The National Provider Identifier (NPI) is a unique, 10-digit number that serves as the standard identification for covered healthcare providers in the United States. This identifier is mandated by the Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification provisions. It is used in all HIPAA standard transactions, such as electronic claims, claim status inquiries, and eligibility verifications, to streamline administrative processes. This guide details the requirements and process for obtaining and maintaining your NPI record.
Eligibility and NPI Classification Types
Any healthcare provider who is a “covered entity” under HIPAA must obtain an NPI. This includes individuals and organizations that transmit health information electronically for standard transactions. The NPI is a single, non-intelligent number assigned by the Centers for Medicare and Medicaid Services (CMS) to replace multiple legacy identifiers.
CMS assigns NPIs based on two primary classification types. A Type 1 NPI is for individual healthcare providers, such as physicians, dentists, nurses, and sole proprietors, who are eligible for only one NPI throughout their career. A Type 2 NPI is for organizational healthcare providers, including hospitals, clinics, and group practices that bill for services as a group. An individual who has incorporated their practice may need both a Type 1 NPI for themselves and a Type 2 NPI for their business entity.
Required Information Before Applying
Before beginning the application process, applicants must gather a specific set of data to ensure a smooth submission.
Type 1 (Individual) Requirements
Individual Type 1 applicants must provide identifying details for verification. These include:
- Full legal name, date of birth, and Social Security Number (SSN) or Individual Tax Identification Number (ITIN).
- Primary practice location address and phone number.
- Professional license information, including the state and license number.
- The 10-digit Healthcare Provider Taxonomy Code, which classifies the applicant’s type and specialization.
Type 2 (Organizational) Requirements
Organizational Type 2 applicants must provide their legal business name, Employer Identification Number (EIN), and the name and contact information of the authorized official.
Step-by-Step Application Methods
The most efficient way to apply for an NPI is through the National Plan and Provider Enumeration System (NPPES) online portal. This process typically takes about 20 minutes and can result in the NPI being issued in as little as 10 days.
Online Application Process
The first step involves creating a user account through the CMS Identity & Access Management (I&A) system to establish login credentials. Once logged into the NPPES portal, the applicant selects the appropriate provider type (Type 1 or Type 2). The system guides the user to input all required information, including practice location details and the provider taxonomy code. After reviewing the data, the application is submitted electronically, and the applicant receives a confirmation number.
Alternative Submission Methods
While the online method is fastest, two alternative options exist. Providers may complete a paper application using the CMS-10114 form, which must be requested from the NPI Enumerator and mailed to the designated address. This manual process is considerably slower, with a typical waiting period of approximately 20 business days. Large organizations also have the option of submitting applications on behalf of their providers through an Electronic File Interchange Organization (EFIO) for bulk enumeration.
Maintaining and Updating Your NPI Record
Upon successful submission, the provider receives a confirmation email, and the NPI is assigned after processing. Once issued, the NPI is a permanent identifier that remains with the provider regardless of job or location changes.
All covered healthcare providers are legally required to report any change to the information associated with their NPI within 30 days of the change’s effective date. This includes updates to the mailing address, practice location, contact information, or the provider’s taxonomy code. Providers can manage these updates by logging back into the NPPES portal using their I&A credentials and modifying the relevant sections of their record. Maintaining an accurate NPI record is necessary for compliance and helps prevent issues like claim denials or delayed payments.