What Are NPI Numbers? 

The NPI (National Provider Identifier) number is a 10-digit numerical identifier that identifies an individual provider or a healthcare entity. An NPI number is shared with other providers, employers, health plans, and payers for billing purposes.

CMS.gov’s Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandated the adoption of a standard, unique health identifier for each healthcare provider. The NPI fulfills this provision. Currently, all covered healthcare providers, all health plans, and healthcare clearinghouses must use NPI numbers in the administrative and financial transactions adopted under HIPAA.

Why Are NPI Numbers Necessary?

Prior to the implementation of NPI numbers, health plans and federal payers assigned identification numbers to healthcare providers and suppliers. The identification numbers were not standardized, resulting in a single provider using multiple identification numbers issued by the various health plans with which a provider was enrolled. This complicated the provider’s claim submission processes, often resulting in the same identification number being assigned to different healthcare providers by the different health plans.

The NPI Final Rule established a standard for a unique health identifier for healthcare providers to use in the healthcare system. The national standard simplifies the claims process and reduces the administrative burdens on healthcare providers.

Providers are required to use their NPI when transmitting any health information in electronic form in connection with a transaction. As stated in 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.”

Who Needs an NPI? 

All individuals and organizations that meet the definition of healthcare provider as described in 45 CFR 160.103 that conduct transactions or use health records that fall under HIPAA regulations are required to obtain an NPI. These include health plans, health plan clearinghouses, healthcare providers who transmit health information electronically, and healthcare organizations that transmit protected health information to covered entities who require access to the protected health information. Whether you are a HIPAA-covered provider, a healthcare provider, or supplier who bills federally funded programs for your services, you must have an NPI. Providers also need an NPI prior to enrolling in Medicare.

What Are the Two Types of NPI Providers?

There are two types of NPI number assignments: Type 1 NPI providers and Type 2 NPI providers. Type 1 NPI includes individuals, such as sole proprietors, dentists, physicians, and surgeons. A provider is eligible for a single NPI. Type 2 NPI are organizations and may include acute care facilities, health systems, hospitals, physician groups, assisted living facilities, and healthcare providers who are incorporated.

When Did NPI Numbers Begin?

In July 1993, the Centers for Medicare and Medicaid Services (CMS) undertook a project to develop a healthcare provider identification system to meet the needs of the Medicare and Medicaid programs and the needs of a national identification system for all providers. The NPI Final Rule, published on Jan. 23, 2004, established the NPI as this standard.

National Provider Identifier (NPI) Replaced the Unique Physician Identification Number (UPIN)

The UPIN (Unique Physician Identification Number) was established by Medicare as an alternative identifier to the Social Security number for physicians and other medical practitioners. The UPIN Registry was discontinued in 2007 when CMS replaced UPINs with NPI numbers as the preferred provider identification number. This was done to standardize and simplify the claims submission process.

How Do You Get an NPI Number?

The fastest way for healthcare providers and organizations to get an NPI number is to apply through the National Plan and Provider Enumeration System (NPPES). The application should take about 20 minutes to complete, and an NPI number may be received in as little as 10 days. Individual providers must first create a username and password through the Identity & Access Management System and log in to NPPES using those credentials.

Providers can also apply for an NPI number through a paper form or through an organization on their behalf. Complete instructions are found on the CMS website.

Since an NPI is required by HIPAA regulations to track healthcare services and reimbursement, health plans will reject any claim submitted without a valid, registered NPI.

Does a Provider’s NPI Change?

Once an NPI is assigned, a provider’s NPI will not change. The NPI remains with the provider regardless of a job or location change.

Does the NPI Replace the Tax Identification Number (TIN) or Other Identifying Numbers?

The NPI does not replace numbers used for other identification purposes, including a provider’s taxpayer identification number (TIN), Drug Enforcement Administration registration, license number, or Social Security number. It does, however, replace all previous identification numbers that providers used for healthcare information transactions, claims, and billing. Health plans may continue to use other provider identification numbers other than the NPI internally, but the NPI must be used for HIPAA transactions. 

How to Look Up an NPI 

There are many ways to perform an NPI lookup for a provider or an organization. The official NPI lookup website is the NPPES NPI Registry. This is a free service open to anyone. You can start with the NPI number or with a name. The search result includes the NPI number, the first and last name of the provider, the NPI type indicated with icons, primary practice address, phone, and primary taxonomy. The results are shown in the search result window and can be downloaded, or, alternatively, captured through an application programming interface.

Understanding NPI Lookup Results 

  • NPI: As explained above, the NPI is a unique, 10-digit National Provider Identifier assigned to the provider.
  • Enumeration Date: The enumeration date refers to the date the NPI was assigned.
  • NPI Type: There are two types of NPI numbers. Type 1 NPIs are assigned to individual providers. Type 2 NPIs are assigned to organizational providers.
  • Status: This shows whether the NPI is active or deactivated.
  • Address: This refers to the address associated with the NPI. It may include a mailing address, a primary address, and/or a secondary address.
  • Taxonomy: Taxonomy Codes categorize the type, classification, and/or specialization of a healthcare provider. Providers can select more than one taxonomy code, but one of them must be designated as the primary taxonomy. In addition to the primary and selected taxonomies, the NPPES search will also return the state code and license number associated with the taxonomy.
  • Other Identifiers: This field matches NPIs with insurers such as Medicare and Medicaid or other insurers to help health plans recognize the provider. This field also returns number and state codes.
  • Endpoint Information: This field shows where the client can access service, usually a direct address and/or a website. It can also include endpoint description, use, content type, and affiliation.

Tracking actions to a standardized identifier provides transparency that can identify and impede fraud. Verisys uses the NPI as one of many data points when verifying provider identity for clients during the provider credentialing process.

NPI Helps Prevent Healthcare Fraud 

In addition to standardizing provider identifiers, verification of the NPI is one of the necessary elements in preventing fraud in Medicare. The NPI number aids in the identity matching of a provider who is treating patients, prescribing, or ordering equipment and supplies. A valid NPI number doesn’t imply that the provider is properly licensed or hasn’t been excluded or sanctioned, but all of these credentialing elements combined prevent healthcare fraud.

Contact Verisys to learn more about how NPI numbers support provider credentialing and prevent fraud.


Verisys Written by Verisys
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