Background: The National Provider Identifier (NPI) will replace the provider identification numbers that physicians, dentists, hospitals and other health care professionals use today in the Health Insurance Portability and Accountability Act (HIPAA) standard transactions they conduct with health plans and clearinghouses. Those transactions include the electronic claim, eligibility inquiry and response, claim status inquiry and response, payment and remittance advice, prior authorization/referral, credit card transactions and coordination of benefits transactions.
Physicians, dentists, hospitals and other health care professionals who conduct any of those electronic transactions must have NPIs and be ready to use them by May 23, 2007.
Q: What is a National Provider Identifier (NPI)?
A: The NPI is a numeric 10-digit identifier, consisting of nine numbers plus a standard check-digit in the 10th position. It is accommodated in all standard transactions and contains no embedded information about the health care professional it identifies.
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Q: Who is required to receive an NPI?
A: Entities who meet the definition of "health care provider," as defined at 45 CFR §160.103, are required to apply for and use NPIs. This includes:
- Hospitals.
- Nursing homes.
- Durable medical equipment and prosthetic/orthotic suppliers.
- Clinical laboratories.
- Pharmacies and pharmacists.
- Physicians, including group practices.
- Chiropractors.
- Dentists.
- Nurses and nurse practitioners.
- Physical, speech and occupational therapists.
- Midwives.
- Behavioral health professionals and treatment centers.
Please note: Health industry workers, such as office managers, admissions and billing personnel, housekeeping staff and orderlies, who support the provision of health care but do not provide health care services, are not required to receive an NPI.
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Q: Does NPI also affect Horizon NJ Health and Horizon Casualty Services physicians and health care professionals?
A: Yes. It is expected that Horizon NJ Health and Horizon Casualty Services network physicians, health care professionals and hospitals will obtain NPIs, even though the electronic transactions conducted with non-covered entities are not subject to the requirement to use an NPI.
Q: How are NPIs issued?
A: The Centers for Medicare and Medicaid Services (CMS) has contracted with a vendor, Fox Systems, to assign NPIs.
There are two ways for you to apply for an NPI:
- Web-based application: Visit https://nppes.cms.hhs.gov.
- Telephone: Call the NPI Enumerator at 1-800-465-3203 or TTY 1-800-692-2326 and request an application.
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Q: Will multi-specialty groups need to apply for subparts?
A: Subparts are components of a health care organization; and if those separate components conduct electronic transactions, they can obtain NPIs. For example, different locations or business structures of your practice (including payment structures) may justify the use of multiple NPIs. However, it is up to the health care organization to determine what subparts need an NPI to be identified on transactions. It may be helpful to review how you submit claims for services today and determine how you want to submit claims in the future.
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Q: Is there a cost to apply for an NPI?
A: No. A hospital, physician, dentist or health care professional will not be charged, nor have to pay a fee, in order to obtain an NPI.
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Q: What is Entity Type 1 and Entity Type 2?
A: Two types of NPIs can be assigned:
Entity Type 1 - The type of NPI issued to health care professionals, including physicians, dentists, nurses, chiropractors, pharmacists and physical therapists.
Entity Type 2 - The type of NPI issued to health care organizations or institutions. This includes hospitals, home health agencies, nursing homes, clinical laboratories, ambulance companies, group practices, durable medical equipment suppliers, residential treatment centers and pharmacies.
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Q: When will the NPI be used?
A: The NPI must be used by May 23, 2007.
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Q: Will my NPI replace current Horizon Provider Numbers?
A: Yes. A seamless transition to NPI is planned. After May 23, 2007, the NPI will be the primary identification number and will replace all Horizon Provider ID numbers.
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Q: Will claims still process if submitted with a Tax ID Number on and after May 23, 2007?
A: Beginning on and after May 23, 2007, all claims submitted electronically to Horizon will need both the NPI and the Tax ID Number.
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Q: What are the advantages of the NPI?
A: Use of the NPI has several advantages, including:
- A unique provider identifier for all health plans to utilize.
- A permanent provider identifier that will not change in the event of practice relocation or changes in specialty.
- An easier process for health plans to track transactions and coordination of benefits and avoid duplication.
