HIPAA Again? The National Provider Identifier Rule
Julia M. Vander Weele, Sunday, October 01, 2006 | Filed under: Health Plans, HIPAA Privacy and Security
After years of compliance efforts relating to the electronic transaction rules, privacy rules, and security rules under the Health Insurance Portability and Accountability Act (“HIPAA”), yet another requirement looms on the horizon. The National Provider Identifier (“NPI”) was adopted as the standard health identifier for health care providers in order to fulfill a requirement in HIPAA for the adoption of such a standard. The purpose of the NPI is to establish a single, unique identifier for health care providers to use in standard health care transactions.
Covered entities must use NPIs in standard transactions by the compliance dates. A “standard transaction” is defined in the same way that this term is used in HIPAA’s Electronic Transactions and Code Sets requirements (e.g., claims transactions and eligibility transactions). The compliance deadline is May 23, 2007, for large health plans ($5 million or more in receipts) and May 23, 2008, for small health plans (under $5 million in receipts).
COVERED ENTITIES
Covered entities include health plans, health care clearinghouses, and health care providers that transmit health information in electronic form in connection with HIPAA standard transactions. “Covered” health care providers,
i.e., those that conduct standard transactions,
must have an NPI. Other health care providers, e.g., a registered nurse who does not conduct transactions,
may obtain an NPI. If a covered health care provider uses business associates to conduct standard transactions on its behalf, the provider must require its business associates to use NPIs.
Individual providers will have only one NPI issued during their lifetimes. Group or institutional NPIs will not be linked with individual NPIs, but health plans may establish such links internally if they so choose. A subpart of a provider organization
must apply for a separate NPI if the subpart would be a covered health care provider itself if it were a separate legal entity. A subpart of a provider organization
may apply for a separate NPI if the subpart would otherwise qualify for assignment of an NPI,
i.e., if the subpart meets the definition of health care provider. The number assigned will be permanent, except in the case of fraud.
NATIONAL PROVIDER IDENTIFIER
The NPI is a 10-position numeric identifier with a check digit in the 10th position. It is a non-intelligent number, which means that the number will not contain any information or coding (such as the type of health care provider or state where the provider is located). The Department of Health and Human Services has contracted with an organization, known as the enumerator, to assign NPIs. Providers will need to apply to the enumerator for an NPI, but there is no fee for obtaining one. In addition to identification in standard transactions, the NPI may be used for any other legal purpose (e.g., coordination of benefits between plans).
The National Provider System (NPS) will maintain data elements about health care providers that are needed for administrative purposes and for the unique identification of the health care provider. NPS will capture the mailing address and one physical location address for each health care provider. A covered health care provider must notify NPS of changes in any of the information that it furnished on its application for an NPI, and must do so within 30 days of the change. A health plan is not required to provide information to the NPS to update health care provider data, but a health plan is encouraged to instruct and remind its health care providers to notify the NPS of changes in their data.
GROUP HEALTH PLAN RESPONSIBILITIES
If a health care provider has been assigned an NPI, health plans are required to use it to identify the provider on all standard transactions that require identification of the provider. Health plans may require health care providers (covered or otherwise) with whom they do business to obtain NPIs, but they may not require a health care provider to obtain an additional NPI. A health plan may continue to use health care provider identification numbers other than the NPI in its internal processes and files. Additionally, a health care provider’s tax identification number can still be used for tax purposes.
Sponsors of group health plans may face many conversion issues, including:
- Software conversion to accommodate the NPI 10-digit format;
- Processes to update legacy information systems with the new NPIs;
- Updating reference files and forms to ensure continuity between old identifiers and the new NPI; and
- Implementation and training.
The complexity of the conversion for a health plan will be affected by the degree to which the health plan’s processing systems currently rely on “intelligent” identifiers. For example, a health plan may currently route claims to different processing routines by keying on a code included in the identifier. Because the NPI will be “non-intelligent,” the health plan may need to alter its processing routines to capture this information in another way. Group health plan sponsors should contact their insurers and administrators to make sure that they are prepared to comply with the NPI Rule.