National Standard
Health Care Provider Identifier
E. Requirements
[Please label written and e-mailed comments about this section
with the subject: Requirements.]
1. Health plans.
In § 142.404, Requirements: Health plans, we would require
health plans to accept and transmit, directly or via a health care
clearinghouse, the NPI on all standard transactions wherever required.
Federal agencies and States may place additional requirements on
their health plans.
2. Health care clearinghouses.
We would require in § 142.406, Requirements: Health care clearinghouses,
that each health care clearinghouse use the NPI wherever an electronic
transaction requires it.
3. Health care providers.
In § 142.408, Requirements: Health care providers, we would
require each health care provider that needs an NPI for HIPAA transactions
to obtain, by application if necessary, an NPI and to use the NPI
wherever required on all standard transactions that it directly
transmits or accepts. The process by which health care providers
will apply for and obtain NPIs has not yet been established. This
proposed rule (in section III., Implementation of the NPI) presents
implementation options by which health care providers will apply
for and obtain NPIs. We are seeking comments on the options, and
welcome other options for consideration. In one of the options we
are presenting, we anticipate that the initial enumeration of health
care providers that are already enrolled in Medicare, other Federal
programs named as health plans, and Medicaid would be done by those
health plans. Those health care providers would not have to apply
for NPIs but would instead have their NPIs issued automatically.
Non-Federal and non-Medicaid providers would need to apply for NPIs
to a Federally-directed registry for initial enumeration. The information
that will be needed in order to issue an NPI to a health care provider
is discussed in this preamble in section IV. Data. Depending on
the implementation option selected, Federal and Medicaid health
care providers may not need to provide this information because
it would already be available to the entities that would be enumerating
them. In one of the options, health care providers would be assigned
their NPIs in the course of enrolling in the Federal health plan
or in Medicaid. Both options may require, to some degree, the development
of an application to be used in applying for an NPI.
We would require each health care provider that has an NPI to forward
updates to the data in the database to an NPI enumerator within
60 days of the date the change occurs. We are soliciting comments
on whether these updates should be applicable to all the data elements
proposed to be included in the national provider file (NPF) or only
to those data elements that are critical for enumeration. For example,
we would like to know whether the addition of a credential should
be required to be reported within the 60-day period, or whether
such updates should be limited to name or address changes or other
data elements that are required to enumerate a health care provider.
F. Effective Dates of the NPI
Health plans would be required to comply with our requirements
as follows:
- Each health plan that is not a small health plan would have
to comply with the requirements of §§ 142.104 and 142.404
no later than 24 months after the effective date of the final
rule.
- Each small health plan would have to comply with the requirements
of §§ 142.104 and 142.404 no later than 36 months after
the effective date of the final rule.
- If HHS adopts a modification to a standard or implementation
specification, the implementation date of the modification would
be no earlier than the 180th day following the adoption of the
modification. HHS would determine the actual date, taking into
account the time needed to comply due to the nature and extent
of the modification. HHS would be able to extend the time for
compliance for small health plans.
Health care clearinghouses and affected health care providers would
have to begin using the NPI no later than 24 months after the effective
date of the final rule.
Failure to comply with standards may result in monetary penalties.
The Secretary is required by statute to impose penalties of not
more than $100 per violation on any person who fails to comply with
a standard, except that the total amount imposed on any one person
in each calendar year may not exceed $25,000 for violations of one
requirement. We will propose enforcement procedures in a future
Federal Register document once the industry has more experience
with using the standards.
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