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HIPAA Frequently Asked Questions |
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The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a permanent component of Children’s Medical Security Plan health care strategy.
Children’s Medical Security Plan is committed to delivering excellent service. Part of that commitment includes compliance with and support of the HIPAA mandates. Most importantly, Children’s Medical Security Plan is committed to complying with the mandates, standardization and protecting patient privacy, but with minimal “administrative hassles” for our members, physicians and other health care professionals.
Additionally, Children’s Medical Security Plan is committed to informing you, our customers, about HIPAA and Children’s Medical Security Plan’s compliance status. Listed below are frequently asked questions that provide a quick overview of the HIPAA National Provider Identifier (NPI) requirements.
National Provider Identifier (NPI)
What is NPI?
NPI is the acronym for the National Provider Identifier. It is one provision of the Administrative Simplification portion of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
What is the purpose of NPI?
The NPI is a single identification number that will be assigned by the federal government to health care providers. The NPI will be used to identify physicians, hospitals and other medical professionals in all electronic HIPAA transactions. It is intended to improve the efficiency of the health care system and help to reduce fraud and abuse.
What are HIPAA transactions?
American National Standards Institute (ANSI) is a committee that defines standards for many American industries. Thus far, HIPAA has mandated that nine ANSI transactions must be used for specific electronic health care transactions. These transactions include: 837 Claim, 835 Remittance Advice, 834 Enrollment, 270 Eligibility Inquiry, 271 Eligibility Response, 276 Claim Status Inquiry, 277 Claims Status Response, 278 Referral, and 820 Premium Payment. It is expected that additional transactions will be mandated in the future.
Who must comply with NPI requirements and when?
The NPI must be used in all HIPAA transactions by all covered entities¾health plans, health care clearinghouses, and health care providers¾by May 23, 2007 (small health plans have until May 23, 2008). |
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Is a NPI required on paper transactions?
The NPI is required in electronic exchanges of HIPAA transactions. Existing identification numbers can continue to be used in paper and non-HIPAA electronic transactions after the mandatory compliance date. However, the NPI mandate does allow payers to require the use of the NPI on all transactions, including paper, to improve processing efficiency. We strongly encourage you to submit your NPI on paper transactions to minimize any claims payment disruption.
Will NPIs only be issued for hospitals and physicians?
No. In addition to hospitals and physicians, NPIs will be issued to institutional and other health care providers such as:
- skilled nursing facilities,
- home health agencies,
- comprehensive outpatient rehabilitation facilities,
- assorted clinics and centers,
- clinical laboratories,
- various licensed/certified health care practitioners, and
- suppliers of durable medical equipment.
They also will be issued to any appropriately licensed or certified health care practitioners or organizations, including pharmacies, nursing homes and many types of therapists, technicians, aides, and any other individual or organization that furnishes health care services or supplies. In other words, a NPI applies to any health care individual or organization that bills and is paid for health care services or supplies. If organizations, such as hospitals, are made up of components, or separate physical locations that qualify as separate health care facilities, they also will be issued their own NPI. These types of arrangements are referred to as “sub-parts” in the NPI Final Rule.
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What does the NPI look like?
The NPI is a ten-digit numeric field that will include one check digit in the tenth position to ensure accuracy. This format will permit 200 billion unique identifiers to be issued without re-using the same values. The NPI will contain NO imbedded intelligence. In other words, you will not be able to determine a provider’s state, region, specialty, or any other information directly from their NPI.
How will the NPI be generated?
The NPI is generated by a new system called the National Plan and Provider Enumeration System (NPPES) and issued by the U.S. Department of Health and Human Services (HHS) through the Centers for Medicare and Medicaid Services (CMS).
What is an Entity Type Code?
An entity type code is a category indicator that will determine the type of provider that is being assigned an NPI:
- Entity Type 1 will be issued to healthcare providers that are individual human beings. Examples include physicians, dentists, chiropractors, pharmacists, nurses, etc.
- Entity Type 2 will be issued to organizations such as hospitals, residential treatment centers, laboratories, group practices, etc.
What is a Subpart?
Subparts of organizational health care providers are eligible to be assigned NPIs. A subpart can be uniquely identified, for example, by separate physical location, by separate licenses or certification. While we cannot tell you how to structure your organization in regard to enumerating, our recommendation is for each incorporated practice to secure an Entity Type 2 NPI to assure that the proper entity is reimbursed for services that are rendered.
How will a provider be issued a NPI?
