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What is a NPI again?
The National Provider Identifier (NPI) is a Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification Standard. The NPI is a unique identification number for covered health care providers. Covered health care providers and all health plans and health care clearinghouses must use the NPIs in the administrative and financial transactions adopted under HIPAA. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number). This means that the numbers do not carry other information about healthcare providers, such as the state in which they live or their medical specialty. The NPI must be used in lieu of legacy provider identifiers in the HIPAA standards transactions.
As outlined in the Federal Regulation, The Health Insurance Portability and Accountability Act of 1996 (HIPAA), covered providers must also share their NPI with other providers, health plans, clearinghouses, and any entity that may need it for billing purposes.
When should you get a new NPI?
The National Provider Identifier (NPI) is meant to be a lasting identifier, and is expected to remain unchanged even if a health care provider changes his or her name, address, provider taxonomy, or other information that was furnished as part of the original NPI application process. There are some situations, however, in which an NPI may change such as when health care provider organizations determine they may need a new NPI due to, for example, certain changes of ownership, the conditions of a purchase, or a new owners subpart strategies. There also may be situations where a new NPI is necessary because the current NPI was used for fraudulent purposes.
A health care provider (or the trustee/legal representative of a health care provider) should deactivate its NPI in certain situations, such as retirement or death of an individual, disbandment of an organization, or fraudulent use of the NPI. To deactivate an NPI, a health care provider (or the trustee/legal representative of a health care provider) must complete a CMS-10114 and mail it to the NPI Enumerator.
Does the NPI replace the tax ID number?
The billing provider’s tax ID number and NPI are always required on claims. Any other providers identified on the claim, such as rendering provider or service facility, must be identified with their NPI only. Their tax ID number should not be included.
For eligibility, claim status inquiry, referral and precertification, only the NPI (no tax ID number) is used.
How does a rendering physician report their National Provider Identifier (NPI) on a claim that includes Physician Quality Reporting Initiative (PQRI) or Electronic Prescribing Incentive Program (eRx) quality-data codes (QDCs)? What if he/she is part of a group and the group NPI is used on the claim?
Your individual National Provider Identifier (NPI) must be included on the claim line items for the quality-data codes (QDCs) you submit as well as the line items for the services to which the QDC is applicable. The PQRI/eRx QDC must be included on the same claim that is submitted for payment at the time the claim is initially submitted in order to be included in PQRI analysis.
If a group NPI is used at the claim level, the individual rendering physician’s NPI must be placed on each line item, including all allowed-charge and quality-data line items. See the PQRI Implementation Guide for a sample CMS-1500 claim. This is available as a download from the Measures/Codes section of the CMS PQRI website. For eRx, see the Claims-Based Reporting Principles for eRx, available on the CMS eRx website.
If a health care provider with a National Provider Identifier (NPI) moves to a new location, must the health care provider notify the National Plan and Provider Enumeration System (NPPES) of its new address?
Yes. A covered health care provider must notify the NPPES of the address change within 30 days of the effective date of the change. We encourage health care providers who have been assigned NPIs, but who are not covered entities, to do the same. A health care provider may submit the change to NPPES via the web or by paper. If paper is preferred, the health care provider may download the NPI Application/Update Form (CMS-10114) from the Centers for Medicare & Medicaid Services’ forms page or may call the NPI Enumerator (1-800-465-3203) and request a form.
What happens when you join a group?
In Section 4B of the CMS-855I, the NPI of the Group should be entered if it has been issued to the Group. If you are joining a group, the group is responsible for providing you with their current Provider Identification Number (PIN) and the NPI, if they have been issued.
If you are a solo physician with an incorporated practice, how many NPIs should you have?
An individual is eligible for only one NPI. In the above example, there are two health care providers: the physician and the corporation. The physician would obtain an NPI (Entity Type Code 1, Individual). The corporation would obtain an NPI (Entity Type Code 2, Organization). Generally, the corporations NPI would represent the Billing and Pay-to Providers and the physicians NPI would represent the Rendering, Referring/Ordering, Attending, Operating and/or Other Providers. These physicians should ensure that their enrollment records with the health plans to whom they will be sending claims are up to date, that those health plans are aware of the assigned NPIs, and that the NPIs are used in a way that is compatible with their enrollment.
I do not submit healthcare claims to Medicare; do I need a National Provider Identifier (NPI)?
Where can you look up NPIs?
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I am one of two providers in a small practice. We currently have a total of three NPI numbers (each provider and the practice).
For tax and accounting reasons, we have been advised to change our corporate structure in a manner that will require a new Federal Tax ID (closing down the old practice entity and creating a new practice entity).
It appears the two providers will not need a new NPI (and should not apply for one), but rather, update their exisitng NPI information via the web to show the new Federal Tax ID when it is in place.
