National Provider Identifier
Encyclopedia
A National Provider Identifier or NPI is a unique 10-digit identification number issued to health care
providers in the United States
by the Centers for Medicare and Medicaid Services
(CMS).
The NPI has replaced the unique provider identification number
(UPIN) as the required identifier for Medicare
services, and is used by other payers, including commercial healthcare insurers. The transition to the NPI was mandated as part of the Administrative Simplifications portion of the Health Insurance Portability and Accountability Act
of 1996 (HIPAA), and CMS began issuing NPIs in October 2006. HIPAA covered entities such as providers completing electronic transactions, healthcare clearinghouses, and large health plans were required by regulation to use only the NPI to identify covered healthcare providers by May 23, 2007. CMS subsequently announced that as of May 23, 2008, CMS will not impose penalties on covered entities that deploy contingency plans to facilitate the compliance of their trading partners (e.g., those healthcare providers who bill them). The posted guidance document can be used by covered entities to design and implement a contingency plan. Details are contained in a CMS document entitled, "Guidance on Compliance with the HIPAA National Provider Identifier (NPI) Rule." Small health plans have one additional year to comply.
All individual HIPAA covered healthcare providers (physician
s, physician assistant
s, nurse practitioner
s, dentist
s, chiropractor
s, physical therapists, athletic trainer
s etc.) or organizations (hospital
s, home health care agencies
, nursing home
s, residential treatment centers
, group practices, laboratories
, pharmacies
, medical equipment
companies, etc.) must obtain an NPI for use in all HIPAA standard transactions, even if a billing agency prepares the transaction. Once assigned, a provider's NPI is permanent and remains with the provider regardless of job or location changes.
Other health industry workers, such as admissions and medical billing personnel, housekeeping staff, and orderlies, who provide support services but not health care, are not required to obtain the NPI.
The NPI was proposed as an 8-position alphanumeric identifier. However, many stakeholders preferred a 10-position numeric identifier with a check digit
in the last position (the first 9 positions are the identifier and the last position is a check digit) to help detect keying errors. The NPI contains no embedded intelligence; that is, it contains no information about the health care provider, such as the type or location of the health care provider.
The NPI must be used in connection with the electronic transactions identified in HIPAA. In addition, the NPI may be used in several other ways:
The NPI number can be obtained online through the National Plan and Provider Enumeration System (NPPES) pages on CMS's website. Turnaround time for obtaining a number is almost instantaneous, unusual for a medical credentialing operation. NPI numbers can be searched on the CMS website listed in external links 'National Plan and Provider Enumeration System information from CMS'.
A 10-digit NPI Number may be validated using the Luhn algorithm
by prefixing "80840" to the 10-digit number.
Health care
Health care is the diagnosis, treatment, and prevention of disease, illness, injury, and other physical and mental impairments in humans. Health care is delivered by practitioners in medicine, chiropractic, dentistry, nursing, pharmacy, allied health, and other care providers...
providers in the United States
United States
The United States of America is a federal constitutional republic comprising fifty states and a federal district...
by the Centers for Medicare and Medicaid Services
Centers for Medicare and Medicaid Services
The Centers for Medicare & Medicaid Services , previously known as the Health Care Financing Administration , is a federal agency within the United States Department of Health and Human Services that administers the Medicare program and works in partnership with state governments to administer...
(CMS).
The NPI has replaced the unique provider identification number
UPIN
A unique physician identification number, or UPIN, was a six-character alpha-numeric identifier used by Medicare to identify doctors in the United States...
(UPIN) as the required identifier for Medicare
Medicare (United States)
Medicare is a social insurance program administered by the United States government, providing health insurance coverage to people who are aged 65 and over; to those who are under 65 and are permanently physically disabled or who have a congenital physical disability; or to those who meet other...
services, and is used by other payers, including commercial healthcare insurers. The transition to the NPI was mandated as part of the Administrative Simplifications portion of the Health Insurance Portability and Accountability Act
Health Insurance Portability and Accountability Act
The Health Insurance Portability and Accountability Act of 1996 was enacted by the U.S. Congress and signed by President Bill Clinton in 1996. It was originally sponsored by Sen. Edward Kennedy and Sen. Nancy Kassebaum . Title I of HIPAA protects health insurance coverage for workers and their...
of 1996 (HIPAA), and CMS began issuing NPIs in October 2006. HIPAA covered entities such as providers completing electronic transactions, healthcare clearinghouses, and large health plans were required by regulation to use only the NPI to identify covered healthcare providers by May 23, 2007. CMS subsequently announced that as of May 23, 2008, CMS will not impose penalties on covered entities that deploy contingency plans to facilitate the compliance of their trading partners (e.g., those healthcare providers who bill them). The posted guidance document can be used by covered entities to design and implement a contingency plan. Details are contained in a CMS document entitled, "Guidance on Compliance with the HIPAA National Provider Identifier (NPI) Rule." Small health plans have one additional year to comply.
