In an increasingly digitized healthcare landscape, the National Provider Identifier (NPI) serves as a critical component for the identification of healthcare providers across the United States.
This unique 10-digit number is essential for individual providers, healthcare institutions, and other entities involved in healthcare that are covered under the Health Insurance Portability and Accountability Act (HIPAA).
This article aims to demystify the NPI number, explaining its significance in the healthcare industry and providing a detailed guide on how healthcare professionals can obtain one. We'll cover who needs an NPI, how to navigate the application process, and how to maintain and update your NPI information.
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What is a National Provider Identifier (NPI) Number?
An NPI is a unique 10-digit number used to identify individual healthcare providers, healthcare institutions, health plans, and healthcare clearinghouses that are covered under HIPAA. NPI was created out of an identified need to streamline the electronic transmission of health data to increase efficacy and speed and reduce mistakes.
It was developed by the Centers for Medicare and Medicaid Services (CMS) and adopted in 1996 in response to the enactment of HIPAA, which required a standard identification number for practitioners (11).
NPI numbers are used on any standard transactions covered under HIPAA, such as insurance claims, referrals, and prescriptions (3).
Once an NPI number is assigned, it is permanently associated with that individual. NPI numbers themselves do not contain any further identifying information beyond the name of the provider and thus do not change even if a practitioner changes clinics, addresses, or obtains additional specialty training (2).
However, NPI numbers are searchable via the NPI Registry available online where primary practice address, practice phone number, and provider taxonomy are provided.
Who Needs an NPI Number?
NPI numbers are mandatory for all healthcare providers and organizations that must comply with HIPAA, including those that electronically transmit HIPAA-covered health data, such as healthcare clearinghouses and commercial and public health insurance plans.
Even providers not directly covered by HIPAA need an NPI if they exchange health information with HIPAA-compliant entities (3).
These numbers are crucial for identifying providers in various financial and administrative transactions, including submitting claims, processing payments, and managing eligibility, enrollments, and preauthorizations.
Additionally, NPI numbers are utilized in electronic health records, patient laboratory orders, referrals, care transfers, and prescriptions, ensuring streamlined operations across healthcare processes (3).
HIPAA-Covered Health Care Provider Examples:
- Physicians, including MDs, DOs, and NDs
- Physician’s Assistants
- Nurse Practitioners
- Physical Therapists
- Chiropractors
- Dentists
- Psychologists
- Nutritionists and Dieticians
- Acupuncturists
- Massage Therapists
- Health Coaches
- Hospitals
- Clinics
- Pharmacies
- Nursing Homes
- Home Health Agencies
- Laboratories
Benefits of Having an NPI Number
The adoption of the NPI system ensures that each provider has a distinct number that is recognized by all HIPAA-covered entities, leading to:
- Quicker processing of claims submissions
- More streamlined transmission of health data
- Simplified coordination of benefit transactions
- Compliance with Medicare credentialing requires an NPI number for applications.
How to Apply for an NPI Number
When ready to apply, here are the next steps:
Step-by-Step Application Process:
- To apply online for an NPI number, visit the National Plan and Provider Enumeration System (NPPES) website. Applying via the NPPES website results in quicker processing times and assignment of NPI numbers.
- When you first visit the NPPES website, you will be asked to create an Identity and Access Management System Account (I&A) where you will create a user ID and password on a separate webpage. Note that NPPES uses multi-factor identification so consider using a personal email or phone number in case you change clinics in the future. When finished, return to the NPPES main page to log in.
- Once logged in, you will be sent to the main application page, where you will choose to apply for an NPI for yourself, for another individual, or for an organization. After choosing one of these three options, the website will guide you step by step through the application process.
- Alternatively, if you rather apply by mail, download the NPI Application/Update Form, fill out the form completely, and sign.
