NPI Number: 2022 Ultimate Guide

According to Advantum Health, an NPI number, short for National Provider Identifier, is a unique 10-digit identification number issued to each and every healthcare provider and organization in the United States. NPIs are issued by the federal government. NPIs were introduced in 1996 as part of the Health Insurance Portability and Accountability Act (HIPAA) in order to improve the efficiency of electronic health records.

NPIs are used by the Center for Medicare and Medicaid Services (CMS) and all healthcare plans and healthcare clearinghouses to identify each provider and to process payment claims and financial and administrative transactions. NPI Numbers are intelligence-free numeric identifiers, meaning that the numbers contain no information about the providers themselves, such as their state of practice, or what their specialty is.

Per Highmark Blue Shield, NPIs can be 1 of 2 Types. Type 1 is at the practitioner level; all of the physicians and mid-level providers in a group practice inancial and administrative transaction have their own NPI. In addition to the individual practitioner NPIs, the group itself will have a Type 2 NPI. A group can have more NPIs depending on how they choose to enumerate. A group with multiple offices or a separate lab facility may choose to get separate Type 2 NPIs for each office or ancillary.

The NPI number is used with any electronic transaction identified in HIPAA. It may also be used by healthcare providers to identify themselves or other providers in healthcare transactions or correspondence; by physicians on prescriptions; by health plans in their communications and transactions; to coordinate benefits with other health plans; to identify health care providers in electronic patient medical records; by the Department of Health and Human Services to track providers in fraud and abuse cases, and other functions.

All healthcare providers, healthcare clearinghouses, and healthcare organizations that conduct transactions or use health records that fall under HIPAA regulations are required to obtain an NPI. This includes any and all organizations and providers that use a medical billing company to process their claims. Any individual, business, or healthcare agency that transmits any patient health information in electronic form in connection with a transaction is required to have an NPI number. The NPI is intended to improve the efficiency of the health care system and help to reduce fraud and abuse.

To get an NPI number, you should complete an online application. The entire application should take you about 20 minutes to complete. Providers can also apply for an NPI number through a paper form or an organization on their behalf. Complete instructions are found on the CMS website here. Here are all of the steps to follow when completing the online application:

• 1.

  Visit the NPPES website
  In the National Plan and Provider Enumeration System (NPPES) website, navigate to the NPI webpage, and look under how to apply for an NPI for individual providers. Create a login through the identity and access management system.

• 2.

  Follow the instructions on the application

  There is a help tab option at the top right of the pages where you can get assistance online. There is also a place to access full, step-by-step instructions on how to complete your application, accessible here. Then click on the new NPI application, read the terms, and submit the new NPI application.

• 3.

  Provider profile
  Fill in the provider profile information and then answer “NO” to the question, ‘is the provider a sole proprietor?’

  Enter your residency program address and residency phone number. Accept the standardized option under the business mailing address standardization. Other identification numbers may be required to be filled like the UPIN provider numbers, but you can proceed to the next step if you do not have one.

• 4.

  Taxonomy/ License information
  There are more than 175 taxonomy codes, and you are required to choose only one taxonomy code. For the non-licensed, select provider type code 39, select students in an organized health care training program. Click on save. For a licensed physician, click provider type code 20. For licensed dentists, select 12, then enter the license numbers and states where you are permitted. Finish by clicking on save.

• 5.

  Provide contact person information
  List yourself as the contact person so that you can respond to your application in case of any questions. You can add your home phone number and address under the “More information.”

• 6.

  Certification statement You will need to submit a certification statement. Once you have, your application can now be processed. Look for an email concerning your NPI in as little as 10 days.

  An NPI is mandatory and in accordance with the HIPAA, and there is no charge to apply or to get your NPI number.

