National Provider Identifier Overview

On January 23, 2004, the Secretary of Health and Human Services (HHS) adopted a National Provider Identifier (NPI) to replace all legacy provider identifiers in HIPAA standard electronic transactions, such as:

• Wellmark provider number
• Unique Physician Identification Number (UPIN)
• Medicare provider number
• Medicaid provider number

To be in compliance, all health care providers, health care payers, and others who conduct standard HIPAA transactions must have and use an NPI by May 23, 2007.

What is an NPI?
An NPI is a ten-digit identifier consisting of nine numbers plus a check digit in the tenth position. The number will be accommodated in all standard transactions and the new paper claim forms.

The NPI does not contain embedded information that identifies personal information, such as:

• the physician
• the location of the practice
• the type of services being performed

The assigned NPI will not expire. It follows an individual provider for life, and follows the organization for as long as it is in existence.

NPI Types
There are two types of NPIs:

• Type I: Individuals
  • Includes health care providers, such as physicians, chiropractors, physical therapists, social workers, dentists, and anyone who is considered a sole proprietorship.
  • Individuals may only have one NPI in a lifetime.
• Type II: Organizations
  • Includes hospitals, ambulatory care facilities, laboratories, group practices, and durable/home medical equipment suppliers.
  • Organizations may have more than one NPI, which are referred to as “subparts.”
  • Subparts allow organizations to uniquely identify parts of their organization that need to be uniquely identified outside the parent organization. A subpart is required to obtain a unique NPI separate from the parent organization.

If you are a sole proprietorship, you are only eligible for a Type I (Individual) NPI. As a sole proprietorship, you use a social security number to apply for an NPI.

If you are a health care provider who is incorporated, you may be required to obtain a Type II (Organization) NPI to identify the corporation separately from your individual provider NPI.

If you have questions about how your corporation should enumerate, please call the CMS HIPAA Hotline at 866-282-0659.

Notification of NPIs for TRICARE Providers
Each week Wellmark sends TriWest a list of NPIs for providers who are contracted through Wellmark as TRICARE participating providers.

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