| FAQs About NPI
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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 a 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 affect Horizon Blue Cross Blue Shield of New Jersey,
Horizon NJ Health and Horizon Casualty Services physicians and health care professionals?
A: Yes. It is expected that Horizon Blue Cross Blue Shield of New Jersey, 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 a NPI.
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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 three ways for you to apply
for a NPI:
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1. |
Web-based application: Visit https://nppes.cms.hhs.gov. |
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2. |
Paper application: Prepare and send a paper application to the NPI Enumerator
(Fox Systems). A copy of the application form, which includes the mailing address,
is available at https://nppes.cms.hhs.gov. |
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3. |
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: When should I start submitting my NPI to Horizon NJ Health?
A: Horizon NJ Health will notify all hospitals, physicians and other health
care professionals when they can begin submitting their NPI for standard electronic
transactions prior to May 23, 2007. In the meantime, Horizon NJ Health is actively
collecting NPIs to load into our systems. Once a physician, hospital or other
health care professional has received a NPI, it should be submitted to Horizon
NJ Health via:
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Fax: |
Please complete the Horizon NJ Health Collection Form and fax it along
with your NPI Certification Notice from CMS to 1-609-583-3043. |
Please note: Hospitals, physicians and other health care professionals should
not begin using NPIs on electronic transactions conducted with Horizon NJ Health
until Horizon NJ Health has communicated an effective date and issued instructions
on its use.
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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 a 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 a 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 NJ Health Provider
ID 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 NJ Health
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 NJ Health 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: Is assistance with NPI available?
A: Horizon NJ Health is preparing for NPI use and can help with any questions
about multiple suffixes or other unique situations. Please send your question
to HNJH_NPI@horizonNJhealth.com
for assistance.
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