National Provider Identifier (NPI)

Key facts

Legal basis

HIPAA Administrative Simplification, 45 CFR Part 162, Subpart D

Format

10 numeric digits, the last of which is a check digit

Issued by

CMS, through the National Plan and Provider Enumeration System (NPPES)

Entity types

Type 1 (individuals) and Type 2 (organizations)

Required since

May 23, 2007 (May 23, 2008 for small health plans)

What is a National Provider Identifier?

The NPI is the standard identifier for health care providers in HIPAA transactions such as claims, eligibility checks and remittance advice. It replaced the many legacy identifiers that individual health plans once assigned, including the Medicare UPIN. Any health care provider that conducts standard transactions electronically must obtain one, and health plans and clearinghouses must use it.

The number carries no embedded meaning: its digits say nothing about the provider's specialty, location or license. An individual keeps the same NPI for life, even after moving to another state, changing specialty or changing employers.

An NPI is not a credential. CMS states that issuing an NPI does not ensure or validate that a provider is licensed or credentialed.

Type 1 vs Type 2 NPIs

Every NPI belongs to one of two entity types:

A single clinician in a group therefore often appears twice on a professional claim: the group's Type 2 NPI as the billing provider and the clinician's Type 1 NPI as the rendering provider.

• Type 1 (individual): physicians, nurse practitioners, dentists, pharmacists, therapists and other individual clinicians. A sole proprietor is a Type 1 provider and can hold only one NPI.
• Type 2 (organization): hospitals, group practices, pharmacies, laboratories, nursing homes, home health agencies and corporations formed by individual clinicians. An organization can also obtain separate NPIs for subparts, such as a hospital's psychiatric unit.

Why the NPI matters

The NPI is the key that links provider data across public sources:

• NPPES files attach a name, practice address and taxonomy codes to each NPI.
• Medicare utilization and payment datasets, including Part B and Part D prescriber files, report activity by NPI.
• Medicare enrollment records in PECOS, Open Payments and Care Compare data all identify clinicians by NPI.
• Pharmacy claims carry the prescriber NPI, so prescription volume can be attributed to a specific clinician.