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J Oncol Pract. 2006 November; 2(6): 281.
PMCID: PMC2793662

The New National Provider Identifier

We've heard a lot of talk lately about the NPI. What is it?

The national provider identifier (NPI) will identify health care providers on a national level. This means that the NPI will be recognized by all entities in the health care industry. The NPI will replace health care provider identifiers currently used. For example, the NPI will replace Medicare legacy numbers like UPINs (unique physician [provided] identification numbers) and PINs (personal identification numbers). See online-only NPI Fact Sheet.

How did the NPI come into existence?

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandated that a unique health identifier be created for each health care provider. The Department of Health and Human Services released a final rule adopting the NPI as that unique number and began the implementation of the NPI.

Why is the NPI important?

The NPI is important because it is a mandated HIPAA standard, and because it should simplify billing. The NPI is a single provider identification number that will be accepted and recognized by all health plans; therefore, eliminating the need to report, maintain, and track multiple provider identification numbers.

When must the physicians have their NPIs?

All HIPAA-covered entities must use NPIs in standard transactions by May 23, 2007. After this date, Medicare, Medicaid, and other private health plans must accept NPIs. Some health plans may allow the use of NPIs before the May 2007 date; however, communication should occur with those plans to verify reporting details.An exception to the aforementioned date has been made for small health plans. They must use NPIs by May 23, 2008.

How does the physician apply for the NPI?

Providers can apply for an NPI by completing a paper application, through a Web-based application, or through an organization (an employer or professional organization). Providers need to apply using one of the options above and need to apply only once. Providers should apply for their NPI if they have not already done so.

Is there a cost associated with obtaining the number?

There is no charge for obtaining an NPI.

How are the numbers being assigned?

The Centers for Medicare & Medicaid Services (CMS) developed the National Plan and Provider Enumeration System (NPPES) to assign NPIs. The NPPES is also responsible for processing NPI applications, handling application problems and/or errors, maintaining updates, and processing deactivation requests. The NPPES can be reached by calling 800-465-3203 or by sending an e-mail tomoc.rotaremuneipn@ecivresremotsuC.

How long does it take to receive the NPI after an application is submitted?

CMS cannot determine the amount of time it will take to obtain a NPI; however, they do suggest following up with NPPES after 15 days.

Will the physician receive only one NPI? What if the physician's name or address changes?

A provider receives only one number. Once a number is assigned, a provider's NPI will not change. The NPI remains with the provider even if a name, job, or an address change occurs. The NPPES should be contacted to update provider information such as name, address, licensing, or other submitted application information.

If the physician has an NPI, do we as a practice or the physician as an individual still need to enroll with health plans?

The assignment of an NPI does not replace the enrollment process for health plans including Medicare. A provider must still enroll in the health plan(s) he or she chooses to participate in.

Is the CMS-1500 form being revised to accept the NPI?

Yes. The CMS-1500 form was revised to accommodate the reporting of NPIs. The revised form, CMS-1500 (08-05), features split provider identifier fields. This allows providers to report their NPI number and other legacy numbers (including Medicare). During the period between January 2, 2007, and March 30, 2007, providers can use either the CMS-1500 (12-90) or the CMS-1500 (08-05). After April 2, 2007, however, only the CMS-1500 (08-05) form should be used.To learn more about the revised CMS form, view Medicare Learning Network Matters article MM5060 or access http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5060.pdf.

Where can I obtain more information about the NPI?There are many CMS resources available to learn more about the NPI. Fact sheets and frequently asked questions can be found on the CMS NPI Web page at http://www.cms.hhs.gov/NationalProvIdentStand/01_Overview.asp#TopOfPage under Educational Resources.


Articles from Journal of Oncology Practice are provided here courtesy of American Society of Clinical Oncology