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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 l.jpg
National Provider Identifier(NPI) an Overview

Janet Hill

June 20, 2006


What is an npi l.jpg
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

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An npi will not l.jpg
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

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Who is an entity type 1 and who is an entity type 2 provider l.jpg
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.

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What is Taxonomy Provider?

  • 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 .

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Provider Communication Strategy Provider?

  • 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.

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Slide7 l.jpg

Examples Option 1 Option 2 Provider?

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

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Examples option 1 option 2 l.jpg
Examples Option 1 Option 2 Provider?

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

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Questions l.jpg
QUESTIONS? Provider?

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