Providers are able to apply to CMS for a NPI starting May 23, 2005 and must have a NPI by May 23, 2007, when exchanging electronic transactions (small health plans have until May 23, 2008). Applications are available on the CMS web site at http://www.cms.hhs.gov/
NationalProvIdentStand/
03_apply.asp
Providers will need to supply adequate information to ensure that they can be identified uniquely by the National Plan and Provider Enumeration System (NPPES). Should any of that information change in the future, CMS must be notified within 30 days.
What if a doctor changes practices, moves, or changes specialties?
Even if a provider moves, changes specialty, or changes practices, the provider will retain the same NPI, but must notify CMS and supply the new information. The NPI is intended to identify the provider throughout his or her career. Organization NPIs also are intended to be permanent except in rare situations such as when a health care provider does not wish to continue an association with a previously used NPI, or when a health care provider's NPI has been used fraudulently by another. |
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How will Children’s Medical Security Plan be able to associate a provider with his or her NPI?
The NPIs will be maintained in a database in the National Plan and Provider Enumeration System (NPPES). CMS will provide a method of extracting data from the NPPES database. Children’s Medical Security Plan has developed a strategy for acquiring NPI data from providers and also via NPPES and will use it to identify providers submitting HIPAA transactions. In most cases, current processes will be modified to include the NPIs.
What is Children’s Medical Security Plan doing to prepare for NPI?
Children’s Medical Security Plan’s NPI program has established Project teams throughout its organization. These teams are dedicated to researching the issues, assessing systems, reviewing business processes, and educating the Children’s Medical Security Plan organization about implementation procedures while helping to ensure an understanding of the expected end-result.
Where can I learn more about NPI?
To learn more about NPI from CMS, visit http://www.cms.hhs.
gov/NationalProvIdentStand/
in the coming months. In addition, we encourage you to log on to www.cmspkids.com to find the most up-to-date information regarding HIPAA and Children’s Medical Security Plan compliance status.
Has CMS issued any additional information on the application process for the NPI?
In early May of 2005, CMS issued a “Dear Provider Letter” that can be accessed at
http://www.cms.hhs.
gov/NationalProvIdentStand/. This letter briefly outlines the application process and the various ways the provider may obtain an NPI.
When will the providers be able to begin applying for an NPI?
Providers began applying as early as May 23, 2005. Providers may apply electronically through CMS’ web-based application system located at the following URL: https://nppes.cms.hhs.gov/NPPES. For those providers who prefer to use the paper format, a copy of the application and the enumerator’s address will be available at the same web site at https://nppes.cms.hhs.gov/NPPES. Also, the provider may choose to submit their application through an organization, professional association, or employer. |
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What if a provider has numerous health plan IDs, will each health plan require an additional NPI?
The NPI is the single provider identifier that will replace each of the different health plans’ numerous identifiers. This regulation requires each of the health plans to use the NPI as the sole identifier for each provider. The provider needs only to apply once for an NPI.
When will Children’s Medical Security Plan begin accepting the NPI?
Effective October 1, 2006, as long as the NPI number is accompanied with the provider’s current Children’s Medical Security Plan provider identification number, Children’s Medical Security Plan will have the capability to accept the 10-digit NPI on electronic claims and CMS1500 (08/05) and UB-04 paper claim forms transactions.
Where will the NPI be located on the Electronic Claims Transactions?
The NPI will be reported within the provider loops on electronic claims transactions. The changes required for HIPAA Standard transactions are:
- NM 108 qualifier will be XX for NPI Submission
- NM 109 field will display the 10-digit NPI
- Tax ID will be required in the REF segment when NPI is reported in the NM109
- REF01 qualifiers (EI=Tax ID, SY= SSN)
- REF02 field will display the Providers/Facilities Tax ID or SSN.
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Will the NPI be located on the Electronic Remittance Advise (835)?
Yes, the NPI will be returned on the 835 electronic remittance advice in the following loops:
| Loop/Segment |
Dent |
Inst |
Prof |
Loop 1000B; N103 |
XX |
XX |
XX |
Loop 1000B; N104 |
NPI |
NPI |
NPI |
Loop 1000B; REF01 |
TJ |
TJ |
TJ |
Loop 1000B; REF 02 |
Tax ID |
Tax ID |
Tax ID |
Loop 2000; TS301 |
Not Used |
Not Used |
Not Used |
Loop 2100; NM108 |
Not Used |
XX |
XX |
Loop 2100; NM109 |
Not Used |
NPI |
NPI |
Where can I learn more about the NPI application process?
