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NPI FAQs

PW_AD088273
What is NPI?
NPI is the acronym for the National Provider Identifier. It is one provision of the Administrative Simplification portion of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). 
 
What is the purpose of NPI?
The NPI is a single identification number that will be assigned by the federal government to health care providers. The NPI will be used to identify physicians, hospitals and other medical professionals in all electronic HIPAA transactions. It is intended to improve the efficiency of the health care system and help to reduce fraud and abuse. 
 
What are HIPAA transactions?
American National Standards Institute (ANSI) is a committee that defines standards for many American industries. Thus far, HIPAA has mandated that nine ANSI transactions must be used for specific electronic health care transactions. These transactions include: 837 Claim, 835 Remittance Advice, 834 Enrollment, 270 Eligibility Inquiry, 271 Eligibility Response, 276 Claim Status Inquiry, 277 Claims Status Response, 278 Referral, and 820 Premium Payment. It is expected that additional transactions will be mandated in the future. 
 
Who must comply with NPI requirements and when?
The NPI must be used in all HIPAA transactions by all covered entitieshealth plans, health care clearinghouses, and health care providersby May 23, 2007 (small health plans have until May 23, 2008). 
 
Is a NPI required on paper transactions?
The NPI is required in electronic exchanges of HIPAA transactions. Existing identification numbers can continue to be used in paper and non-HIPAA electronic transactions after the mandatory compliance date. However, the NPI mandate does allow payers to require the use of the NPI on all transactions, including paper, to improve processing efficiency. We strongly encourage you to submit your NPI on paper transactions to minimize any claims payment disruption. 
 
Will NPIs only be issued for hospitals and physicians?
No. In addition to hospitals and physicians, NPIs will be issued to institutional and other health care providers such as:  

skilled nursing facilities,

home health agencies,

comprehensive outpatient rehabilitation facilities,

assorted clinics and centers,

clinical laboratories,

various licensed/certified health care practitioners, and

suppliers of durable medical equipment.

 
They also will be issued to any appropriately licensed or certified health care practitioners or organizations, including pharmacies, nursing homes and many types of therapists, technicians, aides, and any other individual or organization that furnishes health care services or supplies. In other words, a NPI applies to any health care individual or organization that bills and is paid for health care services or supplies. If organizations, such as hospitals, are made up of components, or separate physical locations that qualify as separate health care facilities, they also will be issued their own NPI. These types of arrangements are referred to as “sub-parts” in the NPI Final Rule. 

What does the NPI look like?
The NPI is a ten-digit numeric field that will include one check digit in the tenth position to ensure accuracy. This format will permit 200 billion unique identifiers to be issued without re-using the same values. The NPI will contain NO imbedded intelligence. In other words, you will not be able to determine a provider’s state, region, specialty, or any other information directly from their NPI. 
 
How will the NPI be generated?
The NPI is generated by a new system called the National Plan and Provider Enumeration System (NPPES) and issued by the U.S. Department of Health and Human Services (HHS) through the Centers for Medicare and Medicaid Services (CMS).  
 
What is an Entity Type Code?
An entity type code is a category indicator that will determine the type of provider that is being assigned an NPI: 

Entity Type 1 will be issued to healthcare providers that are individual human beings. Examples include physicians, dentists, chiropractors, pharmacists, nurses, etc.

Entity Type 2 will be issued to organizations such as hospitals, residential treatment centers, laboratories, group practices, etc.

What is a Subpart?
Subparts of organizational health care providers are eligible to be assigned NPIs. A subpart can be uniquely identified, for example, by separate physical location, by separate licenses or certification. While we cannot tell you how to structure your organization in regard to enumerating, our recommendation is for each incorporated practice to secure an Entity Type 2 NPI to assure that the proper entity is reimbursed for services that are rendered.  
 
How will a provider be issued a NPI?
Providers are able to apply to CMS for a NPI starting May 23, 2005 and must have a NPI by May 23, 2007, when exchanging electronic transactions (small health plans have until May 23, 2008). Applications are available on the CMS web site at http://www.cms.hhs.gov/NationalProvIdentStand/03_apply.asp. Providers will need to supply adequate information to ensure that they can be identified uniquely by the National Plan and Provider Enumeration System (NPPES). Should any of that information change in the future, CMS must be notified within 30 days. 
 