A HIPAA-covered entity is a:

• Health care provider that conducts certain transactions in electronic formm
• Health care clearinghouse
• Health plan (including commercial plans, Medicare, and Medicaid)

Under HIPAA, you’re a covered health care provider if you electronically transmit health information in connection with a HIPAA standard transaction, even if you use a business associate to do so.

If you have further questions, you can refer to the CMS Are You a Covered Entity? Webpage.

According to the Illinois Chiropractic Society, confusion still exists for many physicians as to whether or not they must apply for an NPI. All Individuals and Organizations who meet the definition of healthcare providers as described at 45 CFR 160.103 are eligible to obtain a National Provider Identifier. CMS has declared that if you are a HIPAA-covered provider OR if you are a health care provider/supplier who bills Medicare for your services, you need an NPI. It is unclear if providers not submitting claims to Medicare require the NPI, however, if CMS requires it, all other insurance companies usually follow along. The mandate applies to participating and non-participating physicians.

It has been confirmed that the NPI is required for all providers, regardless of their status with HIPAA. The only known exclusion to the NPI initiative is for small health plans, which is the relatively small group of insurers that process a minimum number of medical claims each year. There is no exclusion for small providers, such as those with less than 10 full-time employees. These physicians will also be required to complete the enumeration process for an NPI number.

Even if you do not bill for services at your practice, you may need to disclose your NPI to those providers who do (such as providers who order lab tests or send patients for diagnostic testing and must be identified on the lab's or testing facility's claims). Without an NPI, claims may be adversely affected, including delayed or denied payments.

In other words, getting an NPI is free - not having one could be costly.

Certified nurse midwives, certified registered nurse anesthetists, nurse practitioners, and clinical nurse specialists are all eligible for an NPI as covered providers with respect to Medicare. In particular, APRNs with master’s degrees providing services within the scope of practice in their state may treat Medicare beneficiaries, and directly bill for those services.

To directly bill for services, APRNs must first obtain their NPI. NPIs are also required for those RNs who directly bill Medicaid.

HIPAA requires the adoption of a standard unique identifier for health care providers. NPIs allow for simpler electronic transmission of HIPAA standard transactions.

NPIs are being used to:

• Identify health care providers on prescriptions and in internal files to link proprietary provider identification numbers and other information
• Coordination of benefits between health plans, patient medical record systems, program integrity files, and other ways as well

Independence Blue Cross (IBX) provides a full explanation of how many NPIs are required by healthcare providers. An individual practitioner is eligible for a single NPI. An individual does not have subparts and cannot designate subparts. In terms of NPI assignment, an individual is an Entity Type 1.

A sole proprietor/sole proprietorship is also eligible for a single NPI. A sole proprietor/sole proprietorship does not have subparts and cannot designate subparts. In terms of NPI assignment, a sole proprietor/sole proprietorship is also an Entity Type 1 (Individual).

In addition to their practitioners’ NPIs, organizations must also apply for a single NPI. In terms of NPI assignment, organization healthcare providers who are covered entities under HIPAA must apply for NPIs as Entity Type 2 (Organization). Organization healthcare providers are corporations/partnerships or other types of businesses that are considered separate from an individual by the state in which they exist. Subparts of such organization healthcare providers who apply for NPIs are also Entity Type 2.

• A subpart must have its own NPI if it conducts any of the HIPAA standard transactions separately from the covered organization health care provider of which it is a part. If your organization has subparts, please ensure that they have their own NPIs.
• Example: A hospital owns ten home health agencies that all operate under the Tax Identification Number of the hospital. Because the hospital and each of the ten home health agencies are separately surveyed and enter into their own provider agreement with Medicare, 11 different NPIs should be obtained in total — one by the hospital and one by each of the ten home health agencies.
• For further clarification regarding entity types and subparts, visit the Centers for Medicare & Medicaid Services website.

Any provider that provides what HIPAA defines as “healthcare” must obtain and use an NPI when performing a HIPAA-covered transaction.

