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NPI on the Way

August 1, 2006
by Peter Mancino and Gregg Reisman
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Healthcare providers would be wise to begin the process of acquiring national provider identifiers.

With the May 23, 2007 deadline for implementation of the national provider identifier (NPI) quickly approaching, the Centers for Medicare and Medicaid Services (CMS) has implemented a number of initiatives to encourage healthcare organizations and professionals (providers) to obtain NPIs.

The NPI will replace all provider numbers (e.g., UPIN Medicare or Medicaid number, individual commercial insurer numbers) currently used in standard transactions. These current provider numbers are commonly referred to as legacy identifiers. After the deadline, the only legacy identifier that will still be accepted is the Tax Identifier Number and then only when required in addition to the NPI. In other words, after May 23, 2007, a provider will not be paid by Medicare or most other insurers if the NPI is not used on standard transactions such as claims submissions or eligibility verification.

CMS is strongly encouraging providers to apply for their NPIs as soon as possible and is taking steps to facilitate this process. In order to expedite applications by large groups of providers, CMS recently established the bulk enumerator process which allows anywhere from a few to thousands of applications to be submitted in one file.

Advice regarding the bulk enumerator process and other aspects of the NPI application has been widely published by CMS. In addition, CMS is now requiring all providers that apply for, or update, the information pertaining to Medicare billing rights with the CMS Medicare 855 Forms (CMS 855 Form) to include NPI information on that form. As the NPI implementation unfolds, CMS anticipates publishing additional policies and guidance regarding dissemination of NPI data and identification of subparts.

Bulk enumerators
Providers can obtain the NPI through a Web-based or paper application available at the Web site for the National Plan Enumerator and Provider System. In addition, CMS and the National Plan Enumerator and Provider System have developed the Electronic File Interchange which is also referred to as the bulk enumerator.

The Electronic File Interchange process is designed to allow provider-designated organizations (EFIOs) to capture multiple provider's NPI application information on a single electronic file for submission to the National Plan Enumerator and Provider System. The Electronic File Interchange is particularly unique because one file can contain hundreds or thousands of provider applications; thereby reducing the administrative and financial burdens of the provider community and the U.S Department of Health and Human Services.

A provider may submit an application through an approved EFIO by authorizing, in writing, that organization to submit the application. The EFIO is then required to gather and format the requisite information and submit it to the National Plan Enumerator and Provider System. Once the information is successfully submitted, the National Plan Enumerator and Provider System will provide the EFIO with the requested NPIs and the EFIO will distribute the NPIs to the individual providers. Providers should note that sole proprietors have slightly different application processes, and therefore, EFIOs will not submit NPI applications for sole proprietors.

Advice from CMS
CMS has also published various additional recommendations related to the NPI process. CMS strongly encourages providers to include all legacy identifiers on their NPI applications, and when reporting Medicaid legacy identifiers, to also include the applicable state name. Many health plans, including Medicare, are preparing crosswalks between the NPI and legacy identifiers, and inclusion of the legacy identifiers on the application will facilitate building of the crosswalks.

In addition, CMS recommends that providers continue to keep abreast of the NPI readiness schedule for each of the health plans with which they do business, as well as any billing companies that provide services to them. Health plans and billing companies must also be able to use the NPI as of the deadline.

Finally, CMS recommends that providers take measures to protect the confidentiality of their NPIs. Covered providers should only share their NPIs with entities that need them to conduct standard transactions (e.g., pharmacies, organizations where healthcare professionals have staff privileges).

Medicare 855 Forms
CMS recently passed legislation requiring providers that have not already done so to complete a CMS 855 Form in order to receive payments from Medicare. Providers must include their NPIs when filing the latest version of the CMS 855 Form and must provide a copy of their NPI notifications with each enrollment application. CMS 855 Forms that do not include this information will be rejected.

Yet to be Published
CMS has indicated that it will soon be publishing a notice regarding the strategy and process for NPI data dissemination by the National Plan Enumerator and Provider System. The notice is expected to include the data that CMS expects to be available from the National Plan Enumerator and Provider System and the protections that will be available for such information. In addition, CMS is developing a policy and additional guidance on identifying Medicare subparts within an organization.

Peter Mancino and Gregg Reisman are partners at Garfunkel, Wild & Travis P.C., a law firm in Great Neck, N.Y.

Becoming an EFIO

An organization that wishes to become an EFIO must register and obtain a certification form at The registration may be submitted electronically, but the certification must be sent to:

  • NPI Enumerator