HealthA 2023 Guide to National Provider Identifier

A 2023 Guide to National Provider Identifier

NPIs are Health Insurance Portability and Accountability Act (HIPAA) Administrative Standards. To improve electronic health information transmission efficiency and effectiveness, NPIs are unique identification numbers for covered health care providers.

The administrative and financial transactions of covered health care providers, health plans, and clearinghouses must include a search for NPI lookups.

NPI: What Is It?

NPIs are numeric identifiers consisting of 10 digits. Provider type, specialty, state, and provider information are not carried out. No matter how your name, address, or taxonomy change, your NPI will remain the same.

NPIs must replace other provider identifiers used in HIPAA standard transactions, such as Provider Transaction Access Numbers (PTANs), Online Survey Certification & Reporting (OSCARs), and National Supplier Clearinghouses (NSCs).

What can an NPI do?

  • HIPAA standard transactions can be transmitted electronically
  • Providers, plans, and employers must use standard unique health identifiers
  • Benefits coordination is efficient

What an NPI can’t do

  • You cant replace or change the current process for enrolling or certifying for Medicare
  • Get you enrolled in a health plan
  • Obtain a license or credential
  • A health plan’s guarantee of payment
  • Transact under HIPAA

NPIs are available to who?

The NPI may be obtained by any health care provider (physician, supplier, hospital, etc.). Health care providers render health care according to 45 CFR 160.103. Check out 45 CFR 160.103 on the GPO website for more information.

An NPI is required

An NPI is required for all HIPAA-covered entities, whether individuals or organizations. Covered entities include:

  • Electronic health care provider
  • Medical clearinghouses
  • Health insurance (commercial, Medicare, Medicaid)
  • If you use a business associate to transmit health information electronically, you are a covered health care provider under HIPAA.

NPIs are not available to everyone?

It is prohibited for entities that do not meet the definition of a health care provider under 45 CFR 160.103 to apply for a license NPI. Health plans, health care clearinghouses, billing services, value-added networks, and transportation companies are just a few entities providing these services.

NPI Categories for Health Care Providers: What Are They?

Entity Type 1 (Individual) and Entity Type 2 (Organization) are the two categories of health care providers for NPI enumeration.

Entity Type 1: Individual / Sole Proprietors Individual

Sole proprietors are eligible for NPIs under Entity Type 1. Even if you have an Employer Identification Number (EIN), you must apply for the NPI using your own Social Security Number (SSN).

Just like any individual, sole proprietors can only have one NPI. Sole proprietors can receive only one NPI (the individual’s NPI). Entity Type 1 status is not affected by the following factors:

  • Locations of offices
  • Employees or not
  • Your employees’ W-2 forms should reflect the EIN rather than your Taxpayer Identification Number (SSN).

Entity Type 2: Organization Health Care Providers

The health care provider is a group health care provider that qualifies for an NPI as an Entity Type 2. There can be a single employee in an organization health care provider or thousands of employees. Individuals may be the only health care providers employed by an organization provider (the corporation they formed).

Some organizations provide health care through components that operate independently from their “parent” organization. Depending on the component, health care may be provided in various ways or at different physical locations. The health care provider (a legal entity) is concerned with these components and their physical locations. Subparts are referred to in the NPI Final Rule.

Organizations can give their subparts NPIs. A subpart must obtain its NPI if it conducts HIPAA standard transactions (apart from its parent).

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