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Identifiers

The Health Insurance Portability and Accountability Act (HIPAA) Transactions, Code Sets and Identifiers (TCS&I) Office facilitates the implementation of nationwide standards of identifiers used in HIPAA-compliant electronic health care transactions for the Military Health System (MHS).

HIPAA requires the adoption of standard unique identifiers for employers, health plans, patients and providers to be used in HIPAA Electronic Transactions. To date, the following are some adopted standard identifiers:

Note: The National Patient Identifier (to be applied to patients) has not yet been named by the Department of Health and Human Services (HHS).

Frequently Asked Questions

Q1:

What is the National Provider Identifier (NPI)?

A:

The NPI is a unique identification number for health care providers. Health care providers, health plans and health care clearinghouses use NPIs in the administrative and financial transactions specified by HIPAA. The NPI is a 10-position numeric identifier with a check digit in the last position to help detect invalid NPIs. The NPI contains no embedded intelligence; that is, it contains no information about the health care provider such as the type of health care provider or state where the health care provider is located.

Q2:

Which entities within and external to the MHS are required to get a National Provider Identifier (NPI)?

A:

There are two Health Affairs (HA) Policies and one HA Guideline that describe the types of providers in the MHS that require NPIs. These include: HA Policy 05-002 (NPI Enumeration of MHS Individual (Type 1) Health Care Providers), HA Policy 05-012 (NPI Enumeration of MHS Organizational (Type 2) Health Care Providers) and HA Guideline dated May 2007. According to these policies and guideline the following MHS providers are required to obtain and use an NPI: 

Individual (Type 1) Health Care Providers

Providers who furnish billable services or those that may initiate and/or receive referrals. In the MHS, this affects the following types of providers: All privileged providers, residents, and certain non-privileged providers such as Independent Duty Corpsmen who request referrals, Independent Duty Medical Technicians working in the cast clinic, or a nurse giving Depo-Provera injections when the patient has not seen the physician. These provider types need to be identified with an NPI in certain HIPAA electronic transactions.

Organizational (Type 2) Health Care Providers

  • Military Treatment Facilities (MTFs) with legislative authority to bill, including Defense Health Program (DHP) funded facilities and air evacuation facilities
  • MTFs that generate ambulatory data records, third party bills, Standard Inpatient Data Records and Standard Ambulatory Data Records
  • MTF pharmacy dispensing locations that currently have an NCPDP provider identification number
  • MTFs that generate or perform referrals
  • MTFs that provide health care services
Q3:

When are MHS providers required to use the National Provider Identifier (NPI)?

A:

MHS providers have been required to obtain and use the NPI since 2007.

Q4:

How are National Provider Identifiers (NPIs) issued?

A:

Health care providers can obtain NPIs by submitting an application to the National Plan and Provider Enumeration System (NPPES). The NPPES was developed by the Centers for Medicare and Medicaid Services (CMS) to process NPI applications. Providers have two options when applying for their NPIs:

After an application is successfully processed, health care providers will be notified of their NPIs. HHS has contracted with an organization, known as the enumerator, to process NPI applications. In addition to receiving and processing NPI applications and notifying health care providers of their NPIs, the enumerator uses the NPPES to perform the following functions: ensure the unique identification of a health care provider; answer questions about the processes of applying for and obtaining NPIs and furnishing updates; collect information via the applications and updates, maintain the NPPES database containing NPIs and information about the health care providers to which they are assigned; and furnish information upon request and in accordance with established guidelines.

Q5:

What should you do now as a MHS provider?

A:

Ensure the MHS has your National Provider Identifier (NPI) on file. MHS providers who furnish billable health care services, write prescriptions, initiate and/or receive referrals should have obtained, submitted and began using an NPI effective May 2007. This includes all privileged providers, residents, and certain non-privileged providers. Non-privileged providers are required to obtain an NPI if they request referrals, request consults, write prescriptions or provide billable services. For example, Independent Duty Corpair smen who request referrals, Independent Duty Medical Technicians working in the cast clinic or a nurse giving Depo-Provera injections when the patient has not seen the physician would need to be identified in certain HIPAA electronic transactions.

  1. Active Duty providers in any of the Services should submit their NPI to their Military Treatment Facility (MTF) Credentialing Office.
  2. Army Reserve providers should submit their NPI to the Army Reserve Centralized Credentialing Affairs (ARCCA), excluding the Individual Mobilization Augmentee (IMA) who will turn it into their MTF of assignment.
  3. Army National Guard providers should submit their NPI into the State Surgeons Office where their credentialing office is located.
  4. Navy Reserve Independent Practitioners should provide their NPI during the normal privileging application process. The Centralized Credentials and Privileging Department, NHSO Jacksonville began collecting NPIs effective June 15, 2005.
  5. Air Force Reserve and Guard providers should submit a copy of their NPI letter to their local reserve or guard unit Credentials Manager.

