HHS Publishes Final Rule for Standard Unique Health Identifier for Health Care Providers for use in Standard Transactions under HIPAA

On January 23, 2004, HHS published the Final Rule that adopts the National Provider Identifier (the NPI) as the standard unique health identifier for health care providers. This rule becomes effective 16 months after its publication date (May 23, 2005). Providers need not take any action to apply for NPIs until that date. This rule is available at: http://a257.g.akamaitech.net/7/257/2422/14mar20010800/edocket.access.gpo.gov/2004/pdf/04-1149.pdf

The CMS web site at http://cms.hhs.gov/hipaa/hipaa2 will also provide a link to this rule.

The compliance date for all covered entities except small health plans is May 23, 2007; the compliance date for small health plans is May 23, 2008. When the NPI is implemented, covered entities will use only the NPI to identify providers in all standard transactions. Legacy numbers (e.g., UPIN, Blue Cross and Blue Shield Numbers, CHAMPUS Number, Medicaid Number, etc.) will not be permitted. Providers will no longer have to keep track of multiple numbers to identify themselves in standard transactions with one or more health plans. (The Taxpayer Identifying Number may need to be reported for tax purposes as required by the implementation specifications.)

All entities who meet our definition of "health care provider" at 45 CFR 160.103 are eligible for NPIs. Providers who are "covered entities" are required to obtain and use NPIs. Providers who are not covered entities may also apply for NPIs. An NPI is expected to last indefinitely; it will not change over time.

Entities who never furnish health care (such as taxi services) are not eligible to be assigned NPIs: they do not meet the definition of "health care provider" and any claims they submit to a health plan would not be "health care" claims and thus would not be subject to HIPAA requirements.

In certain situations, it is possible for "subparts" of organization health care providers (such as hospitals) to be assigned NPIs. These subparts may need to be assigned NPIs in order to conduct standard transactions on their own behalf or to meet regulations that, as an example, may require them to have a billing number in order to be paid by Medicare. The Final Rule requires covered providers to determine if they have subparts that may need NPIs and, if so, to obtain NPIs for the subparts or require the subparts to obtain their own NPIs. (This issue does not pertain to providers who are individuals.)

The NPI is all numeric. It is 10 positions in length (9 plus a check-digit in the last position). It is easily accommodated in all standard transactions. It contains no embedded information about the provider that it identifies. At the current rate of provider growth, NPIs will be available for 200 years.

Providers will be assigned NPIs upon successful completion of an application form. The form can be submitted on paper or over the Internet. Once a provider has been assigned an NPI, the provider must furnish updates to its data within 30 days of any changes.

The National Provider System, being built under a Centers for Medicare & Medicaid Services (CMS) contract, will process the applications and updates, ensure the uniqueness of the provider, and generate the NPIs. It will also produce reports and information based on requests from the health care industry and others.

A single entity, known as the enumerator, and performing under a CMS contract, will operate the NPS. The enumerator will receive applications and updates from providers. The enumerator will assist providers in completing applications, in furnishing updates, and will be responsible for resolving problems and answering questions. The enumerator will notify the providers of their NPIs. The enumerator will also process requests for, and disseminate information containing, providers' NPIs. The Department will prepare a Federal Register Notice describing the NPS data dissemination policy.

Providers who are covered entities may begin applying for NPIs on May 23, 2005, the effective date of the Final Rule. There will be an extremely heavy workload continuing for some time after that date as the NPS processes applications and assigns NPIs to existing providers who are required to obtain and use NPIs by the compliance date. Providers who are not covered entities, but who wish to apply for NPIs, may indeed do so, but should wait at least 1-2 years after the effective date before applying.

Information about NPI implementation, including information on how to apply for NPIs, will be made available to the health care industry by CMS closer to the effective date.

Posted to HIPAAcomply 1/23/03