HIPAA-covered transactions are transactions involving: “the transmission of information between two parties to carry out financial or administrative activities related to health care.”
HIPAA-covered transactions include the following types of information transmissions:

1. Health claims or equivalent encounter information.
2. Health care payment and remittance advice.
3. Coordination of benefits.
4. Health care claim status.
5. Enrollment and disenrollment in a health plan.
6. Eligibility for a health plan.
7. Health plan premium payments.
8. Referral certification and authorization.
9. First report of injury.
10. Health claims attachments.

The HIPAA regulations define “healthcare” as care, services, or supplies related to the health of an individual. Under the regulations, healthcare includes, but is not limited to, the following:

• Care, counseling, services, assessments, or procedures, with respect to the physical or mental condition, or functional status, of an individual.
• Care, counseling, services, assessments, or procedures, that affect the structure or function of the body.
• Sale or dispensing of a drug, device, equipment, or other items in accordance with a prescription.

Care includes preventive, diagnostic, therapeutic, rehabilitative, maintenance, or palliative care. Palliative care is care that eases the pain caused by a condition, without treating the underlying condition.

Providers of any of the above services are regarded as HIPAA-covered healthcare providers. Providers include:

• Physicians, pharmacists, and physician assistants.
• Nurse practitioners, RNs, nurse assistants, and nurse anesthetists.
• Clinical social workers, professional counselors, psychologists, and psychiatrists.
• Occupational and speech therapists.
• Optometrists and ophthalmologists.
• Podiatrists, chiropractors, athletic trainers, physical therapists, and orthopedists.
• Dentists and denturists.
• Specialists.

Healthcare organizations include:

• Ambulance companies
• Clinics
• Group Practices
• Healthcare clearinghouses
• Healthcare plans
• Home healthcare agencies (HHA’s)
• Hospitals
• Medical Equipment suppliers
• Medical Laboratories
• Nursing homes
• Pharmacies
• Residential Treatment Centers

Once a provider’s HIPAA NPI is assigned, the HIPAA NPI is permanent and remains with the provider regardless of job or location changes.

Other health industry workers who provide support services but not healthcare (i.e. admissions and medical billing personnel, housekeeping staff, and orderlies) are not required to obtain an NPI.

CMS adopted a policy for all Medicare and Medicaid providers that mandate the use of the NPI. It has been confirmed that the NPI is required for all providers, regardless of their status with HIPAA. The only known exclusion to the NPI initiative is for small health plans, which is the relatively small group of insurers that process a minimum number of medical claims each year.

HIPAA-covered transactions are transactions involving: “the transmission of information between two parties to carry out financial or administrative activities related to health care.” HIPAA-covered transactions include the following types of information transmissions:

• Health claims or equivalent encounter information.
• Health care payment and remittance advice.
• Coordination of benefits.
• Health care claim status.
• Enrollment and disenrollment in a health plan.
• Eligibility for a health plan.
• Health plan premium payments.
• Referral certification and authorization.
• First report of injury.
• Health claims attachments.

HIPAA requires that health care providers have standard national numbers that identify them on standard transactions. The National Provider Identifier (NPI) is a unique identification number that is required by HIPAA for covered healthcare providers. Covered health care providers and all health plans and health care clearinghouses use the NPIs in the administrative transactions adopted under HIPAA. Not having an NPI is a violation of HIPAA.

To get an NPI number, applying via an online application is preferred. The entire application should take you about 20 minutes to complete. Providers can also apply for an NPI number through a paper form or an organization on their behalf. Complete instructions are found on the CMS website here.

Before you can complete the application on the NPPES website, you will need to create a login through the identity and access management system.

Applying for an NPI is free, simple, and takes only about 20-30 minutes.

You can apply online, by mail, or through a designated CMS contractor.

To apply online, visit the National Plan and Provider Enumeration System (NPPES) website, read the instructions carefully, complete the questionnaire, and submit your application.