Once an MHS provider has an NPI, these offices will forward a copy of the NPI letter to the appropriate support office for entry of the NPI information into the Defense Manpower Human Resource System internet (DMHRSi), which is the MHS repository for the NPI. If you are a new MHS provider, refer to the question, "How are NPIs issued?"

Q6:

Are there any special instructions for Physician Assistants (PAs)?

A:

Due to the inconsistency between state licensure requirements for PAs, they are allowed to obtain an NPI without having to furnish a license number and/or state of license.

Q7:

Will I use the same National Provider Identifier (NPI) that I have for my civilian practice?

A:

Yes, you have just one NPI for life; no matter where you are working or what specialty you are practicing.

Q8:

How are National Provider Identifiers (NPIs) used in the MHS?

A:

The NPI is used as a means of communicating the identity of providers in HIPAA electronic transactions (e.g., billing and referral purposes) both within and external to the MHS. NPIs are also used for non-HIPAA purposes where a provider identifier is needed, such as on paper claim forms (e.g., CMS-1500 and UB-04 claims) referral forms and on prescriptions.

Q9:

What are the uses of the National Provider Identifier (NPI)?

A:

The NPI must be used to identify providers in standard electronic transactions identified by HIPAA. In addition, the NPI may be used in several other ways:

  1. By health care providers to identify themselves in health care transactions identified in HIPAA or on related correspondence;
  2. By health care providers to identify other health care providers in health care transactions or on related correspondence;
  3. By health care providers on prescriptions (however, the NPI could not replace requirements for the Drug Enforcement Administration number or State license number);
  4. By health plans in their internal provider files to process transactions and communicate with health care providers;
  5. By health plans to coordinate benefits with other health plans;
  6. By health care clearinghouses in their internal files to create and process standard transactions and to communicate with health care providers and health plans;
  7. By electronic patient record systems to identify treating health care providers in patient medical records;
  8. By Health and Human Services (HHS) to cross reference health care providers in fraud and abuse files and other program integrity files;
  9. For any other lawful activity requiring individual identification of health care providers, including activities related to the Debt Collection Improvement Act of 1996 and the Balanced Budget Act of 1997.
Q10:

Can health care providers use other numbers besides the National Provider Identifier (NPI) to identify themselves in standard transactions?

A:

As of May 23, 2008, the NPI is the only identifier that can be used to identify a health care provider in standard transactions. Use of legacy identifiers (such as the Unique Physician Identification Number (UPIN), Medicaid Provider Number, Medicare Provider Number, and others) were discontinued on May 23, 2008. Where a health care provider must be identified in standard transactions for tax purposes, it would use its Taxpayer identification as required by the implementation specifications. Health care provider identifiers other than the NPI may continue to be used in the internal processes and files of health plans or health care clearinghouses if they wish to continue to use those identification numbers in those internal processes and files.

Q11:

Can a health plan require its enrolled health care providers who are not covered entities to obtain and use National Provider Identifiers (NPIs)?

A:

Yes, although the NPI Final Rule does not require that health care providers who are not covered entities under HIPAA obtain or use an NPI, the Rule also does not prohibit health plans from requiring their enrolled health care providers that are eligible for an NPI to obtain one.

Note: The NPI Final Rule does prohibit health plans from requiring a health care provider with an NPI to obtain additional NPIs.

Q12:

What if I am a provider who does not use HIPAA electronic transactions for billing or other administrative aspects of providing healthcare? Is there any reason why I should get a National Provider Identifier (NPI)?

A:

While the NPI Final Rule does not require providers who do not conduct HIPAA electronic transactions to obtain an NPI, all eligible providers are encouraged to obtain an NPI. One reason is that the CMS-1500 and UB-04 paper claim forms were updated to accommodate the NPI and health plans have the option to require the NPI be used on these paper forms. Another reason for eligible providers to get an NPI is that there may still be other instances where providers who do not conduct HIPAA standard electronic transactions would need to be identified in standard transactions conducted by other providers. For example, a physician who writes a prescription (electronic or paper) but does not bill health plans directly is not required by the NPI Final Rule to obtain an NPI; however, there are transactions that will be generated after the prescription is written, and some of those are standard electronic transactions. The pharmacy that fills the prescription will most likely bill for the prescription claim electronically (a HIPAA standard electronic transaction). If the physician who wrote the prescription does not have an NPI, the pharmacy is left with the problem of how to identify the prescriber on this billing transaction.

