National Provider Identifier
The National Provider Identifier is a unique, government-issued, standard identification number for individual health care providers and provider organizations such as clinics, hospitals, schools and group practices. NPIs that specify an individual, such as a solo practice dentist, are classified as Entity Type 1 (Individuals) NPIs. NPIs that specify a dental practice organization are classified as Entity Type 2 (Organizations) NPIs.
Any health care provider that uses electronic transactions—like claims or eligibility verifications—is considered a “covered entity” under the Health Insurance Portability and Accountability Act (“HIPAA”) standard and is required under federal law to include an NPI on electronic transactions. This definition applies regardless of whether the provider submits electronic transactions directly or via a third party, like a vendor or a clearinghouse.
Medicare Part D Changes Affecting NPI Use
As of Jan. 1, 2013, all Medicare Part D prescription claims must contain the prescriber’s Type 1 individual NPI. Even a dentist who does not need a Type 1 individual NPI to bill for his or her services directly still needs this identifier to prescribe drugs for patients who have Medicare Part D prescription drug benefits.
As of May 6, 2013, a Type 2 Organizational NPI that identifies a dental practice organization is no longer sufficient to allow patient prescriptions to be billed to third-party insurance carriers. Only the Type 1 individual NPI is now valid for specifying the prescribing doctor on an insurance claim. For more information on this, visit this Centers for Medicare and Medicaid Services site, scroll down to the “Downloads” heading, and click on the resource “NPI Requirement for Prescribers.”
Other NPI Users
Even dentists who are not HIPAA covered entities (because they use only the US mail and/or typical fax machines to transmit claims) may be required to use NPIs. For example, most dental plans require dentists to include NPIs on paper claim submissions (since 2006, all versions of the ADA claim form support the use of NPIs). Non-covered dentists are now also required to use a Type 1 NPI on prescriptions for Medicare Part D beneficiaries.
In addition, a specialist may request a referring doctor’s Type 1 individual NPI to complete a claim, regardless of how the claim is transmitted to the plan. A drug plan may require pharmacists to include prescribing doctors’ Type 1 NPIs on prescription claims for certain drugs.
How to Apply
Applying for an NPI is free of cost and relatively easy. To apply through a secure, Web-based process, visit the National Plan and Provider Enumeration System website. Those with valid applications should receive their NPI via email within one to five business days. The emails may end up in a spam folder, so it’s important to check regularly (including your spam folder)to ensure you receive the message.
Dentists who prefer to submit paper applications should contact the NPPES customer service hotline at 1-800.465.3203. The paper application process should take between four and six weeks. Questions about the status of an NPI application can be emailed to customerservice@NPIEnumerator.com.
During the application, you will be asked for your "Provider Taxonomy Code." This is an alphanumeric code that designates a health care provider's area of specialization. A list of Provider Taxonomy Codes is provided here (PDF) for your use.
For more information about NPIs in general, please visit Center for Medicare and Medicaid Services website.
American Dental Association
Department of Dental Informatics
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