What if a doctor changes practices, moves, or changes specialties?
Even if a provider moves, changes specialty, or changes practices, the provider will retain the same NPI, but must notify CMS and supply the new information. The NPI is intended to identify the provider throughout his or her career. Organization NPIs also are intended to be permanent except in rare situations such as when a health care provider does not wish to continue an association with a previously used NPI, or when a health care provider's NPI has been used fraudulently by another.  
 
How will Empire be able to associate a provider with his or her NPI?
The NPIs will be maintained in a database in the National Plan and Provider Enumeration System (NPPES). CMS will provide a method of extracting data from the NPPES database. Empire has developed a strategy for acquiring NPI data from providers and also via NPPES and will use it to identify providers submitting HIPAA transactions. In most cases, current processes will be modified to include the NPIs. 
 
What is Empire doing to prepare for NPI?
Empire’s NPI program has established project teams throughout its organization. These teams are dedicated to researching the issues, assessing systems, reviewing business processes, and educating the Empire organization about implementation procedures while helping to ensure an understanding of the expected end-result. 
 
Where can I learn more about NPI?
To learn more about NPI from CMS, visit http://www.cms.hhs.gov/NationalProvIdentStand/ in the coming months. In addition, we encourage you to log on to www.empireblue.com to find the most up-to-date information regarding HIPAA and Empire’s compliance status. 
 
Has CMS issued any additional information on the application process for the NPI?
In early May of 2005, CMS issued a “Dear Provider Letter” that can be accessed at http://www.cms.hhs.gov/NationalProvIdentStand/. This letter briefly outlines the application process and the various ways the provider may obtain an NPI.  
 
When will the providers be able to begin applying for an NPI?
Providers began applying as early as May 23, 2005. Providers may apply electronically through CMS’ web-based application system located at the following URL: https://nppes.cms.hhs.gov/NPPES. For those providers who prefer to use the paper format, a copy of the application and the enumerator’s address will be available at the same web site at https://nppes.cms.hhs.gov/NPPES. Also, the provider may choose to submit their application through an organization, professional association, or employer.  
 
What if a provider has numerous health plan IDs, will each health plan require an additional NPI?
The NPI is the single provider identifier that will replace each of the different health plans’ numerous identifiers. This regulation requires each of the health plans to use the NPI as the sole identifier for each provider. The provider needs only to apply once for an NPI. 
 
When will Empire begin accepting the NPI?
Effective February 6, 2006, as long as the NPI number is accompanied with the provider’s current Empire provider identification number (EPIN), Empire will have the capability to accept the 10-digit NPI on electronic claims and CMS 1500 (08/05) and UB 04 paper claim forms transactions. 
 
Where will the NPI be located on the Electronic Claims Transactions?
The NPI will be reported within the provider loops on electronic claims transactions. The changes required for HIPAA Standard transactions are: 

NM 108 qualifier will be XX for NPI Submission

NM 109 field will display the 10-digit NPI

Tax ID will be required in the REF segment when NPI is reported in the NM109

REF01 qualifiers (EI=Tax ID, SY= SSN)

REF02 field will display the Providers/Facilities Tax ID or SSN.

 
Will the NPI be located on the Electronic Remittance Advise (835)?

Yes, the NPI will be returned on the 835 electronic remittance advice in the following loops:

Loop/Segment

Dent

Inst

Prof

Loop 1000B; N103

XX

XX

XX

Loop 1000B; N104

NPI

NPI

NPI

Loop 1000B; REF01

TJ

TJ

TJ

Loop 1000B; REF 02

Tax ID

Tax ID

Tax ID

Loop 2000; TS301

Not Used

Not Used

Not Used

Loop 2100; NM108

Not Used

XX

XX

Loop 2100; NM109

Not Used

NPI

NPI

 
Where can I learn more about the NPI application process?
Up-to-date information regarding the NPI is available on the NPPES web site at https://nppes.cms.hhs.gov/NPPES. You may also contact the enumerator by telephone at 1-800-465-3203 or TTY 1-800-692-2326. In addition, an instructional web tool, called the NPI Viewlet, is now available for viewing at http://www.cms.hhs.gov/apps/npi/npiviewlet.asp
 
How can I register my NPI with Empire?
After receiving your NPI, please complete our online submission form, at www.empireblue.com or https://npi.wellpoint.com, to register your NPI. If you are registering more than one NPI, please complete one form for each NPI. Registration ensures our internal systems accurately reflect your NPI information. If you have a large quantity of NPIs to submit (provider practice or large organization), a bulk submission process is available. Instructions can be found at www.empireblue.com or https://npi.wellpoint.com. Providers without access to the Internet should mail or fax their NPI to their Network Management Representative. 
 
