June 11, 2007
To the relief of clinical laboratories and other healthcare providers, the government has set forth the data details it will make available from the National Plan & Provider Enumeration System (NPPES) and who can access the data. Labs and other provider groups have long complained that lack of guidance on the data availability has been a big factor impeding NPI readiness among various trading partners.
The NPPES assigns a National Provider Identifier (NPI) to a provider and houses the NPI and information from the NPI application/updates. The NPPES creates a record for each provider to whom it assigns an NPI. Providers are categorized as two types: individuals, such as physicians; and organizations, such as hospitals.
Below are major policy points in the NPPES data dissemination notice in the May 30 Federal Register:
What healthcare provider data will not be available from the NPPES?
Social Security numbers, IRS individual taxpayer ID numbers, and date of birth. HHS has determined that under terms of the Freedom of Information Act (FOIA), these data do not have to be disclosed. Accordingly, HHS says that to prevent or minimize fraud in Medicare/Medicaid, it will not release these data.
What provider data will be available from the NPPES?
Data that HHS has determined to be "disclosable" under the FOIA (see table). HHS says these data should be sufficient to enable HIPAA-covered entities to match provider records in the NPPES with the providers for whom they have data.
Who can request NPIs and other provider data?
Anyone may request NPIs and other NPPES provider data from HHS under the FOIA.
How will the data be available?
HHS will make the FOIA-disclosable NPPES healthcare provider data available in downloadable files and in a query-only database whereby users can search by NPI or provider name. Monthly update files will also be posted for downloading from the Internet, though CMS may later opt for less frequent updates.
When will the initial data file and query-only database be publicly available?
On June 28, 2007.
Will there be any charge to use the query-only database?
There will be no charge.
If providers have been assigned NPIs, what should they do before June 28?
Review their NPPES data and make any necessary updates or corrections. This will ensure that their information is accurate when disclosed by CMS. (Reminder: Providers that are HIPAA-covered entities are required by regulation to update their NPPES data within 30 days of any change.)
Also, providers that want to delete any NPPES data that was not required to be furnished in order to obtain an NPI may do so prior to June 28 if they prefer that such data not be disclosed by CMS.
Will a group practice be able to submit NPI applications and obtain NPIs for physician members of the group?
Yes, if the member gives permission for the NPI application/update data to be submitted by the group. The data are submitted to the NPPES for enumeration electronically in a format defined by HHS. The NPPES processes the NPI application data and makes available to the practice the NPIs assigned to the physician members. If NPIs were not assigned to all the members, HHS indicates why the NPIs were not assigned. This process is known as electronic file interchange (EFI) for bulk enumeration.
EFI information can be found at www.cms.hhs.gov/NationalProvIdentStand/. Providers assigned NPIs via this process may update their own NPPES data electronically on the Web with user identifiers and passwords they select. Information on the format of EFI files is at https://NPPES.cms.hhs.gov . The EFI process became available on May 1, 2006.
Will CMS accept custom requests for NPIs?
Yes, but such requests for FOIA-disclosable data will be considered in accord with FOIA procedures and charges (www.cms.hhs.gov/AboutWebsite/04_FOIA.asp). For example, there could be requests for data for specific healthcare providers, or for healthcare providers in certain states or with certain Healthcare Provider Taxonomy Codes, or requests for the data on CD, diskette, or paper. These requests must be submitted in detail to: CMS, Office of Strategic Operations & Regulatory Affairs, Freedom of Information Group, Rm. N2-20-16, 7500 Security Blvd., Baltimore, MD 21244-1850. Requests may be faxed to 410-786-0474.
When will Medicare fee-for-service begin rejecting claims without an NPI in the primary provider field, and what is meant by a primary provider?
Primary providers are billing, pay-to, and rendering providers. When CMS judges that a sufficient number of claims contain the NPIs of these providers, it may start rejecting claims that do not contain these NPIs. At press time, the agency said this could be July 1 or soon after.
All other providers are defined as secondary. These include referring, ordering, supervising, facility, care plan oversight, purchase service, attending, operating, and "other" providers. Legacy numbers are acceptable for these providers until May 23, 2008. Under NPI contingency plans, UPINs and surrogate UPINs may still be used to identify ordering and referring providers until further notice, CMS said.
If a secondary provider’s NPI is on a claim, it will only be edited to assure that it has 10 digits, that it begins with "1", "2", "3", or "4", and that the 10th position of the number is a correct check digit.