Up-to-date information regarding the NPI is available on the NPPES web site at https://nppes.cms.hhs.gov/NPPES. You may also contact the enumerator by telephone at 1-800-465-3203 or TTY 1-800-692-2326. In addition, an
instructional web tool, called the NPI Viewlet, is now available for viewing at
http://www.cms.hhs.gov/apps/
npi/npiviewlet.asp.
How can I register my NPI with Children’s Medical Security Plan?
After receiving your NPI, please complete our online submission form, at
https://npi.wellpoint.com, to
register your NPI. If you are registering more than one NPI, please complete one form for each NPI. Registration ensures our internal systems accurately reflect your NPI information. If you have a large quantity of NPIs to submit (provider practice or large organization), we will be implementing a “Bulk/Batch” submission process in September, 2006. Please be sure to check
https://npi.wellpoint.com periodically for additional information regarding this process. |
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| NPI & Revised Paper Claim Forms Frequently Asked Questions: |
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| In December 2005, Children’s Medical Security Plan established a team dedicated to implementing the NPI usage on the revised institutional healthcare claim form (UB04) and the professional healthcare claim form (CMS1500 version 08/05 was established). Below are some frequently asked questions and responses regarding the revised paper claim forms. We will update this listing and provide more communication as additional information becomes available. |
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When will use of the CMS 1500 (version 08/05) professional healthcare claim form be required?
The National Uniform Claim Committee (NUCC) recommends a transition period beginning October 1, 2006, through April 2, 2007, for physicians and other health care professionals. Children’s Medical Security Plan was assigned a project team to fully evaluate the forms changes and implementation schedule. Children’s Medical Security Plan will begin accepting the CMS 1500 October 1, 2006 as long as your current provider identifier number accompanies your NPI. To stay apprised of our developments, please routinely access our Web site at www.cmspkids.com . To learn more about the CMS 1500 (version 08/05), simply access the NUCC Web site at www.nucc.org.
When will use of the UB 04 institutional healthcare claim form be required?
The National Uniform Billing Committee (NUBC) recommends a transition period beginning March 1, 2007, through May 23, 2007. Children’s Medical Security Plan was assigned a project team to fully evaluate the forms change and implementation schedule. Children’s Medical Security Plan will begin accepting the UB 04 October 1, 2006 as long as your current provider identifier number accompanies your NPI. To stay apprised of our developments, please routinely access our Web site at www.cmspkids.com. To learn more about the UB 04, simply access the NUBC web site at www.nubc.org.
Is there a transition period for the claim forms—UB 04 and CMS 1500 (version 08/05)? If so, for what periods?
Yes, we intend to have a transition period beginning October 1, 2006. During the transition period, you are asked to include your current provider identifier number and NPI.
Can I still use the old forms (HCFA 1500, CMS 1500 and UB 92) after the transition period? If I do, will you return them?
At the completion of the transition period for UB 04 and CMS 1500 (version 08/05), providers are encouraged to only use the current forms to minimize any claims payment disruption. |
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After May 23, 2007, if I do not use the new forms (CMS 1500 (version 08/05) and UB 04) and enter the provider identifier / national provider identifier, will you reject the form?
The use of the NPI on the CMS 1500 (version 08/05) and UB 04 claim forms further minimizes any disruption to claims payment. We strongly encourage providers to submit HIPAA compliant 837 electronic claims, which contain NPI and other elements on the new paper claim forms.
What is the earliest these forms can be submitted?
Children’s Medical Security Plan has evaluated the forms impact and will begin accepting both the CMS 1500 (version 08/05) and UB04 beginning October 1, 2006.as long as your current provider identifier number accompanies your NPI.
What will be the major changes that providers can expect on the new claim forms versus the old ones?
The major changes to the CMS 1500 (version 08/05) and UB 04 forms include the addition of the NPI field(s).
Where will the NPI be located on the new claim forms?
Revised CMS 1500 (08/05)(NUCC):
- NPI to be displayed in Box/Field 17b
- NPI to be displayed in Box/Field 24j for rendering provider
- Locators 32a and 33a are also designated for the NPI for the servicing provider locations and billing provider location
UB-04 (NUBC)
- Box/Field 56 for the Facility
- Box/Field 76 for the Attending Physician
- Box/Field 77 for the Operating Physician
- Box/Fields 78 & 79 for other provider types.
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