| NPI Glossary
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Adjudication
The process of handling and making determinations about the payment of (or coverage
for) services.
Ancillary Services
Auxiliary or supplemental services, such as diagnostic services, home health
services, physical therapy and occupational therapy, used to support diagnosis
and treatment of a patient's condition. Room and board are not considered ancillary
services.
Atypical Provider
Individual or organization that provides non-traditional services that are indirectly
health care related. (Not eligible for NPI.)
Check Digit
A digit attached to the NPI number on the 10th position that is used for validation
purposes.
Clearinghouse
An entity including a billing service or repricing company that processes or
facilitates the processing of health information received from another entity.
CMS 1500
The claim form for physicians and other health care professionals to use. This
form is being revised to accommodate the NPI. The CMS 1500 was formerly known
as the HCFA 1500.
Covered Health Care Provider
A person who is trained and licensed to provide health care services or a facility
that is licensed to provide health care services. Physicians, dentists, nurses,
therapists and hospitals are examples of health care providers under the NPI
system.
Emdeon
A leading provider of business technology solutions that can simplify health
care delivery and reimbursements. Horizon NJ Health recommends that physicians
and health care professionals use Emdeon for electronic transactions. (Formerly
known as WebMD.)
Electronic Data Interchange (EDI)
A method for physicians, health care professionals and hospitals to submit claims
electronically.
Electronic File Interchange (EFI) Submitter
A group/organization who is certified to submit NPI applications in an electronic
file. An EFI submitter might be a professional organization which, when authorized
by a physician, health care professional or hospital, will submit an electronic
application for its members. (Also known as a bulk enumerator.)
Entity Type Code
The type of health care provider that is being assigned an NPI. Codes are:
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(Person): individual health care professionals who furnish health care. |
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2. |
(Non person): entity other than an individual health care professional that
furnishes health care (for example, hospital, skilled nursing facility, hospital
sub-unit or pharmacy). |
Entity Type Code 1
The type of NPI issued to health care professionals including physicians, dentists,
nurses, chiropractors, pharmacists and physical therapists.
Entity Type Code 2
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.
Enumerator
An organization under contract with the Department of Health and Human Services
to assign NPIs. Fox Systems is the NPI Enumerator and will:
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Receive and process NPI applications. |
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2. |
Send notification of NPIs to each applicant. |
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3. |
Use the National Plan and Provider Enumeration System (NPPES) to ensure the
unique identification of each applicant. |
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4. |
Answer questions about applying for and obtaining NPIs. |
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5. |
Collect information, via the applications and updates, and maintain the NPPES
database containing NPIs. |
Health Insurance Portability and Accountability Act (HIPAA)
A federal law that, among other things, set standards for the transmission of
health care information as well as for the privacy and security of that information,
the portability of health care coverage, and uniquely identifying critical players
in the health coverage delivery system.
Individual Health Care Professional
Health care professionals who are human beings. These individuals are considered
Entity Type Code 1. Examples are physicians, dentists, nurses, chiropractors,
pharmacists and physical therapists. May also be called Individual Health Care
Providers.
Luhn Algorithm
A method used to validate identification numbers, such as a NPI. It is a simple
formula used to verify account numbers and check against accidental errors.
Most credit card and government agencies use the Luhn Algorithm to ensure accuracy
of identification numbers.
National Provider Identifier (NPI)
A system for uniquely identifying all providers of health care services, supplies
and equipment, in accordance with HIPAA. NPIs are assigned by CMS and are 10-position,
all-numeric identification numbers that will identify a hospital, physician
or other health care professional in standard transactions, such as electronic
health care claims submissions.
National Plan and Provider Enumeration System (NPPES)
The administrative system for supporting a national plan and provider registry.
This is a comprehensive uniform system for identifying and uniquely enumerating
health care providers and plans at that national level.
Non-covered Entities
Health care providers who do not use standard electronic transactions. (Not
eligible for NPI.)
Organization Health Care Provider
Providers of health care who are not human beings. These providers are classified
as Entity Type Code 2. Examples are hospitals, home health agencies, clinics,
nursing homes, residential treatment centers, clinical laboratories, ambulance
companies, group practices, DME suppliers and pharmacies.
Subpart
A entity/component or separate physical location of a covered organization health
care provider. This entity may function independently of the covered organization
and may have its own billing numbers, license and/or physical location, but
is not, itself, a legal entity. Examples include:
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A subpart of a hospital could include outpatient departments, surgical centers,
psychiatric units and laboratories; |
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Provider chains that generally have a corporate headquarters and a number
of separate physical locations. The separate physical locations are generally
separately licensed or certified, i.e., DME supplier chain. |
Taxonomy Code
An administrative code set that classifies physicians and other health care
professionals by type, classification and specialization.
Tax Identification Number
The number assigned by the Internal Revenue Service (IRS) to uniquely identify
that physician, dentist, hospital or other health care professional as a taxable
entity. This number is used for payment and other HIPAA-related purposes in
the conduct of standard transactions and health plan administration.
UB-04
A new claim form for institutional submitters (hospitals, home health agencies,
etc.) that will replace the UB-92. The new UB-04 was designed by the National
Uniform Billing Committee and includes improvements including better alignment
with the electronic transactions and fields for NPIs.
Universal Provider Identifier Number
A unique number used to identify physicians and other health care professionals.
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