In January 2004, the U.S. Department for Health and Human Services issued a rule establishing the National Provider Identifier (NPI) as the standard unique identifier for eligible healthcare providers that are covered entities under HIPAA.

The NPI replaces all unique payer assigned provider identifiers, individual and facility, and will be the single provider identifier with which you do business.

HIPAA regulations require eligible healthcare providers to replace their current payer legacy provider numbers with a new identifier by May 23, 2007. Currently, providers have a 12-digit provider number with BMC HealthNet Plan.

Under HIPAA regulations, a covered entity is defined as a health plan, a health care clearinghouse, or a health care provider who transmits any health information in electronic form in connection with a HIPAA transaction.

All entities that meet the definition of “healthcare provider” as defined in HIPAA regulation 45 CFR 160.103 are required to apply for and receive a NPI prior to the May 23, 2007 compliance date. This regulation and other HIPAA standards can be reviewed at: http://www.cms.hhs.gov/HIPAAGenInfo

Other useful sources of information include:

• The Centers for Medicare and Medicaid Services (CMS) has consulted with the Workgroup for Electronic Data Interchange (WEDI) in developing standards on data dissemination and other related issues. WEDI has formed several workgroups consisting of various representatives from all areas of the health care industry. For access to published white papers on various topics relating to NPI, please visit their Web site at www.wedi.org.
• National Plan and Provider Enumerations System (NPPES) has information about the NPI application process at https://nppes.cms.hhs.gov or by calling 1-800-465-3203 or TTY 1-800-692-2326.
• Questions or concerns specific to BMC HealthNet Plan should be directed to your provider account representative. You may also e-mail questions or concerns regarding NPI and transactions with BMC HealthNet Plan to NPI@bmchp.org.

The Centers for Medicare & Medicaid Services (CMS) has contracted with National Plan and Provider Enumeration System (NPPES) to administer the assignment of NPIs. You will be able to apply for an NPI in one of the following ways:

• Applications are being accepted through an easy Web-based process at https://nppes.cms.hhs.gov.
• Paper applications may be completed and sent to the entity that will be assigning the NPI (the Enumerator) on behalf of CMS. A copy of the application, including the Enumerator’s mailing address, is available at https://nppes.cms.hhs.gov. You may also call the Enumerator for a copy at 1-800-465-3203 or TTY 1-800-692-2326. With a provider’s permission, an organization may submit the application in an electronic file on behalf of the provider.
• Unique to Massachusetts, providers may authorize the state Board of Registration in Medicine to obtain the NPI on their behalf. This process is available through the Massachusetts Physician Renewal Application process. Information may be obtained on their Web site at http://www.massmedboard.org.

It is expected that the NPI will last indefinitely; it will not change over time, unless the provider is subject to having the NPI revoked or requests a new NPI or identify theft.

Every individual considered a “healthcare provider” must receive his or her own personal NPI, regardless of the number of locations where services are rendered. Clinics, hospitals, and other health care facilities should refer to the definitions and guidelines provided by CMS on its Web site at http://www.cms.hhs.gov.

The NPI will not:

• Guarantee reimbursement by health plans
• Establish a contractual or participating status within health plans
• Replace the tax identification number (TIN), which is an IRS requirement
• Replace the provider’s DEA (Drug Enforcement Agency) number

Providers must continue to include their 12 digit BMC HealthNet Plan provider number currently used on all paper and electronic transactions until the May 23, 2008 NPI compliance date. However, healthcare providers now have the option of submitting their NPI on standard electronic claims transactions in addition to the BMC HealthNet Plan provider number. BMC HealthNet Plan does not consider claim submission an acceptable mode of notification of an NPI - please refer to how to submit your NPI to BMC HealthNet Plan to avoid claim rejections after May 23, 2008. BMC HealthNet Plan will continue to provide updated information before the May 23, 2008 compliance date.

Providers or provider representatives are responsible for notifying all payers of their NPI. At this time, there is no dissemination of NPIs among multiple payers. In addition, all payers may have different timeframes or requirements for NPI notification. Please contact the individual payers for instructions.