Frequently Asked Questions
Q: What is an NPI?
A: The National Provider Identifier (NPI) is part of the “administrative simplification” provision
of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). It is a 10-digit
numeric ID that contains no private information about the provider. This number is intended
to replace all existing national provider identifiers, including the unique provider identification
(UPIN) number, the state (Medicaid) number, and proprietary numbers (individual hospital,
health care systems, commercial payer, etc.). While all health care providers will be eligible
to receive an NPI, only Centers for Medicare & Medicaid Services (CMS) specified health
care entities will be mandated to use the NPI as the sole identifier on all HIPAA electronic
transactions.
Q: How can I get my individual, group, and or subpart NPIs to Humana?
A: NPI forms are available at Humana.com on the Provider Resource menu. You can
also call Humana Customer Service at
800-448-6262 and request to receive forms via mail.
To submit your NPI(s) you can fax or mail the form(s) to Humana (please see your form for
the fax number and mailing address). You can also send your NPI(s) on electronic
transactions and Humana will collect them from your claims submission.
Q: Who assigns the NPI?
A: Fox Systems Inc. has been chosen to process applications and maintain the data in the
National Plan and Provider Enumeration System (NPPES) for CMS.
[i]It is important to note
that the contract awarded is limited to a relationship between Fox Systems Inc. and the
provider.
[ii]The provider has to apply to Fox Systems for the NPI.
Q: Who can apply for an NPI?
A: All HIPAA-covered health care providers, whether they are individuals, such as physicians,
nurses, dentists, chiropractors, physical therapists, or pharmacists, or organizations, such
as hospitals, home health agencies, clinics, nursing homes, residential treatment centers,
laboratories, ambulance companies, group practices, health maintenance organizations,
suppliers of durable medical equipment, or pharmacies, may apply for an NPI.
[iii]
Excluded from the definition of health care providers are “atypical” providers (e.g.,
rehabilitation providers, social services, and nonmedical transportation providers).
[iv]Other
organizations that will not be able to obtain an NPI will include billing services, value-added
networks, repricers, third-party administrators (TPAs), health care clearinghouses, and
others in this category.
Q: What information is required to apply/obtain an NPI?
A: Information regarding paper and Web-based applications, along with their requirements,
can be found on the National Plan and Provider Enumeration System (NPPES). Visit
NPPES
Q: When can providers begin to apply for an NPI?
A: Providers can apply now. Applications for an NPI became available to eligible health
care providers on May 23, 2005.
Q: How many providers currently have NPIs?
A: As of September 2, 2006 (per the Workgroup for Electronic Data Interchange), there
were approximately 1.4 million enumerated providers and/or organizations.
Q: When are NPIs mandated for use?
A: Providers, clearinghouses, and health plans must use the NPI as the primary identifier
beginning May 23, 2007.
Q: Can a provider or organization have more than one NPI?
A: Yes. The purpose of the NPI is to have only one identifier for individual providers. Some
organizations will be required to have subpart identifiers when conditional requirements are
satisfied (see next question).
Q: Will Humana require the NPI on any non-HIPAA transactions?
A: No. For any non-HIPAA transaction, the NPI will not be required by mandate, but it
is recommended.
Q: My organization obtained its NPI. As a physician with this organization, do I have
to obtain an NPI also?
A: Yes. Even though the organization that you are working with has enumerated,
you need to obtain an NPI as an individual provider.
Q: What are the subpart designation guidelines?
A: CMS-specified health care providers are responsible for determining if they have “subparts”
that need to have NPIs. If they do, these health care providers must ensure that the subparts
obtain their own unique NPIs, or they must obtain NPIs for them. Below are some guidelines
to help determine if an enrolled Medicare organization health care provider has a subpart that
will need its own unique NPI. Regarding all of the entities that could be considered subparts:
- A subpart is not itself a separate legal entity, but is a part of a covered organization health
care provider that is a legal entity. (All covered entities under HIPAA are legal entities.)
- A subpart furnishes health care as defined in 45 CFR 160.103. Regarding some or all of the
entities that a CMS-specified health care provider could consider as subparts.
- A subpart may or may not be located at the same location as the covered organization
health care provider of which it is a part.
- A subpart may or may not have a taxonomy (Medicare specialty) that is the same as the
covered organization health care provider of which it is a part.
- Federal statutes or regulations pertaining to requirements for the unique identification of enrolled Medicare providers may relate to entities that could be considered subparts according to the discussion in the NPI Final Rule. If such statutes or regulations exist, the health care providers to whom they apply would need NPIs in order to ensure they can continue to be uniquely identified.
- A subpart that conducts any of the HIPAA-standard transactions separately from the covered
organization health care provider of which it is a part must have its own unique NPI. [v]
Q: Is there a way to link an individual NPI to a group or organization?
A: No. NPIs are not tied together in the national database, NPPES. Each NPI stands alone.
For example, the NPI of an organizational provider is not linked to the NPIs of its subparts or
affiliated corporations except to the extent that they may share certain data, such as tax
numbers, or have similar names.
Q: What is the mandated usage for NPI?
A: NPI must be the primary identifier in each of the following HIPAA-mandated electronic
transactions:
- 837 – Claim Submission, institutional, professional, and dental
- 835 – Remittance Advice
- 270/271 – Eligibility Inquiry and Response
- 276/277 – Claims Status Request and Response
- 278 – Referrals and Response
- Pharmacy – National Council for Prescription Drug Programs (NCPDP) transactions
Q: Can the NPI be used for other purposes beyond those in the mandate?
A: Yes. There are recommendations to use NPIs on paper-claim submissions. Forms
UB04 and CMS 1500 have been modified to accept NPIs. HCFA 1500 new form is available
and the new UB04 form should be available in April of 2007.
Q: If I do not submit electronic transactions, why do I need an NPI?
A: All HIPAA-standard transactions are impacted by the NPI – not just electronic claims.
Also, pharmacy providers will need to access your NPI to process your prescriptions.
Q: How do I submit the NPI on a paper HCFA 1500 form or a UB92 form?
A: An updated HCFA 1500 form is available. The new form has a designated field for the
NPI. Please do not use the old HCFA 1500 form and input the NPI in the tax ID field. Use
the new form with the NPI field. Paper submitters are not mandated to use their NPI but it
is recommended. A new and updated UB92 form (new name UB04) will be available in
April 2007 and will have fields specifically for the NPI.
Q: Can an NPI be deactivated?
A: Yes. However, NPIs are intended to be assigned for life and can be deactivated only under
the most extreme circumstances, such as the following:
- Identity theft cases when the provider’s NPI has been used fraudulently
- Provider’s death
- Provider’s retirement
Q: When can I begin to send my NPI to Humana?
A: Humana began its dual identifier period on October 20, 2006. Providers are being asked to
send their NPI, tax ID, and any Humana IDs they have used in the past on transactions
Q: Where can I find more information about HIPAA and NPI standards?
A: For information about NPI, or other HIPAA standards, see the CMS Website: HIPAA Overview. This site provides information related to NPI and other HIPAA standards. At this time, Humana is not requiring providers to submit their NPIs. Please check back for updates.
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