in the assignment of the same identification number to different health care providers by different health plans."
The AOA Advocacy Group notes the required use of the NPI as provider identification on claim forms will effectively end the practice, on the part of some insurance companies, of using Drug Enforcement Agency (DEA) numbers as a form of provider identification. Many optometrists who do not hold DEA numbers have long complained that the use of DEA numbers as a form of provider identification has effectively barred them from participation in some insurance programs.
While the NPI will greatly simplify the process of identifying health care providers, it will not replace registration as a Medicare provider, state licensure or other processes, both CMS and the AOA Advocacy Group note (see box, NPI at a Glance).
NPI numbers are assigned free of charge. However, it takes about 20 minutes to complete a required questionnaire and submit an application. Optometrists can apply online at the National Plan and Provider Enumeration System Web site (https://nppes.cms.hhs.gov
). A downloadable application form is also available that can be printed and submitted by mail.
Additional information on the NPI can be obtained on the National Provider Identifier page of the CMS Web site (www.cms.hhs.gov/NationalProvIdentStand/
) or by calling (800) 465-3203 or TTY (800) 692-2326.