Q13:

Will a health care provider's National Provider Identifier (NPI) ever change?

A:

The NPI is meant to be a lasting identifier, and does not change based on changes in a health care provider's name, address, ownership, membership in health plans, or Healthcare Provider Taxonomy classification. There may be situations where use of an NPI for fraudulent purposes results in a health care provider requesting a different NPI. Such situations will be investigated and a different NPI may be assigned to the requesting health care provider.

Q14:

Are health care providers required to renew their National Provider Identifier (NPI)?

A:

Health care providers are not required to renew their NPI once issued.

Q15:

If a health care provider with a National Provider Identifier (NPI) moves to a new location, must the health care provider notify the enumerator of its new address?

A:

A covered health care provider must notify the enumerator of changes in any of the information that it furnished on its application for an NPI, and must do so within 30 days of the change. Health care providers who have been assigned NPIs, but are not covered entities, should do the same.

Q16:

How long does it take to get a National Provider Identifier (NPI)?

A:

According to the enumerator, it is difficult to predict the amount of time it takes to obtain an NPI because several factors come into play. Such factors include the volume of applications being processed at a given time, whether the application was submitted electronically or on paper, and whether the application was complete and passed all edits. It is expected that a health care provider who submits a properly completed electronic application could have their NPI within 10 days.

Q17:

Does a health care provider have to pay for a National Provider Identifier (NPI)?

A:

No, a health care provider is not charged, and does not have to pay a fee in order to obtain an NPI.

Q18:

Will there be enough National Provider Identifiers (NPIs) to enumerate all health care providers? Will we ever run out?

A:

Yes, there will be enough NPIs. The format of the NPI and the assignment strategy will enable the enumeration of over 200 million health care providers. Yes, the availability of NPIs will eventually run out. At the current rate of increase in the number of providers in the United States, this should enable HHS to enumerate health care providers for 200 years.

Q19:

Can National Provider Identifiers (NPIs) be used on paper claims transactions?

A:

The use of NPIs on paper claims transactions is allowed. The health plan receiving the claim may make the determination on the use of NPIs on paper claims transactions. HIPAA regulations adopt standards for format and content of certain electronic health transactions; they do not address the content of paper claims transactions.

Q20:

Does the National Provider Identifier (NPI) replace the use of provider Social Security Numbers (SSNs) in medical records and on other medical administrative paperwork?

A:

In some cases, an SSN may be the most appropriate identifier (e.g., in uses where there are tax implications). Over time, users of the NPI will likely find places where the NPI can take the place of other identifiers (possibly including some places where the SSN is currently used). HIPAA only requires the use of NPI for HIPAA-covered electronic transactions, but the MHS and other health care organizations may decide to use the NPI to improve or simplify other healthcare business processes.

Q21:

How do I update information on my National Provider Identifier (NPI)?

A:

To update information associated with your NPI, such as a tax ID and Provider name, or to apply for an NPI, contact the NPI Enumerator. The NPI Enumerator is responsible for assisting health care providers in applying for their NPIs and updating information in the National Plan and Provider Enumeration System (NPPES). For more information, visit the NPPES Website.

Q22:

How do I submit my National Provider Identifier (NPI) to TRICARE?

A:

NPI submission is based on region. Please choose the appropriate region from the following links: 

Q23:

Where can I find National Provider Identifiers (NPIs) for the MHS' providers or facilities? Is there a list of providers at each Military Treatment Facility (MTF)?

A:

MTFs are not providing lists of individual providers' NPIs; however, a list of MHS organizational provider NPIs is available on the Defense Medical Information Systems Identifier (DMIS ID) table.

NPIs of individual providers and organizational providers are included as required on referrals, and HIPAA transactions such as electronic claims, etc. 

In addition, the CMS/NPI Enumerator made an online search Registry available to the public. The NPIs of all providers and facilities that have obtained NPIs are available via this query only database known as the NPI Registry.

UserIDs and passwords are not needed to use the NPI Registry and there is no charge to use it. The NPI Registry enables users to query using the NPI or the name of the provider. The NPI Registry will return the results of the query to the user, and the user will click on the record(s) he/she wants to see. The NPI Registry will then display the Freedom of Information Act (FOIA)-disclosable data for those records. 

NPI data is also available in monthly downloadable files at no charge or need for UserIDs and passwords. Just like the search registry, the file will contain the FOIA-disclosable NPI data for health care providers who have been assigned NPIs.  

Each month CMS makes a file available that replaces the previous month's file. This is a full replacement, not an update file. It reflects updates and changes that were applied to the NPPES records of enumerated health care providers between the date the previous file was created and the date the full replacement file is created.

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