The Health Insurance Portability and Accountability Act (HIPAA) of 1996 required the adoption of a standard unique identifier for healthcare providers. The National Provider Identifier (NPI) Final Rule issued January 23, 2004, adopted the NPI as this standard. NPIs are intended to improve the efficiency of the healthcare system and help reduce fraud and abuse.
The NPI is a 10-digit numeric identifier that is required for all healthcare service providers – both individuals and organizations – that want to enroll in the Indiana Health Coverage Programs (IHCP).
Some providers, such as waiver providers and most transportation providers, are not healthcare providers per se. These providers are called atypical providers and are not required to have NPIs. When doing business with the IHCP, atypical providers use their IHCP Provider IDs, which they receive when they enroll as IHCP providers.
A provider's NPI does not change and remains with the provider regardless of job or location changes. Having an NPI does not:
- Ensure that a provider is licensed or credentialed
- Guarantee payment by a health plan
- Enroll a provider in a health plan
- Turn a provider into a covered provider
- Require a provider to conduct HIPAA transactions
Getting Your NPI
A healthcare services provider needs to obtain an NPI to be able to submit an IHCP provider enrollment application. To get an NPI, a provider may apply at the National Plan and Provider Enumerator System (NPPES) website.
Individuals and organizations that are healthcare providers must obtain the proper type of NPI. There are two types of healthcare provider NPIs:
- Type 1 (individual) – A healthcare provider that is conducting business as an individual or as a sole proprietor must obtain a Type 1 NPI.
- Type 2 (organizational) – A healthcare provider that is conducting business as an organization or a distinct subpart of an organization, such as a group practice, a facility, or a corporation (including an incorporated individual) must obtain a Type 2 NPI.
Note: A healthcare provider rendering healthcare services as an individual practitioner and also conducting business as an incorporated entity must obtain a Type 1 NPI as a practitioner and also a Type 2 NPI as a corporation or limited liability company (LLC).
When providers apply for NPIs, they must supply information such as the provider's business name and address, date of birth, and Social Security number (SSN) or employer identification number (EIN).
Providers are also asked to choose taxonomy codes that describe their provider type and specialty, and supply associated license numbers as part of the enumeration process.
Reporting an NPI to the IHCP
Healthcare service providers must have their NPI on file with the IHCP. Provider enrollment applications submitted to the IHCP must include the proper NPI type, based on the organizational structure of the enrolling individual or entity. Alignment of the NPI type, organizational structure, legal name, and tax identification number are required and verified as follows:
- An individual healthcare practitioner who is enrolling with the IHCP to render services but who will not be billing the IHCP directly for his or her services must enroll with the IHCP under the Rendering Provider classification using his or her Type 1 NPI, personal name, and SSN.
- An individual healthcare practitioner who is enrolling to bill the IHCP directly for his or her services and will be conducting business with the IHCP as an individual or sole proprietor (including a single-member LLC electing to do business as an individual, referred to as a disregarded entity), must enroll with the IHCP under the Billing Provider classification using his or her Type 1 NPI, personal name (even if the individual operates under a doing business as [DBA] designation), and either the individual’s SSN or an EIN.
- An individual healthcare practitioner who is enrolling to bill for his or her services and who will be conducting business with the IHCP as a business entity (C Corporation, S Corporation, Partnership, or an LLC [including a single-member LLC electing to do business as a corporation]) must enroll the business with the IHCP under the Group Provider classification using the business entity's Type 2 NPI, and must enroll him- or herself under the Rendering Provider classification (linked to the group) using his or her personal Type 1 NPI. The business entity must enroll using the business name and the business’ EIN. The practitioner must enroll using his or her personal name and SSN.
- An organization that is enrolling to bill for services and that will be conducting business with the IHCP as a business entity (including a C Corporation, S Corporation, LLC, Partnership, and Trust/Estate) must enroll with the IHCP under the Billing Provider or Group Provider classification using the business entity's Type 2 NPI, the business name, and the business' EIN.
Healthcare service providers must use their NPI on claims to identify the rendering and billing provider. Nonhealthcare providers – also known as atypical providers – must use their IHCP Provider IDs on claims. A provider's claims submitted without an NPI (or an IHCP Provider ID, for atypical providers) will be rejected. For submissions and communication other than claims, all providers should use their IHCP Provider ID as their unique identifier.
NPI Default Information
An NPI default location may be needed when an entity has multiple IHCP Provider IDs but only one NPI.
If you enroll in the IHCP via the IHCP Provider Healthcare Portal, you can designate one of your billing provider locations as your NPI default location. If you enroll in the IHCP using paper, you must complete the IHCP NPI Default Agreement to select the default NPI location. Please note that all claims billed with your NPI will default to the one location you choose.
For claims to process correctly, group providers must ensure that all their rendering practitioners are linked to the default location on record with the IHCP. Rendering providers must be linked to each service location where they render services as well as to the default NPI location. For more information about enrolling in the IHCP, see the Provider Enrollment provider reference module.
Additional Information
See the following sources for more information about NPIs:
Centers for Medicare & Medicaid Services (CMS)
National Plan and Provider Enumerator System (NPPES)
NPI Enumerator Address
NPI Enumerator
P.O. Box 6059
Fargo, ND 58108-6059
800-465-3203
800-692-2326 (TTY)