HIPAAnotes Volume Three, November 2003
No. 44 – National Provider ID
is Coming - Better late than never!
On October 16, 2003, the Department of Health and Human Services
(HHS) submitted the "Standard Unique Health Care Provider Identifier"
-- commonly referred to as the "National Provider Identifier
(NPI)" -- regulation to the White House Office of Management
& Budget (OMB) for final approval. It then typically takes between
two weeks to 90 days until the final rule is published. The industry
is anticipating that the final regulations will be placed on display
at the Government Printing Office in Washington, DC sometime in
the later days of December 2003.
Most healthcare providers would have appreciated the NPI being
in place at the same time the Transactions and Code Sets (TCS) regulation
was finalized. Many healthcare providers have frantically been requesting
and using physicians' Social Security numbers or employer identification
numbers (EIN) to satisfy the 4010-A1 implementation guides. When
the NPI regulations are finalized, the NPI will be the preferred
provider identifier, replacing the use of the Social Security number
or EIN when reporting a healthcare claim or encounter to a payer.
Although only HHS and OMB know the actual final version of the
regulation, it is assumed that the NPI is a unique identification
number for healthcare providers that will be used by all health
plans. All covered entities will use the NPIs in the administrative
and financial transactions specified by HIPAA.
The proposed rule defined the NPI as an 8-position alphanumeric
identifier. HHS has received numerous comments preferring a 10-position
number identifier with a check digit in the last position to help
detect keying errors. The proposed NPI does not contain embedded
intelligence such as information about the healthcare provider.
Our next two HIPAAnotes will explore some of the implementation
issues surrounding NPI. Watch for them!
Josef Spencer, Director
Phoenix Health Systems
No.
45 – NPI, Part 2: Who Gets a Unique Identifier & How Do You
Get One?
The long-awaited finalization of the National Provider Identifier
(NPI) is in its final stage of approval. Similar to other HIPAA
regulations, covered entities will have two years and two months
to comply with the NPI regulation. However, the implementation of
the NPI regulation will be slightly different. Besides the requirement
to use the NPI in appropriate HIPAA transactions, providers will
be required to register with the organization that will administer
the NPI through the National Provider System (NPS). The NPS is the
administrative system envisioned for supporting the registry of
the NPI.
NPIs will be issued to healthcare providers, which will allow them
to submit claims or conduct other transactions specified by HIPAA.
A healthcare provider is defined as an individual, group, or organization
that provides medical or other health services or supplies. This
does not include health industry employees, such as admissions staff,
billing personnel, or technicians who support the provision of healthcare,
but do not provide actual healthcare services to the patient.
The NPI is proposed to be issued from the NPS based on information
entered into the NPS by one or more organizations known as “enumerators.”
Enumerators could be a registry, private organization, federal health
plans, state agency, health plan, or any combination of these.
The enumerators are proposed to have the responsibility of entering
identifying information about a healthcare provider into the system,
conducting data validation, notifying the healthcare provider of
its NPI, and updating information about the healthcare provider
as necessary.
When the final rule is published, the NPS will begin assigning
NPIs to healthcare providers. Because of the enormity and complexity
of this task, the Department of Health and Human Services recommended
in the Notice of Proposed Rule Making (NPRM) that the assignment
of the NPI be completed in phases. The suggested implementation
is as follows:
- Providers that submit electronic Medicare transactions will
automatically be assigned an NPI.
- Non-Medicare health plans such as Medicaid and HMOs will then
“phase-in” enumeration of their providers. Providers
using these programs will not need to apply for an NPI, but will
have to decide which health plan will provide it.
- Providers who do not participate in any Federal health plans
or Medicaid, but who transmit standard HIPAA transactions electronically,
will have to apply directly to the new Federal registry for their
NPIs.
- Finally, providers who don’t participate in any Federal
plans or transmit the electronic transactions covered by HIPAA
are expected to be enumerated after all other providers.
The National Provider Identifier will be retained for the life
of the healthcare provider. If a healthcare provider goes out of
business or dies, the NPI will be de-activated.
Having a unique identifier for each provider in our healthcare
system will help to streamline electronic transactions, as intended
by Administrative Simplification.
Josef Spencer, Director
Phoenix Health Systems
No.
46 – NPI, Part 3: Please, Not Another Identifier!
The establishment of a National Provider Identifier (NPI) will
undoubtedly cause confusion before simplifying claims processing.
Today, the health care industry uses numerous identifiers in a single
claim, including: Social Security number (SSN), employer identification
number (EIN), drug enforcement number, state license number, Unique
Physician Identification Number (UPIN), taxonomy, and payer-specific
identifiers. Deciding which identifiers remain and which will be
eliminated will surely fuel more questions. The reason for the many
different identifiers stems from the fact that these identifiers
have been assigned by the various health plans, as well as government
agencies at both the state and federal levels. Since there has never
been a "central agency" for assigning these identifiers,
it is not surprising that that the industry has such duplication
and variability in this area.
The objective of the NPI is to issue one unique identifier per
provider. NPIs must be used by all providers, and must be accepted
by all clearinghouses and health plans when using any of the standard
electronic transactions that have been mandated by HIPAA. In its
purest form, the NPI should replace the use of SSN or EIN for the
purpose of provider identification.
The NPI will eventually replace the UPIN in the Medicare program.
NPIs and UPINs will not be used concurrently on HIPAA transactions.
Once the NPI is assigned to Medicare providers, reports and files
will be created to crosswalk UPINs to NPIs.
The NPI will not replace taxonomy. The purpose of the taxonomy
is to document the type of provider service, not identify a specific
provider. The NPI will not replace the drug enforcement number.
The NPI must be used in connection with the electronic transactions
identified in HIPAA. However, the proposed rule also outlined other
uses for the NPI, including:
- by healthcare providers to identify themselves in healthcare
transactions identified in HIPAA or on related correspondence;
- by healthcare providers to identify other healthcare providers
in health care transactions or on related correspondence;
- by healthcare providers on prescriptions;
- by health plans in their internal provider files to process
transactions and communicate with healthcare providers;
- by health plans to coordinate benefits with other health plans;
- by healthcare clearinghouses in their internal files to create
and process standard transactions and to communicate with healthcare
providers and health plans;
- by electronic patient record systems to identify treating healthcare
providers in patient medical records;
- by the Department of Health and Human Services to cross-reference
healthcare providers in fraud and abuse files, and other program
integrity files;
- for any other lawful activity requiring individual identification
of healthcare providers, including activities related to the Debt
Collection Improvement Act of 1996 and the Balanced Budget Act
of 1997.
Josef Spencer, Director
Phoenix Health Systems
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