After your application has been processed, you will receive your NPI via email from the address [email protected]. You may need to check your spam folder for your NPI and confirmation message. Be sure to check this folder regularly after submitting your data.

The online application is recommended because it is generally quicker and easier to track the status of your application. However, if you prefer to submit a paper application, contact the NPPES customer service hotline at 800.465.3203 to request a paper application form.

The Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandated the adoption of standard unique identifiers (NPI numbers) for healthcare providers and health plans.

The purpose of these provisions is to improve the efficiency and effectiveness of the electronic transmission of health information. The Centers for Medicare & Medicaid Services (CMS) developed the National Plan and Provider Enumeration System (NPPES) specifically to assign these unique identifiers.

Step-by-Step Process Be sure to use the “Previous” button within the NPI software rather than your browser back button. If you accidentally use the back button on your internet browser, the program will close automatically and you will need to start over on your application

1. Go to NPI Welcome page

1. Look under “Individual Providers”
2. Click on “Create a Login”
3. Create a login using the Identity & Access Management System
4. Print the page with your username and password for your records. You will
5. need your user ID and password to update your information throughout your
6. medical career.
7. Once you have created your login, you will return to the NPPES homepage.
8. Login to NPPES under “Manage or Apply for your personal NPI Record”

2. NPI Application Instructions

1. Click on “NEW NPI Application”
2. Read Terms
3. Click on “Submit New NPI Application”
4. If you need help or have questions, you can refer to the “Help” page at the
5. top right at any time during the application

3. Provider Profile

1. Complete Provider Profile
2. Answer “No” to the question, “Is the Provider a Sole Proprietor?”

4. Business Mailing Address

1. Enter your Residency/Fellowship program address
2. DO NOT use your personal address

5.Business Practice Location

1. Click on “Same as Business Mailing Address”
2. Enter the program phone number
3. DO NOT use your personal phone number

6. Business Mailing Address Standardization

1. Click on “Accept Standardized Address”

7. Other Identification Numbers

1. Some staff may have obtained Medicare, Medicaid, or UPIN Provider Numbers. If so, enter the information on this page
2. If you don’t have those numbers, click “Next” to go on to the next page

8. Taxonomy/License Information

1. This is the most complicated part of the application. There are over 175 Taxonomy codes to choose from, and you only need one for this application. If you have any doubts about selecting the appropriate code, choose the most general. You will update your Taxonomy code throughout your career if you pursue additional specialties. Taxonomy Codes are available to choose from.
2. If you are not licensed as a physician or dentist in the United States, these are the appropriate steps for you:
   1. Click on “Add Taxonomy”
   2. Select Provider Type Code 39 for “Student, Health Care”
   3. For Classification Name-Area of Specialization Select: Highlight "39020000X-Student in an Organized Health Care Education/Training Program"
   4. Your Taxonomy Code is 390200000X
   5. Click on “Save”
3. If you are licensed in any state in the United States, these are the appropriate steps for you:
   1. Click on “Add Taxonomy”
   2. Select Provider Type Code 20 (Allopathic & Osteopathic Physicians). Licensed
   3. Dentists select Code Type 12.
   4. Select the Taxonomy Code corresponding to the residency/fellowship program in
   5. which you are currently enrolled
   6. Enter the license numbers and states where you are currently licensed. You will likely use the same Taxonomy Code for all of these license entries
   7. Click on “Save”

9. Contact Person Information

1. You are the best person to answer questions that may come up in reference to your application, so use yourself (the Provider) as the Contact Person.
2. Click on “Same as Provider”
3. Under Additional Information for the Contact Person, use your home phone number and email address

10. Certification Statement

1. Read the statement, check the box, and Submit.

Your application will be processed and you will receive an email notification with your NPI within 2-10 days. Print a copy of this email and retain it for your files, as the information will be needed throughout your medical career.

Per the CMS, the NPI consists of 9 numeric digits followed by one numeric check digit.