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Q: When filling out the Horizon BCBSNJ NPI Collection Form is both the SSN and TIN required?
A: Yes, we ask that you please provide us with both the TIN and SSN that you used when you requested an NPI number from CMS. For example, if you registered the physician's SSN when requesting an Entity Type 1 NPI (individual) that is what you should place on the individual practitioner/physician form.
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Q: Do I need to fill out the NPI Collection Form for the group and also the individual form for each physician?
A: Please complete the forms for the individual physicians and also for the group.
Single Practitioners: If a physician or health care professional operates a solo practice and is incorporated for malpractice, etc., he/she can apply for their own individual NPI as "Entity Type 1."
Group Practices: In a group practice, each physician or health care professional can apply for his/her own NPI as "Entity Type 1." Entity Type 1 is the type of NPI issued to health care professionals including physicians, dentists, nurses, chiropractors, pharmacists and physical therapists.
The group practice can apply for an NPI as "Entity Type 2." Entity Type 2 is the type of NPI issued to health care organizations or institutions. This includes hospitals, home health agencies, clinics, nursing homes, residential treatment centers, clinical laboratories, ambulance companies, group practices, durable medical equipment suppliers, prosthetics and orthotics suppliers and pharmacies.
Once you have completed the forms, please fax to 1-973-274-4416.
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Q: What is a J/K Code?
A: Horizon BCBSNJ only assigns J/K Codes to physicians who are credentialed as Primary Care Physicians (PCPs) with Horizon BCBSNJ. Specialist physicians do not have J/K Codes and can leave the J/K Code field blank on the NPI Collection Form.
If you are a PCP and do not know your J/K Code, you can easily find your J/K Code by looking up your practice in our on-line provider directory. Please visit www.HorizonBlue.com and click the Provider Directory link at the top of the page. Perform a search using the PCP's last name and you will be shown the practice information and J/K Code.
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Q: What is a suffix?
A: Some physician groups have a unique identifier assigned by Horizon BCBSNJ which must be appended to their group TIN number when submitting claims. This is referred to as a suffix. If you do not use a suffix when submitting claims to Horizon BCBSNJ, please leave the "suffix"field blank on the NPI Collection Form.
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Q: How do I obtain a taxonomy code?
A: To obtain taxonomy codes, please go to http://www.wpc-edi.com/taxonomy for assistance. Once you have obtained your NPI(s) and completed the collection forms, please fax them along with your NPI Certification Notices from CMS to us at 1-973-274-4416.
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Q: I have already obtained an NPI - should I start using it?
A: If you submit claims electronically, the NPI Compliance Date is 5/23/2007.
If you submit paper claims, the NPI is not required, but you may begin using your NPI on the new CMS 1500 form (replacing the HCFA 1500 form) beginning 10/1/2006. Between 10/1/2006 and 2/1/2007 you may use either the old or new form. After 2/1/2007, please use only the new CMS 1500 form.
On the new CMS 1500 form, an NPI can be entered in boxes 17b, 24j, 32a or 33a. Your Federal Tax ID number (EIN or SSN) goes in Box 25.
It is also important to note that Horizon BCBSNJ is actively collecting NPIs. Please forward your NPI Certification Notices to Horizon BCBSNJ. You can fax it to us at 1-973-274-4416.
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Q: Is there a field for NPIs on the UB-92 form?
A: The UB-92 form does not have fields for reporting of NPIs. UB-92 forms received with an NPI in the fields that exist for reporting of legacy provider identifiers will be rejected. UB-92 submitters must continue to report the Medicare legacy provider identifier of each provider for which data is reported in the provider identifier fields of a UB-92.
Horizon BCBSNJ is following National Uniform Claim Committee (NUCC), National Uniform Billing Committee (NUBC), and CMS timelines with regard to the effective dates of the new claim forms. Horizon BCBSNJ will be ready to accept the new UB-04 form in accordance with the compliance dates set forth by these organizations. As of May 23, 2007 you should submit all your institutional claims on the new UB-04 form (replacing the UB-92 form). For additional information about the new form, please visit www.nubc.org.
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