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National Provider Identifier (NPI)On this page: UPDATES
5/24/07 The NPI Compliance Deadline is Here!
At this point, any covered entity that is noncompliant, and has not implemented a contingency plan, is at risk for enforcement action. Please review the April 2, 2007 CMS “Guidance on Compliance with the HIPAA National Provider Identifier (NPI) Rule.” As this guidance pertains to claims transactions, it means that:
1. Providers must have and use their NPI;
2. Clearinghouses must accept and use NPIs; and
3. Health plans must accept and send NPIs in claims transactions.
Providers should be: 1. Aware of contingency plans for any health plans they bill. Contingency plans may differ by health plan.
2. Aware that health plans may lift their contingency plans (and require an NPI on claims or other HIPAA transactions) any time before May 23, 2008.
3. Working with vendors and clearinghouses with whom they contract, to make sure the NPI is being passed to health plans.
4. Paying close attention to how and when health plans will be testing implementation of the NPI.
5. Aware that, for those health plans that did not establish a contingency plan, providers are required to use their NPIs now. This means that if you are not using your NPI, your claim may be rejected or denied.
5/24/07 New Tip Sheet Available
A Tip sheet entitled What the “Guidance on Compliance with the HIPAA National Provider Identifier (NPI) Rule” Means for Health Care Providers is now available at http://www.cms.hhs.gov/NationalProvIdentStand/Downloads/ContingencyTipSheet.pdf This product provides helpful steps for providers based on the contingency guidance released on April 2, 2007. This guidance does not mean that providers have an extra year to get an NPI, so please view the Tip Sheet for additional information.
5/17/07 Contingency Plan Update As the May 23rd, 2007 NPI deadline approaches, the WSPA office has fielded questions regarding use of NPI numbers for billing purposes. With the release of the CMS Guidance on NPI Contingency Rule that allowed plans the latitude to implement the NPI requirements over the next year, WHO is doing WHAT WHEN is anybody’s guess. What we do know is that DSHS will not be ready to accept NPIs. Continue to bill DSHS as usual, using a NABP number and prescriber DEA (see number memo on our website)
Caremark released a memo that will require the pharmacy NPI number as of May 23rd 2007, but does not require the prescriber’s NPI yet. Caremark will assess a $.99 penalty per claim if you do not use the pharmacy NPI. While Express Scripts expects its network pharmacies to submit NPIs effective May 23, Express Scripts will continue to accept either the pharmacy NPI or NCPDP number until further notice. WSPA advises making sure the pharmacy NPI number is loaded into your system. National Provider Identifier (NPI) Overview
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 will 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. Beginning May 23, 2007 (May 23, 2008, for small health plans), the NPI must be used in lieu of legacy provider identifiers in the HIPAA standards transactions. Covered entities may invoke contingency plans after May 23, 2007, and guidance about contingency plans may be found in the Downloads section below. If you are a health care provider who bills for services, you probably need an NPI. If you bill Medicare for services, you definitely need an NPI! Getting an NPI is easy. Getting an NPI is free. The first step is to get your NPI. If you delay applying for your NPI, you risk your cash flow and that of your health care partners as well. 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. Over 2 million providers have their NPIs – do you have your NPI yet? Covered entities (including health plans, covered health care providers and clearinghouses) across the country are making decisions regarding their need for contingency plans for NPI implementation. It is more important than ever to obtain an NPI as soon as possible and begin testing it on claims, as directed by your health plan.Providers can apply for an NPI online at https://nppes.cms.hhs.gov or can call the NPI enumerator to request a paper application at 1-800-465-3203. As always, more information and education on the NPI can be found at the CMS NPI page www.cms.hhs.gov/NationalProvIdentStand on the CMS website.
Providers should remember that the NPI Enumerator can only answer/address the following types of questions/issues:
Providers needing this type of assistance may contact the enumerator at 1-800-465-3203, TTY 1-800-692-2326, or email the request to the NPI Enumerator at CustomerService@NPIenumerator.com .
Please Note: The NPI Enumerator’s operation is closed on federal holidays. The federal holidays observed are: New Year's Day, Independence Day, Veteran’s Day, Christmas Day, Martin Luther King's Birthday, Washington's Birthday, Memorial Day, Labor Day, Columbus Day, and Thanksgiving. CMS has posted FAQs related to the previously posted NPI Compliance Contingency Guidance. Questions include:
To view these FAQs, you should:
1) Go to the CMS dedicated NPI web page
2) Scroll down to the section that says “Related Links Inside CMS”
3) Click on NPI Frequently Asked Questions. To find the latest FAQs, click on the arrows next to “Date
Updated”. Look for the word “NEW” in red font to appear beside the most recent FAQs.
