Quick Guide to Understanding NPI Numbers

The term NPI (National Provider Identifier) is familiar to most healthcare professionals because it is frequently used to authenticate and verify a wide range of authentication, process control, individual claims, contracts/agreements, and much more.


What is a National Provider Identifier (NPI)?

The National Provider Identification (NPI) is a 10-position, intelligence-free numeric identifier, according to the Centers for Medicare and Medicaid Services (CMS) (10-digit number). This means that the data don’t contain any further information about healthcare providers, such as where they live or what medical specialty they practice. In HIPAA standards transactions, the NPI number lookup must be used instead of traditional provider identification.

The National Provider Identifier (NPI) is an Administrative Simplification Standard under the Health Insurance Portability and Accountability Act (HIPAA). For covered healthcare providers, the NPI is a unique identifying number.

National Provider Identifier (NPI) Replaces the Unique Physician Identification Number (UPIN)

The Centers for Medicare & Medicaid Services (CMS) created the UPIN (Unique Physician Identification Number) to replace the SSN as a unique provider identity. Physicians, as well as some non-physician practitioners and medical group practises, were given UPINs.

“Due to the changing nature and format of Provider/Profiling Identification Numbers (PINs) and our concerns for accuracy,” CMS ended the UPIN Registry in 2007. Since 2007, the National Provider Identifier (NPI) has been the CMS provider identification number, replacing the UPIN.

HIPAA Rules for NPI

In the administrative and financial activities required by HIPAA, covered healthcare providers, all health plans, and healthcare clearinghouses must use NPIs.

Covered providers must also provide their NPI with other doctors, health plans, clearinghouses, and any entity that may need it for billing purposes, according to the Federal Regulation, The Health Insurance Portability and Accountability Act of 1996 (HIPAA).

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According to CMS, there are two types of healthcare providers in terms of NPI – Type 1 and Type 2.

Type 1 NPI Providers

Individual healthcare professionals, such as physicians, dentists, and all sole proprietors. A person is only allowed to have one NPI.

Type 2 NPI Providers

Healthcare providers which are organizations, including physician groups, hospitals, nursing homes, and the corporation formed when an individual incorporates him/herself.