Frequently Asked Questions - NPI

• An NPI is a 10-digit, intelligence-free numeric identifier. Intelligence-free means that the numbers do not carry information about health care providers, such as the state in which they practice or their provider type or specialization.
• NPIs will replace health care provider identifiers that are currently being used for Health Insurance Portability and Accountability Act (HIPAA) standard transactions. Those numbers include payer-specific IDs and Medicare legacy IDs (e.g. UPIN, OSCAR, PIN, and National Supplier Clearinghouse or NSC).
• A provider's NPI will not change and will remain with the provider regardless of job or location change(s).

Yes. Under the National Provider Identifier Regulation (published in the Federal Register on January 23, 2004), a health care provider who is a "covered entity," as defined in the HIPAA Regulations at 45 C.F.R. § 160.103, and who transmits any health information in connection with a standard transaction, is required to obtain an NPI.

• HIPAA required the adoption of a standard identifier for health care providers.
• NPI allows for simpler electronic transmission of HIPAA standard transactions, and more efficient coordination of benefits transactions.
• The NPI will be the only health care provider identifier that can be used for identification purposes in standard electronic transactions by covered entities.

Providers who have not yet obtained their NPI may apply for it in one of the following ways:

• Through an easy, web-based application process that takes approximately 20 minutes to complete online at https://nppes.cms.hhs.gov.
• Through a paper application that is mailed to the National Provider Identifier Enumerator. Paper applications may be downloaded from https://nppes.cms.hhs.gov. You may also call the National Provider Identifier Enumerator call center at (800) 465-3203 to request a paper application.
• Through an electronic file submitted by an Organization (see question 5 for the definition of an Organization). You must have the permission of the health care provider to apply for an NPI by this method.

• An individual is eligible for a single NPI. An individual cannot have subparts and cannot designate subparts. In terms of NPI assignments, an individual is an Entity Type 1 (Individual).
• A sole proprietor/sole proprietorship is eligible for a single NPI. A sole proprietor/sole proprietorship cannot have subparts and cannot designate subparts. In terms of NPI assignment, a sole proprietor/sole proprietorship is an entity Type I (individual).
• Organizations must also apply for a single NPI. In terms of NPI assignment, Organization health care providers who are covered entities under HIPAA must apply for NPIs as Entity Type 2 (Organizations). Organization health care providers are corporations or partnerships or other types of businesses that are considered separate from an individual by the State in which they exist. Subparts of such Organization health care providers who apply for NPIs are also Entity Type 2 (Organizations).
  • A subpart must have its own NPI if it conducts any of the HIPAA standard transactions separately from the covered Organization health care provider of which it is a part. If your organization has subparts, please ensure that they each obtain their own unique NPIs, or obtain the NPIs for them.
  • For further clarification regarding Entity Types and Subparts, please visit the Centers for Medicare and Medicaid Services website.

The Provider Taxonomy is an alphanumeric code, ten characters in length that allows a single provider (individual, group, or institution) to identify their specialty category. Information on provider taxonomy codes is available at www.wpc-edi.com/taxonomy.

The Centers for Medicare & Medicaid Services (CMS) cannot predict the amount of time it will take to obtain an NPI due to several factors. Such factors CMS considers include:

• Volume of applications being processed at a given time
• If the application is submitted electronically or on paper
• If the application is complete and free of errors. When gathering information for the application, be sure that all provider information, such as Social Security Number and Federal Employer Identification Number (FEIN), are correct.

You can report your NPIs to AmeriHealth Caritas Pennsylvania by completing and returning the AmeriHealth Caritas National Provider Identifier Submission Form also found in the Provider Center online. Instructions for faxing or mailing are on the form. Always include your AmeriHealth Caritas Plan ID when reporting your NPI.

The Centers for Medicare & Medicaid Services website is an excellent resource for detailed information on the National Provider Identifier. Visit the Centers for Medicare and Medicaid Services website at: https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/NationalProvIdentStand.