Quick Guide to Understanding National Provider Identifiers (NPI)

Posted by: Prof. Jayson Howell at 08/05/2021 2,737 views

Are you a healthcare professional? Then you've come across the National Provider Identifier (NPI). NPI is an integral aspect commonly utilized in validation and verification of various considerations, including process control, claims, contracts, and authentication, to mention a few.

There are hundreds of thousands of NPI Registry searches carried out every day, and as you navigate the industry, understanding what it is and its functions are important. Here is a quick guide to help you understand NPI's framework and functionality if you are a little fuzzy.coupons up to 89

What is NPI?

As described by CMS (Centers for Medicare and Medicaid Services), NPI is an intelligence-free, 10-position numeric identifier. The 10-digit number identifies a healthcare provider but doesn't carry information such as their medical specialty or residence state. It is HIPAA (Health Insurance Portability and Accountability Act) administrative simplification standard, a unique identification for the covered insurance providers.

NPI is the replacement for the Unique Physician Identification Number (UPIN) that was discontinued in 2007. Under HIPAA's administrative and financial transactions, all covered healthcare professionals, health plans, and healthcare clearinghouses must use NPI.

As stated by Federal Regulations, HIPAA covered providers are required to share their NPI with other clearinghouses, providers, health plans, among other entities that may require if for billing purposes.

If you aren't familiar with clearinghouses, they are organizations that process non-standard health information. Clearinghouses process the information to ensure that it is in conformity to standards for data format or content on behalf of organizations.

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The healthcare professionals, who submit HIPAA transactions electronically, such as claims, are included under NPI. Examples of such healthcare providers include doctors, psychologists, pharmacies, chiropractors, clinics, and nursing homes, to mention a few.

They are covered under health plans such as employer-sponsored health plans, government programs like Medicaid, Medicare, military and veterans, health programs, health insurance companies, and health maintenance organizations (HMOs).

As per the CMS, under NPI, healthcare providers are categorized into two as follows.

  • Type 1 NPI providers: This category holds all sole professionals, such as dentists and physicians, among other sole practitioners. You are eligible for only one NPI under this category.
  • Type 2 providers: This category includes providers operating as organizations. Examples include hospitals and nursing homes. Under Type 2 NPI, you can obtain both types, such as a case where you operate as an individual healthcare provider and also incorporated. If you determine that you have subparts required to be identified in HIPAA standard transactions, you can obtain its NPI.

Applying for the NPI isn't such a hassle, especially if you opt for online registration. You simply visit the National Plan and Provider Enumeration System (NPPES) site, create an account, and follow the prompts. NPPES maintains a free and searchable directory provided by CM, allowing you to look up the active NPI information.

As a healthcare professional, understanding what NPI is and its functionality is essential as you navigate the field. In essence, every professional described as a healthcare provider must have an NPI and other suppliers/providers who bill Medicare.

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