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NPI deadline is fast approaching

January 1, 2007
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Providers are required to obtain a National Provider Identifi er by May 23

The deadline for obtaining a National Provider Identifier (NPI) is fast approaching. Under HIPAA rules, by May 23, 2007, healthcare providers must obtain an NPI for use in submitting standard electronic claims and eligibility inquiries to Medicare and most health plans (although smaller health plans do not have to use NPIs until May 23, 2008). If claims are submitted to Medicare without an NPI after May 23, they likely will be rejected, says Barbara Cebuhar, a spokeswoman for the Centers for Medicare and Medicaid Services (CMS).

Both individual and organizational healthcare providers must obtain a unique NPI even if they use a clearinghouse to prepare and submit claims, notes Cebuhar. Although standard transactions must carry NPIs by May 23, Medicare provider numbers should be used in addition to NPIs to help build “crosswalks” for Medicare and health plans that choose to employ the “dual use” strategy. Using both NPI and legacy provider numbers until May 23 will help reduce delays in payment until the provider's, Medicare's, and other payers' software programs are fully tested and operational. After May 23, only NPIs may be used on claims.

There are several ways to obtain an NPI. Applications may be made online at, which allows the applicant to receive a number quickly. Providers can call (800) 465-3203 to request a paper application or if they encounter problems in applying. Providers also can have an electronic file interchange organization (EFIO) apply for NPIs on their behalf.

Cebuhar offers provider organizations the following advice on the NPI process:

  • Establish a program management office (or at least assign a person) to manage tasks associated with the NPI initiative.

  • Develop a master plan for compliance that involves business and IT personnel.

  • Check software programs to make certain that they meet NPI standards.

  • Monitor developments on the CMS NPI Web site.

Some behavioral healthcare providers already are behind the eight ball. That's because CMS strongly recommended that providers obtain their NPIs by the end of last year to test them against their software systems and to share them with business partners. Federal officials don't know how many behavioral healthcare providers have obtained NPIs, but only 1.4 million healthcare entities (individuals and organizations) had applied by late November for NPIs, out of at least 2.3 million total expected applications, according to Cebuhar.

Industry sources say that many behavioral healthcare providers are among those who have yet to apply, but no one in the industry seems to know exactly why. Among the explanations: Some providers may be unaware of the requirement; some may be waiting for their software systems to be upgraded; some may be chronic procrastinators; and some may be confused about the service category codes that providers must choose when applying for their NPI.

Indeed, choosing service category codes seems particularly vexing. To obtain an NPI, providers must choose a code that most appropriately identifies the kind of service they render at the time of application. Since NPIs are permanent, providers will be required to update some demographic information within 30 days of changes.

In general, taxonomy codes, describing a provider's type/category/classification/specialization, may be problematic, says Russ Newman, executive director for professional practice at the American Psychological Association. The National Uniform Claim Committee, which is responsible for developing the codes, already has been asked to review proper coding for Louisiana practitioners designated by state law as “medical psychologists” authorized to dispense medications. Newman admits that the NPI system appears to be a viable administrative solution to replace the multiple numbers providers currently use, but he believes potential billing issues could crop up. “The codes simply don't adequately portray how psychology is practiced today,” he explains.

“We're discussing the pros and cons of having various modifiers to the designated service categories,” adds John Russell, executive director of the West Virginia Behavioral Health Care Providers Association. “NPI certainly has everyone nervous.”

In neighboring Ohio, providers face additional difficulties in complying with the NPI requirement. Before the May 23 deadline, providers must successfully run a test file using their newly acquired NPI for several publicly funded state programs, explains Margaret Spurgeon, associate director of the Ohio Council of Behavioral Healthcare Providers (OCBHP). As of mid-November, 62% of the 790 OCBHP provider organizations had obtained their NPI numbers, but just 20% had passed the claims file testing requirement.

Most provider organizations that haven't obtained NPIs say they've been too busy, reports Spurgeon. Others say that they're waiting for their software vendors to upgrade their systems to accommodate NPIs. There also is an inaccurate perception that there's still plenty of time to get NPIs.

Other organizations are further along. McLean Hospital, a comprehensive mental healthcare system affiliated with Harvard Medical School, expects to have NPIs assigned to clinicians and entered into the hospital's billing system in the next month or so, according to Terry Bragg, director of professional staff affairs. He says that so far there have been few, if any, problems in obtaining NPIs, with most applications processed within 24 hours. But the first quarter of 2007 will be a test, he says, as more insurance companies ask for NPIs on claim forms. Bragg is concerned that the ten-digit numbers could be inaccurately entered into provider dictionaries because of human error, which will have a negative impact on processing claims.