CMS strongly urges providers to pay attention to information from the health plans they bill so that they are aware if, and when, a specific health plan announces its own contingency plan. Guidance on Compliance with the NPI Contingency Rule Medicare NPI Contingency Plan
CMS is testing the new software that has been developed to use the National Provider Identifier (NPI) in the existing Medicare fee-for-service claims processing systems. Providers have until May 23, 2007, before you are required to submit claims with only an NPI. Until testing is complete within the Medicare processing systems, CMS urges providers to continue submitting Medicare fee-for-service claims in one of two ways: Use your legacy number, such as your Provider Identification Number (PIN), NSC number, OSCAR number or UPIN; or
Until testing of the new software that uses the NPI in the Medicare systems is complete and until further notice from CMS, the following may occur if you submit Medicare claims with only an NPI:
On and after May 23, 2007, the Health and Recovery Services Administration (HRSA) will continue to require pharmacy providers to include their National Council for Prescription Drug Programs (NCPDP) Number and Prescriber Drug Enforcement Agency (DEA) or Prescriber Medicaid Provider Number on all prescription drug claims submitted through the Point-of-Sale (POS) system. HRSA is in the process of developing a new POS system, which is called Provider One. Although HRSA’s implementation of federal NPI requirements is dependent on the new POS, it may not occur at the same time that the new POS is put into production. HRSA will give pharmacy providers 60 days notice prior to implementing the new POS system. HRSA will give pharmacy providers 90 days notice prior to implementing the NPI requirement in the new POS system. Read more. Learn about WSPA partnership with OneHealthPort to provide NPI numbers.
Express Scripts will accept the Pharmacy NPI or NCPDP Number after May 23, 2007. While Express Scripts expects its network pharmacies to submit their NPIs effective May 23, 2007, they will continue to accept either the pharmacy NPI or NCPDP number until further notice.
Express Scripts will not charge pharmacies for submitting a legacy ID (NCPDP number) to ESI after May 23, 2007.
Express Scripts will not accept the Prescriber NPI until CMS releases its data dissemination policy and prescriber information has been shared with all stakeholders.
If a pharmacy submits a claim using its NCPDP number and later needs to reverse that claim using its NPI, the claim will not reject. Express Scripts’ system will “crosswalk” the NCPDP number with the pharmacy’s new NPI and the claim will process.
If a pharmacy submits a claim using its NCPDP number, the additional message will specify “Provider” as indicated below:
“ESI is accepting Provider NPI, please submit your Provider NPI on all future claims.”
Caremark NPI Contingency Update
ATTENTION: CAREMARK TO CHARGE $0.99 PENALTY FOR NON-COMPLIANT NPI TRANSACTIONS Caremark is mandating that all its network pharmacies use a National Provide Identifier (NPI) from May 23rd on or face a "penalty fee" of 99 cents on each transaction. Those transactions without a pharmacy NPI "will be considered non-compliant but will not reject in order to minimize patient and pharmacy disruption". "However, a penalty fee of 99 cents will be charged for every non-compliant transaction received from 5/23/07 onwards." CMS recently stated that it would not impose penalties on covered entities, including pharmacies and health plans, for non-compliance with the NPI requirement that takes effect May 23rd. Private health plans and PBMs, however, do not have to abide by the one-year extension granted by CMS. If you have contingency Plan details from another plan, please share them with the WSPA so we can place them on the website for other pharmacies. Contact Jeff Rochon ar jrochon@wsparx.org.
Big question…how do I get NPI numbers for other providers? CMS was supposed to have a national data bank up and running to meet this need. However, it is not up and running and no word on when that might happen. In the meantime, WSPA has partnered with OneHealth Port to provide you the opportunity to access their Washington State data base. The data base is dependent upon voluntary reporting, but to date they have over 12,000 individual provider NPI’s and 3000 vender NPI’s. You can access the data base at www.onehealthport.com for free to input your own NPI numbers or find an individual NPI number. If you want access to the entire data base there is a minimal subscription fee. For more information: WSPA partners with OneHealthPort to provide NPI numbers.
While Express Scripts expects its network pharmacies to submit their NPIs effective May 23, 2007, we will continue to accept either the pharmacy NPI or NCPDP number until further notice. CMS Releases NPI Data Dissemination Policy…
CMS has placed on display its notice outlining how pharmacists and other providers may access NPIs and other information required to be disclosed under the Freedom of Information Act (FOIA). CMS expects this National Plan Provider Enumeration System (NPPES) Data Dissemination Notice to be published at the Office of the Federal Register on May 30th. CMS states that the NPI information will be made publicly available on June 28.
All health care providers who have been assigned NPIs are encouraged to review their NPPES data and make any necessary corrections prior to the end of the 30-day period to ensure that their information is accurate when disclosed by CMS. The list of data elements that will be disclosed is included in the Notice. We will not be disclosing a health care provider’s Social Security Number (SSN), Internal Revenue Service (IRS) Individual Taxpayer Identification Number (ITIN), or date of birth. Providers who wish to delete any NPPES data that was not required to be furnished in order to obtain an NPI may do so prior to the end of the 30-day period if they prefer that those data not be disclosed by CMS.
… with more NPI information to come
CMS will post an announcement on the CMS NPI web page that will contain the locations of the downloadable files and the query-only database. The data will be available free of charge in an initial file downloadable from the Internet, with monthly update files also downloadable from the Internet, and in a query-only database whereby users can query by NPI or provider name. However, entities who would like more or less data than what are available in the downloadable files or in the query-only database, or who would like data in different formats or on different media, must submit requests under the FOIA to the CMS FOIA Office either in writing or by fax machine. There may be a charge to the requester for CMS to furnish data under FOIA.
Once providers have received their NPIs, they should share their NPIs with other providers with whom they do business, and with health plans that request their NPIs. In fact, as outlined in current regulation, providers who are covered entities under HIPAA must share their NPIs with any entities that need them for billing purposes -- including those who need them for designation of ordering or referring physician. Providers should also consider letting health plans, or institutions for whom they work, share their NPIs for them.
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