What is HIPAA NPI?

HIPAA NPI

Under HIPAA, a national provider identifier (NPI) is a unique identification number for covered entities. Healthcare providers, health plans, and healthcare clearinghouses must use their NPI when performing HIPAA covered transactions. The HIPAA NPI is a 10-digit, intelligence-free numeric identifier. This means that the numbers contain no information about the providers themselves, such as their state of practice, or what their specialty is. A covered entity must share its HIPAA NPI with other providers, health plans, clearinghouses, and other entities that need the HIPAA NPI for billing purposes.

What Healthcare Providers Must Use the HIPAA NPI?

Any provider that provides what HIPAA defines as “healthcare” must obtain and use an NPI when performing a HIPAA covered transaction. 

HIPAA-covered transactions are transactions involving: “the transmission of information between two parties to carry out financial or administrative activities related to health care.”

HIPAA-covered transactions include the following types of information transmissions: (1) Health claims or equivalent encounter information. (2) Health care payment and remittance advice. (3) Coordination of benefits. (4) Health care claim status. (5) Enrollment and disenrollment in a health plan. (6) Eligibility for a health plan. (7) Health plan premium payments. (8) Referral certification and authorization. (9) First report of injury. (10) Health claims attachments.

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The HIPAA regulations define “healthcare” as care, services, or supplies related to the health of an individual. Under the regulations, healthcare includes, but is not limited to, the following:

Care, counseling, services, assessments, or procedures, with respect to the physical or mental condition, or functional status, of an individual.

Care, counseling, services, assessments, or procedures, that affect the structure or function of the body.

Sale or dispensing of a drug, device, equipment, or other item in accordance with a prescription

Care includes preventive, diagnostic, therapeutic, rehabilitative, maintenance, or palliative care. Palliative care is care that eases the pain caused by a condition, without treating the underlying condition.

Providers of any of the above services are regarded as HIPAA covered healthcare providers. Providers include:

Physicians, pharmacists, and physician assistants.

Nurse practitioners, RNs, nurse assistants, and nurse anesthetists.

Clinical social workers, professional counselors, psychologists, and psychiatrists.

Occupational and speech therapists.

Optometrists and ophthalmologists.

Podiatrists, chiropractors, athletic trainers, and orthopedists.

Dentists and denturists.

Specialists.

Healthcare organizations include hospitals, physician offices, home health care agencies, nursing homes, residential treatment centers, labs, pharmacies, and medical equipment companies. Once a provider’s HIPAA NPI is assigned, the HIPAA NPI is permanent, and remains with the provider regardless of job or location changes.

Other health industry workers who provide support services but not health care (such as admissions and medical billing personnel, housekeeping staff, and orderlies) are not required to obtain an NPI.

What are HIPAA NPI Optional Uses?

The NPI must be used in connection with the electronic transactions identified in HIPAA. The NPI may be used (but is not required to be used) in several other ways:

By a healthcare provider to identify itself in HIPAA-related correspondence.

By a provider to identify another provider in health care transactions.

By a provider on a prescription (note that the NPI will not replace the requirement for the prescription to have a DEA number or state license number).

By a health plan, to arrange for coordination of benefits with another health plan.

How Does a Provider Obtain a HIPAA NPI?

A provider can obtain a HIPAA NPI by going to the CMS website’s National Plan and Provider Enumeration System (NPPES) pages and following the instructions to obtain an NPI. It may take several weeks for CMS to provide the number. NPI numbers may be searched on CMS’ website as well.