The NPI does not have embedded intelligence.

Each card issuer identifier used on a standard health identification card must be unique. Therefore the NPI must be generated in a manner that will avoid collisions with other identifiers, such as the standard unique health plan identifier, that might be used as card issuer identifiers on standard health identification cards. In order to avoid such collisions, NPIs will initially be issued with the first digit = 1 or 2. These digits will not be used as the first digits for other card issuer identifiers. Use of other first digits for the NPI must be coordinated with the use of first digits by the standard health plan identifier when it is adopted.

The NPI generation will use a scattering algorithm that has the capability to use all possible numerical combinations beginning with 1 or 2.

11. Go to NPI Welcome page

1. Look under “Individual Providers”
2. Click on “Create a Login”
3. Create a login using the Identity & Access Management System
4. Print the page with your username and password for your records. You will need your user ID and password to update your information throughout your medical career.
5. Once you have created your login, you will return to the NPPES homepage. Login to NPPES under “Manage or Apply for your personal NPI Recor

12. NPI Application Instructions

1. Click on “NEW NPI Application”
2. Read Terms
3. Click on “Submit New NPI Application”
4. If you need help or have questions, you can refer to the “Help” page at the top right at any time during the application

13. Provider Profile

1. Complete Provider Profile
2. Answer “No” to the question, “Is the Provider a Sole Proprietor?”

14. Business Mailing Address

1. Enter your Residency/Fellowship program address
2. DO NOT use your personal address

15. Business Practice Location

1. Click on “Same as Business Mailing Address”
2. Enter the program phone number
3. DO NOT use your personal phone number

16. Business Mailing Address Standardization

1. Click on “Accept Standardized Address”

7. Other Identification Numbers

1. Some staff may have obtained Medicare, Medicaid, or UPIN Provider Numbers. If so, enter the information on this page
2. If you don’t have those numbers, click “Next” to go on to the next page

18. Taxonomy/License Information

1. This is the most complicated part of the application. There are over 175 Taxonomy codes to choose from, and you only need one for this application. If you have any doubts about selecting the appropriate code, choose the most general. You will update your Taxonomy code throughout your career if you pursue additional specialties. Taxonomy Codes are available to choose from.
2. If you are not licensed as a physician or dentist in the United States, these are the appropriate steps for you:
   1. Click on “Add Taxonomy”
   2. Select Provider Type Code 39 for “Student, Health Care”
   3. For Classification Name-Area of Specialization Select: Highlight "39020000X-Student in an Organized Health Care Education/Training Program"
   4. Your Taxonomy Code is 390200000X
   5. Click on “Save”
3. If you are licensed in any state in the United States, these are the appropriate steps for you:
   1. Click on “Add Taxonomy”
   2. Select Provider Type Code 20 (Allopathic & Osteopathic Physicians). Licensed
   3. Dentists select Code Type 12.
   4. Select the Taxonomy Code corresponding to the residency/fellowship program in
   5. which you are currently enrolled
   6. Enter the license numbers and states where you are currently licensed. You will likely use the same Taxonomy Code for all of these license entries
   7. Click on “Save”

19. Contact Person Information

1. You are the best person to answer questions that may come up in reference to your application, so use yourself (the Provider) as the Contact Person.
2. Click on “Same as Provider”
3. Under Additional Information for the Contact Person, use your home phone number and email address

20. Certification Statement

1. Read the statement, check the box, and Submit.

Your application will be processed and you will receive email notification with your NPI within 2-10 days. Print a copy of this email and retain it for your files, as the information will be needed throughout your medical career.

The NPI Certification Statement that appears at the end of the application reads:

After reading the terms and conditions below, check the box at the bottom of this page then click “Submit” to submit your application.

