Skip to Content
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a permanent component of our health care strategy. We are committed to delivering excellent service. Our commitment includes compliance with and support of the HIPAA mandates. Most importantly, we are committed to complying with the mandates, standardization and protection of patient privacy, but with minimal "administrative hassles" for our members, physicians and other health care professionals. We are also committed to informing you about HIPAA and our compliance status. Here are frequently asked questions that provide a quick overview of the HIPAA National Provider Identifier (NPI) requirements. We will update this listing regularly and encourage you to visit often to find the most up-to-date information regarding HIPAA and our compliance status.
What is an 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).
They also are 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, an 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, each location is issued its own NPI. These types of arrangements are referred to as "sub-parts" in the NPI Final Rule.
What does the NPI look like? The NPI is a 10-digit numeric field that includes 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 contains no imbedded intelligence. In other words, you cannot determine a provider’s state, region, specialty or any other information directly from his or her NPI. How is the NPI generated? The NPI is generated by a 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 & Medicaid Services (CMS). How is the NPI issued to providers? Providers can apply electronically through the CMS Web-based application system. Providers who prefer to use the paper format can call the enumerator at 800-465-3203 for a copy. A copy of the application and the enumerator’s address will be available at the same Web site. Also, the provider may choose to submit his or her application through an organization, professional association or employer, known as Electronic File Interchange (EFI), or Bulk Enumeration. Providers must supply adequate information to ensure they can be identified uniquely by the National Plan and Provider Enumeration System (NPPES). Should any of that information change in the future, providers must notify CMS 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. How can payers associate a provider with his or her NPI? The NPIs are 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. We are developing a strategy for acquiring NPI data from the database and will use it to identify providers submitting HIPAA transactions. In most cases, it will probably mean modifying current processes to include the NPIs. Where can I learn more about NPI? To learn more about NPI from CMS, visit the CMS Web site or call the CMS HIPAA Hotline at 866-282-0659. In addition, we encourage you to visit the HIPAA Critical Center to find the most up-to-date information regarding HIPAA and our compliance status. When can providers apply for an NPI? Providers can apply electronically now through the CMS Web-based application system. Providers who prefer to use the paper format can call the enumerator at 800-465-3203 for a copy. A copy of the application and the enumerator’s address will be available at the same Web site. Also, the provider may choose to submit his or her application through an organization, professional association or employer, known as Electronic File Interchange (EFI), or Bulk Enumeration. What if a provider has numerous health plan IDs? Does each health plan require an additional NPI? The NPI is the single provider identifier that replaces 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 only needs to apply once for an 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. You can also contact the enumerator by telephone at 800-465-3203 or TTY 800-692-2326. How are NPIs reflected on remittances? If you obtained a National Provider Identifier (NPI) for each location previously loaded to the BlueCross® BlueShield® of South Carolina provider file, only minor changes are reflected on your remittances (i.e., the NPI number will be printed on your hard copy remits and My Remit Manager/835s will have the NPI number reflected on them as well.) If you did not get an NPI for each location, your remittances are summarized at the NPI level. You will no longer receive separate remittances for each location. Everything will be summarized by NPI.
How are NPIs reflected on Electronic Funds Transfer (EFT)? As with remittances, EFTs are generated based on your NPI number. The EFT payment will show the NPI instead of the Tax ID.
Why are you requiring rendering provider information since NPI implementation? Prior to NPI implementation, we were able to determine the specialty of the provider based on the billing number because BlueCross ID numbers were assigned not only based on location but also on specialty. With the implementation of NPI, we are no longer able to require providers to file with a specific BlueCross ID number to assist us in identifying the specialty of the provider. As a result, we must rely on the rendering provider information to get the specialty. The specialty of the rendering provider affects both reimbursement and benefit payments. It is critical that the rendering provider NPI be included on your claim submissions. BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.