- Purpose and Definition
- Accuracy of the NPI Data
- When Do Medical Students Get Their NPI Number?
- Questions about the NPI
- Updating Your NPI Record
- Obtaining the NPI Database
- Additional Resources
The purpose of the National Provider Identifier (NPI) program is to assign a unique national identification code to all providers of health care whose services fall under HIPAA, including individuals, organizations and groups of individuals. Included are physicians, nurses, nurse practitioners, dentists, optometrists, pharmacists, physical therapists, pharmacists, physician group practices, acute care hospitals, specialty hospitals, nursing homes, ambulatory care facilities, hospices, home health agencies, ambulance services, clinical labs, DME suppliers, pharmacies, etc. The number would be used in standard transactions by all health plans eliminating the current system of multiple numbers for a single provider. (Take a look at included healthcare providers.)
A work group consisting of representatives from the private sector, Federal and State agencies came together in 1993 to define the NPI and establish a system for assigning the numbers to every U.S. HIPAA-covered entity. They developed the National Plan and Provider Enumerations System (NPPES) to operate as the central database for the NPI. While the word "Plan" in the system's name would imply that health plans are also included in the data, this extension of the system has not yet materialized.
The National Provider Identifier (NPI) is a Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification Standard. It replaces a fragmented system of identifiers that included UPINs, Medicare PINs, state Medicaid numbers, provider identifiers assigned by thousands of health plans, and other identifiers—all of which were needed to disambiguate a particular provider across the healthcare system. The NPI is a unique identification number intended to solve this problem. Covered health care providers and all health plans and health care clearinghouses must use the NPIs in the administrative and financial transactions adopted under HIPAA. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number). This means that the numbers do not carry other information about healthcare providers, such as the state in which they live or their medical specialty. The NPI must be used in lieu of legacy provider identifiers in the HIPAA standards transactions.
As outlined in the Federal Regulation, The Health Insurance Portability and Accountability Act of 1996 (HIPAA), covered providers must also share their NPI with other providers, health plans, clearinghouses, and any entity that may need it for billing purposes.
Providers must apply for their NPI number (a process called "enumeration"), which is generally accomplished using an online tool provided by the Centers for Medicare and Medicaid Services (CMS), a division of the U.S. Department of Health and Human Services (HHS). Information supplied by the provider is kept in the National Plan and Provider Enumeration System (NPPES) database. Information includes in-depth contact information, specifics regarding the provider's practice or facility, and other identifying codes such as Medicare and Medicaid identification numbers and the deprecated UPIN.
Providers may choose to use a written form that can be submitted by mail. Download the NPI enumeration form to review the kinds of information collected in the NPPES database. The current database includes more than 7.3 million records.
The NPPES database does not include a provider's PECOS status (enrollment to bill Medicare), or whether or not the provider is on the federal List of Excluded Individuals/Entities (LEIE) from the HHS Office of Inspector General (OIG); however, CarePrecise compiles this information into the CarePrecise Access and CarePrecise Select database products. The NPPES database, as released by CMS, is of a size and format that is not ready for use on ordinary computers in standard office software, such as Microsoft Office® products; CarePrecise makes the complete NPPES data, along with added information from PECOS, LEIE and other sources, available for such use.
Accuracy of NPI Data
CarePrecise uses the NPI Registry (NPPES) data as one of its primary sources because of the comprehensive nature of the data. By law, every HIPAA-covered U.S. healthcare provider must be in this database, and as stated in the law, "Covered health care providers must communicate to the NPS any changes in their required data elements within 30 days of the change." The penalty for false information is severe:
18 U.S.C. 1001 authorizes criminal penalties against an individual who in any matter within the jurisdiction of any department or agency of the United States knowingly or willfully falsifies, conceals, or covers up by any trick, scheme or device a material fact, or makes any false, fictitious or fraudulent statements or representations, or makes any false writing or document knowing the same to contain any false, fictitious or fraudulent statement or entry. Individual offenders are subject to fines of up to $250,000 and imprisonment for up to five years. Offenders that are organizations are subject to fines of up to $500,000. 18 U.S.C. 3571(d) also authorizes fines of up to twice the gross gain derived by the offender if it is greater than the amount specifically authorized by the sentencing.
"Penalties for Falsifying Information" section of the HHS NPI registration information publication.
In a study conducted by Mathematica Policy Research and published in the Journal of General Medicine, investigators found that The NPPES database scored best at 94% accuracy, the SK&A at 92%, while the AMA Masterfile had significantly lower rates of correct address information across all specialties scoring only 54%.
