NATIONAL PROVIDER IDENTIFIER (NPI)
Frequently Asked Questions
If you are confused about implementation of the new National Provider Identifier (NPI), you are not alone. Government agencies have admitted that there are still many hurdles to full implementation by the deadline in May 2007, not the least of which is that “providers” seem to be reluctant to apply until they have a better understanding as to how the NPI will be used. For example, more than 1,000 telephone lines weren’t enough to handle all of the questions during a phone roundtable held by CMS in September 2006.
So the government has decided to provide more training kits for you that they refer to as “NPI 101.” But AAPS is concerned that even these training tools won’t answer all of your questions. Further, because some of the regulations are yet to be written, some questions simply have no answers yet. Those are of great concern to us, and we suggest that you demand answers from your contracted insurance companies and the government. We expect to issue more guidance, so contact us with your concerns and questions. Unanswered questions at this time include:
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandated that the Secretary of Health and Human Services adopt a standard unique health identifier for health care providers. On January 23, 2004, the Secretary published a Final Rule that adopted the National Provider Identifier (NPI) as this identifier.
All HIPAA-covered health care providers, whether they are individuals or organizations, must obtain an NPI to use to identify themselves in HIPAA standard transactions. Once enumerated, a provider’s NPI will not change. The NPI remains with the provider regardless of job or location changes.
HIPAA-covered entities, such as providers completing electronic transactions, health care clearinghouses, and large health plans, must use only the NPI to identify covered health care providers in standard transactions by May 23, 2007. Small health plans must use only the NPI by May 23, 2008.
When applying for your NPI, CMS urges you to include your legacy identifiers, not only for Medicare but for all payers. If reporting a Medicaid number, include the associated State name. This information is critical for payers in the development of “crosswalks” to aid in the transition to the NPI.
1. Am I required to get an NPI to practice medicine?
2. But what if I’ve opted for the “Country Doctor” exclusion established by AAPS that allows me to remain a non-covered entity under HIPAA, and I have no third-party contracts?
3. What if I do see Medicare patients and file only paper claims (qualifying me as a HIPAA non-covered entity)?
4. So the only way I can avoid getting and using an NPI is to be a HIPAA non-covered entity AND opt out of Medicare?
You’ll protect your patients from having their private records entered into a nation-wide computer data base, potentially accessible by thousands of private and public bureaucrats, law enforcement agencies, employers, and hackers. You’ll save up to tens of thousands of dollars in compliance efforts.
And finally, you keep the practice of medicine free from the straitjacket of working through a recipe book of 200,000 government-imposed codes and almost 200,000 pages of Medicare rules.
5. So what’s the purpose of the NPI?
6. Will I keep my old identification numbers?
7. What’s the deadline for using the NPI?
8. Any other deadlines?
9. So can I wait until the deadline to apply and still be in compliance?
10. After the May 2007 deadline, will I be able to use my old “legacy” numbers?
However, on October 11, 2006, industry representatives urged HHS to allow the use of legacy numbers in addition to the NPI for a minimum of six months past the deadline to allow for ease of transition. They fear that because so few providers have been “enumerated” at this point, there will be tremendous problems in bringing systems into compliance by the May 2006 deadline. Some have expressed concerns that they expect long delays in payments to providers. At a recent forum on Medicaid, about one-third of states admitted that they do NOT expect to be ready to process only NPIs for payments.
11. What is the NPPES? What is the “Enumerator?”
12. How do I apply?
CMS says they expect processing to take 10 days, but that depends on the volume of applications, paper vs. electronic, and whether the application passes all edits.
14. How much does it cost to apply?
15. What’s the format of the number?
16. Do I have to notify the Enumerator if I move or change jobs?
17. Will change the way I get paid or how long it takes to get paid?
18. What’s a primary vs. secondary provider?
19. How do I update my billing software?
20. Can I use my NPI before May 23, 2007? Should I use both legacy numbers and my NPI before then?
21. What happens if I don’t have an NPI?
The information above represents the analysis of the Association of American Physicians and Surgeons for public discussion and debate. This may not be construed as legal advice. Please consult an attorney for legal advice.
Resources used in preparation of this paper:
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