The National Provider Identifier (NPI)

Date Issued: November 3, 2014

RECIPIENT: All OASAS-Certified Treatment Providers, Local Governmental Units (LGUs)

PURPOSE: To remind OASAS certified treatment providers and Local County Governmental Units of the Federal National Provider Identifier (NPI) requirement. In addition, this Bulletin provides Web links to Federal and New York State information and guidance on NPI requirements, as well as information on how to obtain an NPI number.

BACKGROUND: Beginning in 2006, the New York State Department of Health (NYS DoH) and its contracted Medicaid intermediary, Computer Sciences Corporation (CSC), asked State agencies to support their efforts to increase Medicaid providers' awareness of the National Provider Identifier (NPI) requirements and to emphasize that Medicaid providers and practitioners must obtain and begin using an NPI number by May 23, 2007 to bill Medicaid.

The National Provider Identifier (NPI) is the standard unique health identifier for health care providers. It is mandated by the Federal Health Insurance Portability and Accountability Act of 1996 (HIPAA). The purpose of the NPI is to uniquely identify a health care provider in standard transactions, such as health care insurance claims; NPIs may also be used in other ways, such as: identifying health care providers on prescriptions; in internal files to link proprietary provider identification numbers and other information; in coordination of benefits between health plans; in patient medical record systems; and in program integrity files.

Effective May 23, 2007, the National Provider Identifier (NPI) replaced all previous provider identifiers in HIPAA standard transactions. Previous provider identifiers that will no longer be valid include: UPIN; Medicaid provider number; Medicare provider number; and Blue Cross and Blue Shield number. (Note, however, that chemical dependence providers must continue to report required data as required by the Federal government for purposes unrelated to Medicaid/HIPAA, using other prescribed identifiers such as the Inventory of Substance Abuse Treatment Services or I-SATS.)

APPLICABILITY: HIPAA requires that any provider that transmits health information in electronic form, in connection with a transaction for which the Secretary of Health and Human Services has adopted a standard, will be required to obtain and use an NPI number. Accordingly, covered entities include, but are not limited to: individual practitioners, providers of OASAS certified services; health insurance plans; and health care clearinghouses.

REQUIRED ACTION: Medicaid claims cannot be submitted without the appropriate NPI numbers. All OASAS certified providers (including hospitals and clinics) and individual practitioners (including salaried staff, ordering, referring or otherwise) who are required by HIPAA to be identified on a billing claim, must have and use an NPI number.

The NYS DOH has issued a Medicaid Update Article informing providers about NPI. To view a copy of this update article please go to: http://www.health.ny.gov/health_care/medicaid/program/update/2005/oct2005.htmNYSDOH has also directed that additional questions should be referred to the CSC call center at 1-800-343-9000.

HOW TO APPLY FOR AN NPI: Apply through a web-based application process. The web address is https://nppes.cms.hhs.gov/NPPES/Welcome.do.

The Enumerator’s phone number is 1-800-465-3203 or TTY 1-800-692-2326. Individual practitioners employed by a large provider (e.g. hospitals with more than 200 employees) may choose to designate the hospital as the electronic file organization (EFIO) responsible for submitting their NPI information. The EFIO (in this example the hospital) will submit the individual employee’s NPI application information to the National Plan and Provider Enumeration System (NPPES) in an organization (hospital) specific electronic file. For more information please call 1-800-465 3203 and ask for the EFI specialist or refer to the EFI web section at: https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/NationalProvIdentStand/efi.html