Saturday, February 18, 2012

Beginning Credentialing - NPI

So now to the nitty-gritty of credentialing. 

In previous posts, I mentioned something called an NPI number. NPI stands for national provider identifier. Similar to how you and I are identified by our social security numbers for many things, the NPI is a nationally recognized identification number for medical care providers including doctors, nurse practitioners, hospitals, laboratories, physical therapists and  even insurance companies.  If a medical provider does not have an NPI, one must be obtained in order to credential the provider with any insurance company.

NPI numbers are assigned and maintained by a division of the Centers for Medicare and Medicaid Services (CMS), called NPPES or the National Plan and Provider Enumeration System. The NPI application can be completed online at the NPPES website (https://nppes.cms.hhs.gov/NPPES/StaticForward.do?forward=static.instructions). To enroll for an NPI, you will need some information from the provider including: Provider Name, Social Security Number or ITIN if not eligible for SSN, Provider Date of Birth, Country of Birth, State of Birth (if Born in the U.S.), Provider Gender, Mailing Address, Practice Location Address and Phone Number, Taxonomy ( This is the provider type or specialty. A list can be found at http://www.wpc-edi.com/codes/taxonomy), State Medical License, and Contact Person information.

To apply for the NPI initially,  create an account on NPPES website and enter all of the information listed above in to the NPPES web application. Be sure to keep the NPPES website account log in information safe as you will need it later when credentialing with Medicare and for Meaningful Use registration. Assuming you entered all of the information correctly, the NPI number will be emailed to the contact person in just a few days. Kudos to CMS as this is the easiest, fastest, and most reliable part of credentialing!

Every provider will need one individual NPI number. The individual NPI identifies the provider. At times, the provider may belong to or wish to form a group practice (multiple providers working together as a single business entity).  If the provider is part of a group or wants to form a group , you may also need to apply for a group NPI. In a former post, I gave the first name/last name analogy. For clarity, I will explain that again. The Individual NPI is like your first name. Your first name identifies you as an individual. The Group NPI, is like your last name. Your last name identifies the family to which you belong as a member.

Applying for a group NPI is just like applying for an individual NPI. You will go to the same website and need similar information as mentioned above. The difference is that rather than using information belonging to a single person, you will use the business’ information. Further, as a business is not born in the traditional sense, you will not need to indicate the place of birth (I know, that was probably obvious to you before I said it). As an additional side note, in the event that a provider who has no individual NPI is joining an existing group that already has an NPI, you do not need to apply for another group NPI.  The existing NPI is sufficient. You will only need to apply for the individual NPI in that case.  Using the name analogy again, this is like a new born baby. You only need to give the new baby a first name - the last name is already taken care of by the parents. 

Only AFTER you have gotten all required NPI numbers (individual and group, if applicable), then you can begin credentialing with each insurance company individually.   More on that is coming soon…

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