National Provider Identifier

The National Provider Identifier (NPI) is a unique identification number for use in standard health care transactions. It is issued to health care professionals and covered entities that transmit standard HIPAA electronic transactions (e.g., electronic claims and claim status inquiries).

The Centers for Medicare and Medicaid Services (CMS) began issuing NPIs to health care professionals who applied and qualified in May 2005. Health care professionals and covered entities may apply for NPIs through the National Plan and Provider Enumeration System (NPPES) established by CMS for this purpose.

The NPI fulfills a requirement of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), and was to be used by health plans and health care clearinghouses for HIPAA standard electronic transactions beginning May 23, 2007. Health care professionals and covered entities were given an additional year to become fully compliant with the NPI rule. The contingency period expired May 23, 2008.

The NPI is intended to:

• Replace other identifiers previously used by health care professionals and assigned by payers (e.g., Unique Physician Identification Number [UPIN], Medicare or Medicaid numbers);
• Establish a national standard and unique identifier for all health care professionals
• Simplify health care system administration
• Encourage the electronic transmission of health care information

No. The TIN should continue to be used on the HIPAA 837 electronic claim to identify the tax entity to which claims should be paid.

The NPI also does not replace the health care professional's Social Security number or Employer Identification number (EIN) where it is required in other business processes or electronic feeds not covered by HIPAA (e.g., credentialing).

Cigna collects and updates NPI information from the CMS National Plan and Provider Enumeration System (NPPES) database, and from individual health care professionals and facilities.

Cigna will contact health care professionals directly if more details about NPI enumeration are needed. This will ensure that their information is correct in our systems.

Contact your EDI vendor for more information about including the NPI on transactions to ensure accurate submissions and reporting of transactional data.

In general, only the NPI should be used for identification purposes for a health care professional or any covered entity. "Legacy" identifiers may not be used. Your appropriate TIN should be used for tax purposes in standard transactions.

Cigna accepts the NPI on standard HIPAA transactions as outlined below. This approach should not be confused with any guidance specific to Medicare claims requirements.

837 Electronic Claim

• Required data elements such as the "Billing Provider" TIN, "Rendering Provider" name and "Rendering Provider" address must always be included on professional, institutional, and dental claims. Inclusion of this information should not change as a result of NPI implementation.
• As with any change to a health care professional's billing process, if a health care professional plans to change the way claims are submitted to Cigna as a result of their NPI implementation or enumeration, the health care professional should contact Cigna Customer Service to communicate this change. One example would be an organization that has enumerated multiple NPI subparts and will start to bill using the "new" subpart health care professionals.
• When using the NPI to identify the "Billing Provider", the TIN must be submitted as the secondary provider identifier. This TIN is the number used on the 1099, which is either the EIN for organizations or the Social Security number for individuals; both numbers should not be included concurrently. Other identifiers, such as Medicare provider number, are considered "legacy" identifiers and should not be included.
• Submission of the "Billing Provider" TIN on the electronic claim is a HIPAA requirement. The National EDI Transaction Set Implementation Guide specifically states the following:
  
  
  • "If 'code XX - NPI' is used, then either the Employer's Identification Number or the Social Security Number of the provider must be carried in the REF in this loop. The number sent is the one which is used on the 1099."


• Under HIPAA 5010 standards "Pay To Provider" information is limited to an alternate address only. No additional identifiers, neither TIN nor NPI, are permitted. The "Pay To Provider" address is only needed if it is different than that of the "Billing Provider."

Real-Time Request Transactions (270, 276, 278)

• All real-time request transactions will be accepted with NPI. Contact your EDI vendor for details regarding the submission of NPI on these transactions.

Cigna will send the NPI on standard HIPAA transactions as outlined below.

835 Electronic Remittance Advice (ERA)

• In most instances, Cigna will include the "Billing Provider" (claim payee) NPI on the 835. If more than one claim is included in a single 835, the NPI will be included in the 835 only if all NPIs are equal. The NPI for the "Rendering Provider" will be included in the 835, if the "Rendering Provider" NPI was submitted on the 837 electronic claim

Real-Time Response Transactions (271, 277, 278)

• The NPI will be returned on real-time response transactions when the NPI is submitted on the corresponding request transaction.

Yes. Only the NPI may be used for identification purposes for a health care professional or any covered entity. "Legacy" identifiers may not be used. The appropriate TIN should be used for tax purposes in standard transactions.

Regulations only require the use of the NPI on electronic transactions. However, the standard professional and institutional paper claim forms (CMS 1500 and UB-04) allow the NPI to be included.

We recommend, but do not require, that health care professionals send their NPI on paper claim forms.

No. HIPAA standards prohibit the use of "legacy" identifiers. Cigna also does not use "legacy" identifiers in the claim adjudication process.

Claim submission still requires a TIN in addition to the NPI. A TIN is not considered a "legacy" identifier, as it is not payer assigned. It identifies the tax entity to which claim payments should be made; it does not identify a health care professional.

Cigna will continue to accept dental claims submitted with the dental license number as an additional identifier.

Taxonomy codes are not required on claims submitted by health care professionals that participate in the Cigna network. However, non-participating health care professionals should include taxonomy codes on submitted claims.

Cigna can validate NPI information on file with an individual health care professional or health care professional organization. Health care professionals will be required to validate their TIN in order to receive this information. Cigna will not disclose the NPI of other health care professionals. The NPPES Data Dissemination Notice states:

"Entities wishing to obtain the NPI of a health care provider for use in a standard transaction may contact that health care provider directly and request the NPI. Health care providers who are covered entities under HIPAA (known as "covered health care providers") are required by the final rule to disclose their NPIs to any entity that needs them for use in standard transactions."

For additional information on NPIs, visit the CMS website and type "NPI" in the search box.

To access the NPPES database, go to
https://nppes.cms.hhs.gov/NPPES/NPIRegistryHome.do.