When will paper claims start being rejected?
Medicare will begin rejecting the old Part A paper form, the UB-92, after May 22, 2007, and will only accept the UB-04.
Medicare will continue accepting the old CMS-1500 (12-90) form to July 1, 2007. Its use had been set for April 1 but was delayed when CMS discovered printing errors on the new form. Medicare will accept only the new CMS-1500 (08-05) as of July 1.
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Healthcare Provider Data Available From NPPES |
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For health care providers/individuals |
For health care providers/organizations |
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NPI (This is the provider’s NPI. If the provider has had an NPI |
NPI (This is the provider’s NPI. If the provider has had an NPI |
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replaced, this will be the same NPI as the Replacement NPI.) |
replaced, this will be the same NPI as the Replacement NPI.) |
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Entity Type Code: 1=Individual |
Entity Type Code: 2=Organization |
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Replacement NPI (This is the provider’s NPI if the provider has been assigned a Replacement NPI. If the provider has never been assigned a Replacement NPI, this data element will be blank.) |
Replacement NPI (This is the provider’s NPI if the provider has been assigned a Replacement NPI. If the provider has never been assigned a Replacement NPI, this data element will be blank.) |
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— |
Employer Identification Number (EIN) |
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Provider Last Name (Legal Name) |
Provider Organization Name (Legal Business Name) |
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Provider First Name |
— |
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Provider Middle Name |
— |
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Provider Other Last Name |
Provider Other Organization Name |
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Provider Other Last Name Type Code |
Provider Other Organization Name Type Code |
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1=Former Name |
3=Doing Business As Name |
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2=Professional Name |
4=Former Legal Business Name |
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5=Other |
5=Other |
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Provider Other First Name |
— |
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Provider Other Middle Name |
— |
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Provider Name Prefix Text |
— |
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Provider Name Suffix Text |
— |
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Provider Credential Text |
— |
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Provider First Line Business Mailing Address |
Provider First Line Business Mailing Address |
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Provider Second Line Business Mailing Address |
Provider Second Line Business Mailing Address |
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Provider Business Mailing Address City Name |
Provider Business Mailing Address City Name |
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Provider Business Mailing Address State Name |
Provider Business Mailing Address State Name |
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Provider Business Mailing Address Postal Code |
Provider Business Mailing Address Postal Code |
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Provider Business Mailing Address Country Code |
Provider Business Mailing Address Country Code |
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(If outside U.S.) |
(If outside U.S.) |
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Provider Business Mailing Address Telephone Number |
Provider Business Mailing Address Telephone Number |
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Provider Business Mailing Address Fax Number |
Provider Business Mailing Address Fax Number |
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Provider First Line Business Location Address |
Provider First Line Business Location Address |
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Provider Second Line Business Location Address |
Provider Second Line Business Location Address |
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Provider Business Location Address City Name |
Provider Business Location Address City Name |
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Provider Business Location Address State Name |
Provider Business Location Address State Name |
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Provider Business Location Address Postal Code |
Provider Business Location Address Postal Code |
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Provider Business Location Address Country Code (If outside U.S.) |
Provider Business Location Address Country Code (If outside U.S.) |
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Provider Business Location Address Telephone Number |
Provider Business Location Address Telephone Number |
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Provider Business Location Address Fax Number |
Provider Business Location Address Fax Number |
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Healthcare Provider Taxonomy Code (Primary Taxonomy required; up to 15 may be reported) |
Healthcare Provider Taxonomy Code (Primary Taxonomy required; up to 15 may be reported) |
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Other Provider Identifier |
Other Provider Identifier |
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Other Provider Identifier Type Code |
Other Provider Identifier Type Code |
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Provider Enumeration Date |
Provider Enumeration Date |
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Last Update Date |
Last Update Date |
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NPI Deactivation Reason Code |
NPI Deactivation Reason Code |
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NPI Deactivation Date |
NPI Deactivation Date |
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NPI Reactivation Date |
NPI Reactivation Date |
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Provider Gender Code |
— |
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Provider License Number |
— |
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Provider License Number State Code |
— |
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— |
Authorized Official Last Name |
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— |
Authorized Official First Name |
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— |
Authorized Official Middle Name |
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— |
Authorized Official Title or Position |
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— |
Authorized Official Telephone Number |
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Source: Federal Register, May 30, 2007. |
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June 11, 2007 - Table of Contents
