Why you should use NPI number In Standard Electronic Transactions

What is NPI (National Identifier Number)?

The Health Care Provider Taxonomy code is a unique alphanumeric code, ten characters in length. The code set is structured into three distinct “Levels” including Provider Grouping, Classification, and Area of Specialization.

What is NPI

The Health Care Provider Taxonomy code set is published (released) twice a year on July 1st and January 1st. The July publication is effective for use on October 1st and the January publication is effective for use on April 1st. The time between the publication release and the effective date is considered an implementation period to allow providers, payers, and vendors an opportunity to incorporate any changes into their systems.

Purpose of NPI?

It is a single unique identification number that is issued by the federal government to health care providers. It is intended to improve the efficiency of the health delivery system and help to reduce fraud and abuse.

Who needs an NPI Number?

NPIs will be given to health care providers who need them to submit claims or conduct other transactions specified by HIPAA(Health Insurance Portability and Accountability Act).

A “health care provider” is defined as an individual group or organization that provides medical or other health services or supplies.

This includes:

  1. Physicians and other practitioners
  2. Institutions such as hospitals/Research center
  3. Laboratories
  4. Nursing homes
  5. Dental service providers
  6. Physician/practitioner groups
  7. Suppliers such as pharmacies and medical supply companies
  8. Any health care provider who transmits any health information in electron9ic form in connection with a standard transaction
NPI assigned letter

How do you use NPI assigned letter?

Healthcare providers must use their NPIs on electronic transactions adopted by HIPAA.

837 Claims Submission

270/271 Eligibility

276/277 Claim Status Inquiry 

278 Referral/Authorization 

  • NPI assigned letter is used to identify themselves in HIPAA-Compliant health care transactions.
  • NPI assigned letter is used to identify other health care providers in health care transactions.
  • NPI assigned letters to help to identify themselves on related correspondence.
  • NPI is used to process health plans to process transactions and communication with providers.
  • NPI is used for electronic patient records files to identify treating service providers in medical records.

Health care, delivery providers need an NPI so they can be identified on electronic transactions performed by other entities.

The hospital needs the NPIs of admitting and attending physicians to submit electronic claims to a health plan. 

Does the NPI replace the tax ID number on eligibility, claims status inquiry, referral, and precertification transactions?

For eligibility, referral, precertification transactions, federal regulations require submission for providers’ NPI number unless the provider is not considered a health care provider as defined under HIPAA.

For claim status inquiry, NPI is required in the servicing provider field, but the billing provider ID can be an NPI, Tax ID, or PIN/PVN

Are providers allowed to send other identification numbers such as PIN, PVN, and TIN in electronic transactions?

To be compliant with the regulations, covered entities must use the NPI of any health care provider that has been assigned an NPI to identify that health care provider in HIPAA standard transactions. The use of other IDS is permitted only to identify an entity or individual as a taxpayer.

Other identification numbers may be used in certain situations:

  • Non covered health care providers
  • Providers acting in another role, such as information submitter or receiver or as a utilization management organization.
  • Nonmedical living arrangements.
  • Nonemergency transportation providers.
  • Independent practice associations (IPAs).

NPI data

NPI registry: The NPI Registry is a query-only database that is updated daily to enable users to query the NPPES (e.g., search by NPI, provider name, etc.) and retrieve the FOIA-disclosable data from the search results. There is no charge to view the data.

NPI Downloadable File:  Full Replacement Monthly NPI File, Weekly Incremental NPI File, and Full Replacement NPI Deactivation File.  There is no charge to download the data.

Starting June 18, 2018, the zipped NPPES Downloadable file will include the following 3 new reference files:

  1. Other Name Reference File – this file contains additional Other Names associated with Type 2 NPIs.
  2. Practice Location Reference File – this file contains all of the non-primary Practice Locations associated with Type 1 and Type 2 NPIs.
  3. Endpoint Reference File – this file contains all Endpoints associated with Type 1 and Type 2 NPIs.