Who may need a National Provider Identifier?

HIPAA’s Administrative Simplification Standard for Health Insurance Portability and Accountability Act (NPI) facilitates the identification of healthcare providers. NPIs are unique identifiers for healthcare providers.

NPIs are accessible to all health care providers. They are eligible for NPIs because they are health care providers. In the absence of any transmission of health information, they are not “covered” health care providers under HIPAA. They are not required to obtain a National Provider Identifier under the final NPI rule. They would, however, need NPIs if they do.

Who Is or not Eligible To Obtain A National Provider Identifier?

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Physicians who wish to bill Medicare or Medicaid must have an NPI. Regulations permit only lawful permanent residents and students to apply. Pharmacy and durable equipment companies should require a physician’s NPI on orders so that residents who order prescriptions and home health services are reimbursed for their services.

NPIs are provided to healthcare providers who need them to submit claims or perform HIPAA-required activities. A healthcare provider provides medical or other health services to the general public. It includes hospitals, nursing homes, physician/practitioner groups, dental clinics, laboratories, and pharmacy is an example of an organization that provides health care services. 

Interns and residents who prescribe medications that pharmacies fill may refer patients to other health care providers or order testing for patients. Pharmacies and other providers of health care must identify them in their health plan claims transactions as providers or as prescribers who referred patients or ordered tests for patients.

The NPI can identify providers, referrers, and orders of those medications. The NPI Final Rule may not require these providers to obtain NPIs, but they may need them to be reimbursed by health plans if they are to receive NPIs.

Do Medical Students, Interns, Residents, and Fellows Use Healthcare Provider Taxonomy Codes?

Students, interns, and residents who do not yet hold a license (based on state licensing requirements) may use the Healthcare Provider Taxonomy Code: Student Health Care (390200000X). An individual enrolled in an organized health care education, or training program leads to a degree, certificate, registration, or license for health care provision. NPIs should be selected for medical students, interns, and residents who are not licensed.

To indicate the change in status from medical student to physician, the physician needs to submit a change in the HPTC in the National Plan and Provider Enumeration System (NPPES).

The American Medical Association recommends that a licensed physician who changes from a medical student to a physician in the National Plan and Provider Enumeration System (NPPES) modify the HPTC to reflect the change in status. Any change in “covered” healthcare providers must notify NPPES within thirty days of taking effect to avoid a fine.

Physicians assigned NPIs must keep the NPPES data updated with any changes to their specialties (i.e., healthcare Provider Taxonomy Codes are used to indicate changes in databases). If their contact information changes, covered health care providers must update NPPES within 30 days of updating.