Are you a HIPAA-covered healthcare provider? If so, take a number—a National Provider Identifier (NPI) number, that is. NPIs have been the go-to provider identification mechanism in the US healthcare system since May of 2007, replacing legacy identifiers like Unique Physician Identification Numbers (UPIN), Medicaid Provider Numbers, and Medicare Provider Numbers. But, as with any government-mandated requirement, the rules surrounding NPIs aren’t always so clear cut—and they’ve generated many questions over the years. Here, we answer some of the most common ones, as adapted from these CMS FAQs, this APTA page, and the questions we’ve received over the years.
Why do I need an NPI number?
If you try to submit a claim without an NPI number, it will probably be denied. And that doesn’t just go for Medicare claims—it’s also the rule for private payers. So, if you want to get paid for your services, you better get one of these 10-digit identifiers ASAP. Furthermore, as CMS explains, “NPIs may also be used to identify health care providers on prescriptions, in coordination of benefits between health plans, in patient medical record systems, in program integrity files, and in other ways.”
So NPIs aren’t just another logistical hoop for healthcare providers to jump through—they actually save time. NPIs help streamline the electronic claims submission process, as they prevent providers from having to track and submit insurer-specific identifiers.
How do I get an NPI number?
There are three ways to obtain an NPI number:
- Apply online through the National Plan and Provider Enumeration System (NPPES) page on the United States Department of Health and Human Services (HHS) website. There, you’ll set up an NPPES username and password, log in to your account, and fill out the electronic application. This is definitely the fastest and easiest way for an individual provider to get an NPI. The whole process should take about 20 minutes.
- Complete and mail an application to the address listed on the form, which you can access and print here. Don’t have a printer? No worries; you can request a hard copy of the application by calling the NPI Enumerator at 1-800-465-3203 or emailing firstname.lastname@example.org.
- Ask an electronic file interchange organization (EFIO) to apply for your NPI on your behalf. This method—also known as “bulk enumeration”—is geared toward submission of large batches of provider information. For more information on electronic file interchange, check out this CMS page.
If I’m part of a practice or facility that has a group NPI, do I also need an individual NPI?
Yes. Healthcare providers are encouraged to obtain their own NPIs—even if they’re operating under a group NPI. This is because some claims require that the practitioner’s NPI is used to differentiate the rendering, referring, and/or attending provider, while the group NPI notates the billing and pay-to provider.
Can I change the information associated with my NPI?
Yes. In fact, if any provider details (e.g., the address of your practice) change, you must notify NPPES within 30 days. You can do this in one of three ways:
- access the online portal;
- print, complete, and mail this form; or
- call the NPI Enumerator at 1-800-465-3203 to request a form.
Would I ever need to get a new NPI?
Like a diamond, an NPI is forever—most of the time. As CMS explains, a provider’s NPI is “meant to be a lasting identifier, and is expected to remain unchanged even if a health care provider changes his or her name, address, provider taxonomy, or other information that was furnished as part of the original NPI application process.”
If you need to update any of that information, you would follow the process outlined in the fourth item above. However, there is a very narrow set of circumstances in which you might need to obtain a completely new NPI—if the original one has been used fraudulently, for example. You also may need to obtain a new group NPI number as a result of “certain changes of ownership, the conditions of a purchase, or a new owner’s subpart strategies.”
What’s the difference between a Type 1 and Type 2 NPI?
Type 1 NPIs are for individual healthcare providers and sole proprietors. This identifier sticks to the provider and follows them throughout their career—regardless of where they go. And when it comes to sole proprietorship, the Type 1 NPI persists, regardless of:
- How many locations you have,
- Whether you have employees, and
- “Whether the IRS issued an EIN to you.”
Type 2 NPIs are group identifiers for incorporated healthcare organizations or LLCs. Any provider who furnishes care through an incorporated organization or LLC will bill using the org’s Type 2 NPI—whether there’s one employee or a thousand.
Should I get multiple NPIs for multiple locations?
If you’re a sole proprietor, nope! You can use your Type 1 NPI at multiple locations. Regarding Type 2 NPIs, whether or not you need to get multiple identifiers depends on the structure of your organization. If your organization is composed of components that “function somewhat independently from their parent organization”—think providing different types of health care or operating in different locations—then each subpart may get its own NPI. To further expand upon that point, CMS says, “If a subpart conducts any HIPAA standard transactions on its own (separately from its parent), it must get its own NPI.”
Don’t see your NPI question on this list? Ask it in the comment section below, and we’ll do our darndest to dig up an answer for you. And for answers to other common PT, OT, or SLP billing questions, be sure to check out our upcoming webinar.