"NPPES and SK&A had the highest rates of matching mailing address information, while the AMA Masterfile had low rates compared with the NPPES... the NPPES and to a lesser extent, the SK&A file, appear to provide reasonably accurate, up-to-date address information for physicians billing public and [private] insurers."
"The Results Are Only as Good as the Sample: Assessing Three National Physician Sampling Frames," Journal of General Internal Medicine. 2015. Catherine M. DesRoches, Dr.P.H., et al.
Providers have learned that keeping their NPI data up to date can shorten reimbursement cycles, and improve relationships with payers as well as consumers of healthcare.
When Do Medical Students Get Their NPI Numbers?
All health care providers are eligible for NPIs and may apply for them. Because medical students, interns, residents and fellow are health care providers, they are eligible for NPI registration and an NPI number. If they do not transmit any health data in connection with a transaction for which the Secretary of health and Human Services has adopted a standard, they are not "covered" healthcare providers under HIPAA and are not required by the NPI Final Rule to obtain NPIs. If they do, however, they would be covered healthcare providers and they must get NPIs.
If interns or residents prescribe medications for patients whose prescriptions are filled by pharmacies, refer patients to other healthcare providers, or order test for patients from other healthcare providers, those pharmacies and other healthcare providers will need to identify them as prescribers or as providers who referred patients or who ordered tests for patients in the claims transactions that they submit to health plans. Health plans may require that the NPI be used in those claims to identify the prescriber, the referring provider, and the ordering provider. Therefore, while the NPI Final Rule might not require these providers to obtain NPIs, it may be necessary for them to have NPIs in order for the pharmacies and other providers to be reimbursed by health plans.
Basically, all students need the "student" NPI number, so identified by the Provider Taxonomy Code 390200000X, Student in an organized healthcare education/training program towards a medical degree. Then, when the student becomes a healthcare provider, as described above, they are required to update their NPI record with the Taxonomy Code appropriate for the type of medicine that they now practice.
Questions About the NPI
Almost everything you ever wanted to know about the NPI is here.
CMS provides an NPI search tool for looking up providers' NPI numbers.
CarePrecise provides a listing of the data fields from the NPPES (NPI registry database) that are included in CarePrecise healthcare provider data products.
CarePrecise cannot access or edit NPI registry records. To update your record, as required within 30 days of any change, visit the NPPES website and login using the credentials that were created with the NPI registration.
Updating Your NPI Record
At any time, providers, or someone acting on their behalf, may edit their records by going to https://nppes.cms.hhs.gov, or by obtaining a paper NPI Application/Update Form (CMS-10114) from the CMS forms page (/Medicare/CMS-Forms/CMS-Forms) and mailing the completed, signed form to the NPI Enumerator. Providers who need assistance in editing their records should contact the NPI Enumerator by phone at 1-800-465-3203, by email firstname.lastname@example.org, or by letter: NPI Enumerator, 7125 Ambassador Rd, Suite 100, Windsor Mill, MD 21244-2751.
The information disclosed on the NPI Registry and in the downloadable files are FOIA-disclosable and are required to be disclosed under the FOIA and the eFOIA amendments to the FOIA. There is no way to ‘opt out’ or ‘suppress’ the NPPES record data for health care providers with active NPIs.
CarePrecise cannot assist in NPI registry matters.
Obtaining the NPI Database
Review CarePrecise Complete for the full NPI database, with added data from related federal healthcare provider databases.
CarePrecise Gold and CarePrecise Platinum both offer the complete database, plus special tools for segmenting providers by specialty, geographic radius, wealth, urban/rural, and other parameters. Platinum contains additional extended data.
NPI data can be obtained for individual states; see CarePrecise State.
Historical NPI data is also available from CarePrecise. More than 100 monthly data releases are available. CarePrecise also archives the NPPES dissemination files from CMS. Contact us for details on purchasing historical physician data and historical data on all U.S. healthcare providers.
Refer to the CMS field descriptions for technical descriptions of the data fields. CarePrecise uses abbreviated field names.
Refer to the CMS field codes document for details on field codes used in CarePrecise.
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CP Select Plus - Custom databases. Permits clients to select specific provider specialties and facilities in particular geographic areas, and many other selection criteria.
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Get the full NPI Registry Database, Ready to Use
CarePrecise offers the full FOIA-permissioned NPI Registry database, ready to use on your computer. Includes all 7.3 million physicians, clinics, nurses, dentists – all HIPAA-covered U.S. healthcare providers. Order a full download that you can use immediately in Microsoft Office's Access software, or upload to your own FileMaker Pro or other database software.
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