- Information needed for the application includes: some text
- Provider Name or Organization Name
- Social Security Number or Employer Identification Number if Organization
- Provider Date of Birth
- Country of Birth
- State of Birth (if within the United States)
- Provider Gender
- Mailing Address
- Practice Location and Phone Number
- Taxonomy Code(s) aka Provider Type (such as Physician, Pharmacist, Chiropractor, etc). If you are unsure of what taxonomy code you fall under, use this list for guidance.
- State License Information
- Contact Person Name
- Contact Person Phone Number and Email
- Once you have filled out the application, check to verify all information is correct and submit it online. If you are submitting a hard copy via mail, mail to the NPI Enumerator at the following address: 7125 Ambassador Rd, Ste 100, Windsor Mill, MD 21244-2751
- If at any point you have questions about the application process, you can contact the NPI Enumerator Monday through Friday from 9 am-5 pm EST:some text
- By Phone: 1-800-465-3203
- By Phone: 1-800-692-2326 (for individuals with hearing or speech difficulties)
- By Email: [email protected]
Documentation Needed:
The NPI application process does not require the submission of documents such as a medical license or state ID. CMS will only verify the associated social security number or EIN and whether the business address listed is legitimate. Note that it does not verify any of the other information provided and instead depends on the accuracy of self-reporting by applicants (3).
Processing Time and What to Expect:
NPI numbers are assigned promptly. Providers that submit applications via the NPPES website can expect to receive their NPI number within 10 days. Providers who submit hard copies by mail take longer, at 20 days. Once applications are processed and approved, the NPI Enumerator office will contact applicants with their NPI number via email. Additionally, NPI numbers will be added to the NPI registry, where it can be searched for by provider or organization name.
Maintaining and Updating Your NPI Information
Once an NPI is obtained, there are no scheduled updates required to make sure the information originally provided on the NPI application is current (2). However, CMS advises providers and organizations to update their information within 30 days of practice location, name, taxonomy, or contact information changes. This is done via the online application system on the NPPES website where original applications are submitted or mailing updated information on the NPI Application/Update Form to the NPI Enumerator office (11). Although updates are urged, there are no penalties for failing to provide updates (2).
Because an NPI number is meant to be permanent, there are only a few circumstances in which an NPI number might be deactivated. These include:
- The provider is no longer practicing
- Provider has passed away
- Fraudulent activity
- An organization assigned an NPI is disbanded
If an NPI was mistakenly deactivated or if a previously disbanded organization reactivates, they can apply for reactivation, which CMS will allow when appropriate (11).
Common Questions and Challenges
How do I figure out if I need to apply for an NPI number?
Any healthcare provider that meets the legal definition can apply for an NPI, though it may not be required.
For providers who do not take insurance and do not engage in the electronic transmission of health information such as ordering prescriptions or labwork, the answer may not be clear. For help determining if you meet these requirements, the CMS website has a Covered Entity Decision Tool to help you decide.
Do I need a separate NPI number for my clinic if I am a solo practitioner?
The answer to this depends on how your business is structured. If you are a sole proprietor, then you do not need a separate NPI number and instead can use your individual NPI.
If however, your business is incorporated, such as a single-owner LLC or SCorp, then you do need to acquire a separate NPI for the business even if you are the only employee (3).
What if I am a medical student or intern?
As long as you are a healthcare provider and you participate in the transmission of electronic health data as a HIPAA-covered entity, you are required to obtain an NPI (12).
If I move to a different practice or change my specialty, do I need a new NPI?
No, once your NPI number is issued it is permanent and remains with you unless deactivated for the reasons discussed above. You should, however, update your information on the NPI Registry (11).
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Key Takeaways
- The NPI is crucial for modern healthcare administration, simplifying the management of administrative and financial transactions under HIPAA.
- Healthcare providers need to obtain their NPI and keep their information up to date to ensure compliance and operational efficiency.
- Prioritizing the management of your NPI number enhances practice functionality and adherence to federal regulations.
- A well-managed NPI is key to streamlined healthcare delivery and administrative ease.
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