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National Provider Identifier (NPI) an Overview

National Provider Identifier (NPI) an Overview. Janet Hill June 20, 2006. What is an NPI?. It is the new HIPAA regulated National Provider Identifier. It will replace the current Horizon Legacy ID used in all HIPAA standard electronic transactions to identify a Health Care Professional.

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National Provider Identifier (NPI) an Overview

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  1. National Provider Identifier(NPI) an Overview Janet Hill June 20, 2006

  2. What is an NPI? • It is the new HIPAA regulated National Provider Identifier. • It will replace the current Horizon Legacy ID used in all HIPAA standard electronic transactions to identify a Health Care Professional. • It is a 10 position numeric data-element • Assigned by National Plan and Provider Enumeration System (NPPES) • It does not convey information about the provider or SUBPARTS it defines. -The 10th position on the right is a check digit based on Luhn Formula Algorithm 2

  3. An NPI will not • Guarantee reimbursement by health plans • Enroll professionals in health plans • Make health care professionals covered entities • Require health care professionals to conduct electronic transactions • Replace Employer Identification Number (EIN) • Replace Social Security Number (SSN) • Replace State License Number 3

  4. Who is an Entity Type 1 and who is an Entity Type 2 Provider? • A health care provider - individual human – must apply for an Entity Type 1 NPI. This includes, but is not limited to physicians, dentists and chiropractors • An organization, such as a hospital, must apply for an Entity Type 2 NPI. The definition of an organization includes, but is not limited to hospitals, residential treatment centers, laboratories, and group practices • Group -A business entity under which one or more individuals practice. A group does not require multiple professional providers. A single provider group is a valid group and would be identified by the business entity name, for instance - John Doe, PC. 4

  5. What is Taxonomy • This is a 10 digit alphanumeric data element that indicates Specialty. • This data-element carries no identifying information about the Specialty. • A Type 1 Entity may have many Taxonomies for specialties. • A Type 2 Entity Will have a Taxonomy indicating Multi-Specialty. • The Taxonomy of the Type 1 Entity from within the multi specialty group will be used to indicate what Specialty was being performed . 5

  6. Provider Communication Strategy • Develop and implement provider communication plans to support NPI awareness, identify NPI transition processes/schedules and set expectations in a proactive manner. • Meet with providers who have complex contracting frameworks to determine strategies that will meet both provider and health plan needs. • Coordinate with clearinghouses and direct connect providers • Take the lead in communicating with providers. • Provider bulletins, newsletters, websites, etc., will be used to educate about NPI, the health plan’s timeframe for accepting NPIs, and using the NPI. 6

  7. Examples Option 1 Option 2 Current Numbering ABC HOSPITAL NPI Enumeration at Subpart Level NPI Enumeration at Facility Level TAX-ID 123456789 Medicare UPIN (legacy id) Acute Care - 320029 Skilled Nursing - 313025 Sub-Acute - 312025 Transactions submitted With TAX-ID 123456789 Unique NPI by Subpart Hospitals NPI 3012345670 -A unique NPI for each Subpart NPI 3123456780 or 3223456780 or 3323456780 or Transactions submitted with TAX ID - 123456789 NPI – 3012345670 Unique Taxonomy by Subpart Hospitals NPI 3012345670 -A unique Taxonomy for each Subpart 282N00000X 313M00000X 261QR0200X 7

  8. Examples Option 1 Option 2 Current Numbering Dr. Smith NPI Enumeration at Location Level Taxonomy / Zip Code +4 TAX ID 234567891 Smith Pediatric PCPs 1st Street Legacy # 2345678910 JCODE - J1012 2ND Street Legacy # 234567891A JCODE - J1014 234567891 2222444466 Location 1 3333555566 Location 2 234567891 NPI = 22222444466 2080A0000X 07981-2000 2080A0000X 07981-2300 8

  9. QUESTIONS? 9

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