It further appears that the NPI of the previous practice will be terminated and a new NPI should be sought for the new legal entity.
Does this sound correct?
Hi William,
Yes, this sounds perfectly correct! Good advice.
Best wishes,
Mary Pat
Currently have 5 locations all owed by same provider. Other providers work for him. We have NPI’s for each location and each provider. Do now have one for the group. Currently bill from a different address from any of the above. Do I need an NPI for the Billing address and one for the Group?
Hi Linda,
You do not need one for the group based on this information from CMS:
What types of business structures are considered organization health care providers and thus eligible for organization NPIs? What types are not?
The NPI final rule defines “organization health care providers” as providers who are not individuals (persons). These are classified as Entity Type 2 providers. Examples are 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, among others.
A sole proprietorship is a form of business in which one person owns all of the assets of the business and is solely liable for all debts on an individual basis. Sole proprietors are individuals, and they must apply for their NPIs as Individuals (Entity Type I). The subpart concept does not apply to a sole proprietorship, even one with multiple locations, because the sole proprietorship is not an organization as defined in the Final NPI Rule (69FR3434).
State laws enable the creation of many other different types of businesses. While we cannot address every possible type of business structure, we apply the following broad principle to determine whether a business is eligible for an organization NPI: Any organization that is recognized by the State as separate and distinct from the individual is eligible for an organization NPI. The law in each State will govern how different business types are recognized by the State.
Your billing address does not need an NPI.
Best wishes,
Mary Pat
I am a psychologist who just formed a PLLC, where I am the only practitioner. Prior to that, I was just a sole practitioner. I have obtained a new tax ID number for the PLLC and was planning on just using my existing NPI. Since I am the only practitioner (member) of the PLLC, I don’t think I need a new NPI for the PLLC. Is that correct?
Hi Josh,
You are absolutely correct! Organizational NPIs are not needed for solo owners.
Best wishes,
Mary Pat
We are billing for a solo incorporated provider that travels to two rural communities once a month. He recently acquired an additional tax id for the rural areas for billing purposes.
He already has an organizational NPI for his non-rural tax id. For this additional rural tax id, he has formed a new corporation but is still a solo inc provider. Based on what I am reading, we do not need an additional organizational NPI for the rural tax id as he is a solo inc provider. However, because he already has an NPI with his non-rural tax id corp, do I need to acquire a new organizational NPI with his rural corp to be consistent?
Thanks!
Hi Margi,
I don’t see any reason for you to get an additional NPI. It only complicates things unnecessarily.
Best wishes,
Mary Pat
I have the same question as Josh above. The Q&A from CMS below seems to contradict your guidance. What do you think? Thanks.
Does an incorporated individual (e.g., a physician who has formed a corporation) whose corporation employs only one person (i.e., the physician who formed the corporation) need to apply for two National Provider Identifiers (NPIs)?
An individual is eligible for only one NPI. In the above example, there are two health care providers: the physician and the corporation. The physician would obtain an NPI (Entity Type Code 1, Individual). The corporation would obtain an NPI (Entity Type Code 2, Organization). Generally, the corporation’s NPI would represent the Billing and Pay-to Providers and the physician’s NPI would represent the Rendering, Referring/Ordering, Attending, Operating and/or Other Providers. These physicians should ensure that their enrollment records with the health plans to whom they will be sending claims are up to date, that those health plans are aware of the assigned NPIs, and that the NPIs are used in a way that is compatible with their enrollment.
Hello,
my doctor currently has 2 npi one for the practice and one for him. He just advised that he is moving, changing the practice name, and has a new NPI. Called NPPES and was told that i would still have the same npi number.
When I called and spoke to WPS Medicare to update my info they advised me that I needed to obtain NEW NPI numbers and that i could not use my old ones. That I would need to have the doctor reapply/enroll. why would I have to do this.
Thank you
chris
Hi Chris,
There seems to be a lot of confusion surrounding NPI numbers – you are not the first one who has gotten conflicting information!
There is a much heavier focus on fraud, and NPI numbers are the root of billing Medicare.
Sorry I don’t have an explanation for you.
Best wishes,
Mary Pat
Hi Cornelia,
You are right! The Q & A now states that two NPIs are appropriate. Why they changed this language is unclear, but they definitely have changed the language. I’m not clear on their statement that the corporation’s NPI would represent the Billing and Pay-to Providers – why would a solo provider needs a separate number to delineate which entity is billing and should be paid? Unless they’ve decided that as a corporate entity, payers should not be paying his individual NPI and thereby by his social security number instead of his EIN.
Maybe there is a CPA who can clarify – anyone?
Thanks for bringing this up, Cornelia!
Best wishes,
Mary Pat