• I have read the contents of the application and the information contained herein is true, correct, and complete. If I become aware that any information in this application is not true, correct, or complete, I agree to notify the NPI Enumerator of this fact immediately.
• I authorize the NPI Enumerator to verify the information contained herein. I agree to keep the NPPES updated with any changes to data listed on this application form within 30 days of the effective date of the change.
• I have read and understand the Privacy Act Statement.
• I have read and understand the Penalties for Falsifying Information on the NPI Application / Update Form as stated in this application. I am aware that falsifying information will result in fines and/or imprisonment.

Penalties for Falsifying Information:
18 U.S.C. 1001 authorizes criminal penalties against an individual who in any matter within the jurisdiction of any department or agency of the United States knowingly or willfully falsifies, conceals, or covers up by any trick, scheme or device a material fact, or makes any false, fictitious or fraudulent statements or representations, or makes any false writing or document knowing the same to contain any false, fictitious or fraudulent statement or entry. Individual offenders are subject to fines of up to $250,000 and imprisonment for up to five years. Offenders that are organizations are subject to fines of up to $500,000. 18 U.S.C. 3571(d) also authorizes fines of up to twice the gross gain derived by the offender if it is greater than the amount specifically authorized by the sentencing statute.

I certify that this form is being completed by, or on behalf of, a health care provider as defined at 45 CFR 160.103.

After completing your application in full, you can expect an email notification with your NPI number in 2-10 days.

There is no charge to get an NPI.

All individuals and Organizations who meet the definition of health care provider as described at CFR 160.103 are eligible to obtain a National Provider Identifier or NPI.

Note the following definition from 45 CFR 160.103:
“Health care provider means a provider of services (as defined in section 1861(u) of the Act, 42 U.S.C. 1395x(u)), a provider of medical or health services (as defined in section 1861(s) of the Act, 42 U.S.C. 1395x(s)), and any other person or organization who furnishes, bills, or is paid for health care in the normal course of business.”

Section 1861(s) of the Social Security Act references explicitly the services of the following health professionals:

• Physicians
• Nurse practitioners
• Physician assistants
• Certified nurse-midwives
• Qualified psychologists
• Clinical social workers
• Certified registered nurse anesthetists

All health care providers who are HIPAA-covered entities, whether individuals or organizations, must obtain an NPI. A “covered entity” is defined as a health care provider that transmits any health information in electronic form, such as submitting a claim. This includes:

• Health care providers that conduct certain transactions in electronic form.
• A health care clearinghouse.
• A health plan (including commercial plans, Medicare, and Medicaid).

If you electronically transmit health information in connection with a HIPAA standard transaction, you are considered a “covered entity,” even if you use a business associate to do so.

There are two categories of health care providers for NPI purposes: Type 1 (Individual) and Type 2 (Organization).

Type 1 entities include:

• Physical Therapists
• Physicians
• Chiropractors
• Dentists
• Nurses
• Pharmacists

Type 2 entities include:

• Ambulance Companies
• Clinics
• Group Practices
• Health Maintenance Organizations
• Home Health Agencies
• Hospitals
• Laboratories
• Nursing Homes
• Pharmacies
• Residential Treatment Centers
• Suppliers of Durable Medical Equipment

Group practices, in addition to the individual physical therapists working in the practices, are each required to obtain an NPI.

With solo incorporated practices, the corporation and the individual therapist each should have an NPI. You must apply for each NPI.

Covered healthcare providers and all health plans and healthcare clearinghouses must use NPIs in the administrative and financial transactions adopted under HIPAA.

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.

Even if you do not bill for services at your practice, you may need to disclose your NPI to those providers who do (such as providers who order lab tests or send patients for diagnostic testing and must be identified on the lab's or testing facility's claims). Without an NPI, claims may be adversely affected, including delayed or denied payments.

Any entity that doesn’t meet the definition of a health care provider as defined in 45 CFR 160.103 may not apply for an NPI. Such entities include billing services, value-added networks, repricers, health plans, health care clearinghouses, non-emergency transportation services, and others.