Which HIPAA Standard Transactions require use of an NPI?
There are nine electronic transactions in which the NPI must be used:  

837 Claim

835 Remittance Advice

834 Enrollment

270 Eligibility Inquiry

271 Eligibility Response

276 Claim Status Inquiry

277 Claims Status Response

278 Referral

820 Premium Payment

It is expected that NPI use in additional transactions will be mandated in the future. 
 
How will a medical practice obtain the NPI number of a requesting provider when doing a consult, etc.?
Because the database is not yet available, it is recommended that you share your NPIs with other providers including but not limited to:  

Referring providers

Physicians who deliver services at hospitals and other institutional settings

Providers who order tests from clinical or imaging laboratories

Providers who order medical equipment/supplies

Not doing so may result in claim delays. 
 
How do providers communicate NPIs with vendors?
We encourage providers to contact their vendor representatives by telephone or e-mail and ask the vendor what format would work best for notifying the vendor of NPIs, etc.  
 
If a single doctor is owns a provider practice that is incorporated, does he need two NPIs one for the corporation and one for him?
Yes, since every covered health care provider must obtain and utilize the NPI, the corporation may apply for an Entity Type 2 NPI, and the individual provider may apply for their own Entity Type 1 NPI.  
 
If a provider has 6 hospital-based clinics using 1 Tax ID number, does each clinic need their own NPI?
We recommend that providers review their current payer provider contracts and their unique numbering scheme for each of their payers, as well as the NPI ruling prior to applying for NPIs. It is left up to providers how they enumerate their practices, facilities, etc. We recommend a one-to-one relationship between NPIs obtained and the provider ID numbers you use with Empire today. 
 
If a provider has 2 offices with 2 different doctors that go to each office but they only have one Tax ID number, does the provider need just one NPI number for both offices and doctors?
Each Type 1 provider (the doctors) will need his/her own NPI if they are covered health care providers. The group would be an entity type 2 and may want to obtain an NPI for each location. 
 
Will the NPI replace the Universal Provider Identification Number (UPIN)?
Yes, the NPI will replace the UPIN.  
 
In some states the same provider may be getting multiple ID’s but in others they are just getting one?  How are these handled?
At this time, we recommend that providers work closely with all of their payers and discuss your enumeration scheme with them. Some payers will have suggestions on how providers may want to use their NPIs based on the current contract with the payer. 
 
Currently, most payers use provider identification numbers to drive adjudication.  For example, ABC Practice has one provider identification number for each payer. ABC Practice will only have one NPI for all payer numbers.  Will this affect Your Plan Name Here’s ability to pay according to the contract?
Your Plan Name Here is in the process of implementing a “crosswalk” solution that will match up ABC Practice’s current Provider Identification Number to its NPI. The reimbursement will be paid based on the provider contract that is in place on the date the services are rendered. 
 
What are the advantages or disadvantages of obtaining an NPI in the name of the corporation (provider group)? 
Providers should review the NPI Ruling available on the CMS web site at: http://www.cms.hhs.gov/NationalProvIdentStand/01_overview.asp. It provides guidelines as to who is required to receive an NPI. On CMS’s NPI web site, it states:  
“Health care providers who are individuals are eligible for an Entity Type 1 (Individual) NPI. If these individuals incorporate themselves (i.e., if they form corporations) and the corporations are health care providers, the corporations are organization providers that are eligible for an Entity Type 2 (Organization) NPI. If either of these health care providers (the individual or the corporation) are covered providers (i.e. providers that send electronic transactions) under HIPAA, the NPI Final Rule requires them to obtain NPIs.” 
 
How will Empire test with providers to validate that the NPIs are coming through to Empire and that the information is able to be returned properly to the provider all the way through to either an electronic remittance advice or paper remittance?  With whom does a provider work in this testing phase?
We will begin testing with our high volume trading partners, direct submitters, and software vendors.  We are currently in the process of reaching out to these trading partners/software vendors to schedule testing for the timeframe now through May. Providers should check with their software vendor or systems department to see if they have been scheduled to test with Empire.  

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