All individual HIPAA covered healthcare providers (physician
Physician
A physician is a health care provider who practices the profession of medicine, which is concerned with promoting, maintaining or restoring human health through the study, diagnosis, and treatment of disease, injury and other physical and mental impairments...
s, physician assistant
Physician assistant
A physician assistant/associate ' is a healthcare professional trained and licensed to practice medicine with limited supervision by a physician.-General description:...
s, nurse practitioner
Nurse practitioner
A Nurse Practitioner is an Advanced practice registered nurse who has completed graduate-level education . Additional APRN roles include the Certified Registered Nurse Anesthetist s, CNMs, and CNSs...
s, dentist
Dentist
A dentist, also known as a 'dental surgeon', is a doctor that specializes in the diagnosis, prevention, and treatment of diseases and conditions of the oral cavity. The dentist's supporting team aides in providing oral health services...
s, chiropractor
Chiropractor
A Chiropractor, according to the Association of Chiropractic Colleges , "focuses on the relationship between the body's main structures – the skeleton, the muscles and the nerves – and the patient's health. Chiropractors believe that health can be improved and preserved by making adjustments to...
s, physical therapists, athletic trainer
Athletic trainer
An athletic trainer is a certified, health care professional who practices in the field of sports medicine. Athletic training has been recognized by the American Medical Association as an allied health care profession since 1990....
s etc.) or organizations (hospital
Hospital
A hospital is a health care institution providing patient treatment by specialized staff and equipment. Hospitals often, but not always, provide for inpatient care or longer-term patient stays....
s, home health care agencies
Home care
Home Care, , is health care or supportive care provided in the patient's home by healthcare professionals Home Care, (also referred to as domiciliary care or social care), is health care or supportive care provided in the patient's home by healthcare professionals Home Care, (also referred to as...
, nursing home
Nursing home
A nursing home, convalescent home, skilled nursing unit , care home, rest home, or old people's home provides a type of care of residents: it is a place of residence for people who require constant nursing care and have significant deficiencies with activities of daily living...
s, residential treatment centers
Drug rehabilitation
Drug rehabilitation is a term for the processes of medical or psychotherapeutic treatment, for dependency on psychoactive substances such as alcohol, prescription drugs, and so-called street drugs such as cocaine, heroin or amphetamines...
, group practices, laboratories
Laboratory
A laboratory is a facility that provides controlled conditions in which scientific research, experiments, and measurement may be performed. The title of laboratory is also used for certain other facilities where the processes or equipment used are similar to those in scientific laboratories...
, pharmacies
Pharmacy
Pharmacy is the health profession that links the health sciences with the chemical sciences and it is charged with ensuring the safe and effective use of pharmaceutical drugs...
, medical equipment
Medical equipment
Medical equipment is designed to aid in the diagnosis, monitoring or treatment of medical conditions.-Types:There are several basic types:* Diagnostic equipment includes medical imaging machines, used to aid in diagnosis...
companies, etc.) must obtain an NPI for use in all HIPAA standard transactions, even if a billing agency prepares the transaction. Once assigned, a provider's NPI is permanent and remains with the provider regardless of job or location changes.
Other health industry workers, such as admissions and medical billing personnel, housekeeping staff, and orderlies, who provide support services but not health care, are not required to obtain the NPI.
The NPI was proposed as an 8-position alphanumeric identifier. However, many stakeholders preferred a 10-position numeric identifier with a check digit
Check digit
A check digit is a form of redundancy check used for error detection, the decimal equivalent of a binary checksum. It consists of a single digit computed from the other digits in the message....
in the last position (the first 9 positions are the identifier and the last position is a check digit) to help detect keying errors. The NPI contains no embedded intelligence; that is, it contains no information about the health care provider, such as the type or location of the health care provider.
The NPI must be used in connection with the electronic transactions identified in HIPAA. In addition, the NPI may be used in several other ways:
- by health care providers to identify themselves in health care transactions identified in HIPAA or on related correspondence;
- by health care providers to identify other health care providers in health care transactions or on related correspondence;
- by health care providers on prescriptions (however, the NPI will not replace requirements for the Drug Enforcement AdministrationDrug Enforcement AdministrationThe Drug Enforcement Administration is a federal law enforcement agency under the United States Department of Justice, tasked with combating drug smuggling and use within the United States...
number or State license number); - by health plans in their internal provider files to process transactions and communicate with health care providers;
- by health plans to coordinate benefits with other health plans;
- by health care clearinghouses in their internal files to create and process standard transactions and to communicate with health care providers and health plans;
- by electronic patient recordElectronic Health RecordAn electronic health record is an evolving concept defined as a systematic collection of electronic health information about individual patients or populations...
systems to identify treating health care providers in patient medical records; - by the Department of Health and Human Services to cross reference health care providers in fraud and abuse files and other program integrity files;
- for any other lawful activity requiring individual identification
The NPI number can be obtained online through the National Plan and Provider Enumeration System (NPPES) pages on CMS's website. Turnaround time for obtaining a number is almost instantaneous, unusual for a medical credentialing operation. NPI numbers can be searched on the CMS website listed in external links 'National Plan and Provider Enumeration System information from CMS'.
A 10-digit NPI Number may be validated using the Luhn algorithm
Luhn algorithm
The Luhn algorithm or Luhn formula, also known as the "modulus 10" or "mod 10" algorithm,is a simple checksum formula used to validate a variety of identification numbers, such as credit card numbers, IMEI numbers, National Provider Identifier numbers in US and Canadian Social Insurance Numbers...
by prefixing "80840" to the 10-digit number.
External links
- National Plan and Provider Enumeration System information from CMS
- NPI Database Lookup
- NPI lookup