National Provider Identifer (NPI)

General NPI

What is an NPI?

The National Provider Identifier (NPI) is a federally mandated identification number issued to health care providers by the National Plan and Provider Enumeration System (NPPES).

What is the definition of a health care provider?

The NPI rule defines a health care provider as follows:

A provider of services as defined in section 1861(u) of the Act, 42 U.S.C. 1395X(u) (http://www.ssa.gov/OP_Home/ssact/title18/1861.htm) , as a provider of medical or health services as defined in section 1861(s) of the Act, 42 U.S.C. 1395x(s)- (see hyperlink above) of the Act and any other person or organization who furnishes, bills, or is paid for health care in the normal course of business. Please go to this link to read the regulation's definition of health care provider.

Are all NM Medicaid providers required to have an NPI?

All NM fee-for-service Medicaid providers who meet the NPI definition of a health care provider must have an NPI.

Is case management considered a health care service under NPI?

The Centers for Medicare and Medicaid Services (CMS) has determined that case management is a health care service and case managers are health care providers under the NPI rule.

How do I get an NPI?

Providers apply for their NPI with the National Plan and Provider Enumeration System (NPPES). Go to the following web site to register for your NPI: https://nppes.cms.hhs.gov/NPPES/Welcome.do

Do I have to use the web to register an NPI?

You can also register on paper. Health care providers can obtain a copy of the paper NPI Application/Update Form (CMS-10114) and mail the completed, signed application to the NPI Enumerator located in Fargo, ND, whereby staff at the NPI Enumerator will enter the application data into NPPES. The form is available only upon request through the NPI Enumerator. Health care providers who wish to obtain a copy of this form must contact the NPI Enumerator in any of these ways:

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What is an "atypical" provider?

Atypical providers are those providers who do not meet the definition of a health care provider under the NPI rule. This means that the services they provide do not meet the definition of health care in the Social Security Act and are not considered medical services. The NM Medicaid program has a number of atypical providers such as:

  • Personal care option providers, taxis, handivans, meals and lodging providers,
  • Some HCBS waiver services providers such as those providing environmental modifications and emergency response services,
  • Those who ONLY render administrative services such as helping coordinate non-medical services,
  • Those who support living arrangements (assisted, family, independent, supported, and environmental modifications), or
  • Those who supply home maker, respite or transportation services.

Do atypical providers need an NPI?

In general, an atypical provider does not need an NPI nor should get an NPI. Atypical providers will be able to continue billing NM Medicaid with their NM Medicaid provider number. Atypical providers who ALSO render health care services need an NPI and can use the NPI to bill for both atypical and health care services.

If I provide atypical services and health care services, do I have to use my Medicaid number for the non-health care services and the NPI for the health care services?

You will need an NPI to bill for your health care services and you can also use that NPI to bill for the atypical services.

Do waiver providers need an NPI?

If an HCBS waiver provider ONLY renders administrative services such as helping coordinate non-medical services, supports living arrangements (assisted, family, independent, supported, and environmental modifications), or supplies home maker, respite or transportation services, the provider would be "atypical" and will not need an NPI number. Generally, however, a HCBS waiver provider will need to apply for and use an NPI, particularly if any of their services are provided by a licensed health care provider, such as an RN, an LPN, a therapist, etc.

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Do schools and school-based providers need an NPI?

Schools must apply for an NPI number for the school, and each individual within the school system that currently has a Medicaid Provider ID number must have an NPI.

If I have more than one office, all in different locations and each billing NM Medicaid using its own Medicaid ID number, do I have to get one NPI for each location?

When a professional provider practices at multiple locations and has multiple Medicaid ID numbers in order to be paid different tax rates, it may not be possible for the provider to obtain different NPI numbers for each location unless each location constitutes a different entity, such as a different group practice. The best alternative for a provider in this situation is to (1) work with the NM Taxation and Revenue Department to use just one tax rate as usually they allow a provider to use the tax rate of a billing or head office; or (2) obtain NPI numbers for each location when possible.

The preferred alternative from NM Medicaid's perspective is for the provider to only retain one Medicaid ID number for the primary location and all claims for all locations are paid at that tax rate. If these alternatives are not possible, the billing provider ZIP code must be the ZIP code for the physical location which matches the Medicaid ID number for that location. For example, if an individual provider were an optometrist that has individual Medicaid ID numbers for practices in Santa Fe and Taos but only one NPI for both locations, in order to know which NM Medicaid provider number to pay, the optometrist's claim would contain the NPI, the taxonomy, and then the ZIP code for either the Santa Fe or Taos location, depending at which location the service took place. When the multiple locations are each individually certified or licensed, such as hospitals and nursing facilities for example, the Medical Assistance Division expects the provider to have NPIs for each location.

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If a provider is a group practice, does the practice need to get its own NPI and do its members each have to get an NPI, too?

Providers who form an "entity" such as a group practice, corporation, association, partnership, or other organization are able to obtain an NPI number for the "entity" as well as for the individual members of the group. If Medicaid payment is to be made to any business entity other than the individual provider, there must be separate NPIs for the practitioner(s) and the entity.

When there is more than one pharmacy owned by a single corporation, does each pharmacy have to get their own NPI?

Each pharmacy must have an NPI number even if part of a chain owned by the same corporation.

When a corporation owns a number of nursing facilities in the state, does each facility need its own NPI?

If the facilities are separately licensed and certified, the NM Medicaid program expects the provider to obtain separate NPI numbers for each facility. This allows the program to assure the facility is properly licensed and certified.

When an organization owns a number of hospitals in the state, does each hospital need its own NPI?

If the facilities are separately licensed and certified, the NM Medicaid program expects the provider to obtain separate NPI numbers for each facility. This allows the program to assure the facility is properly licensed and certified.

If a provider renders multiple types of service under the same business address and uses the same federal tax ID, can the provider have just one NPI?

Yes.

When will NM Medicaid require the NPI to be on a paper claim?

All paper claims received by Conduent after May 4, 2007, must use the NPI to identify billing, rendering, attending and referring providers.

When will NM Medicaid require the NPI to be on an electronic claim?

All electronic claims submitted to Conduent after May 17, 2007, must use the NPI to identify billing, rendering, and attending providers.

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Are NPIs required for rendering (servicing) providers on paper and electronic professional (CMS-1500) and dental claims?

Yes.

Are NPIs required for attending and "other" providers on an institutional claim?

Yes.

Are NPIs required on a professional claim to identify the facility where the service was rendered?

Yes, if the place of service on the claim is one of the following: 21, 22, 23, 31, 32, 51 or 54.

Are NPIs required for the prescribing provider on a pharmacy claim?

Yes.

What is taxonomy?

Taxonomy is a ten (10) digit number that enables providers to indicate their type of practice and specialty on a claim form. Use of taxonomy and the NPI is mandatory on healthcare claims.

Where can I find a list of the taxonomy codes?

Taxonomy codes are listed on the web site where you register for an NPI. That website is https://nppes.cms.hhs.gov. Another web resource with a list of taxonomy codes is www.wpc-edi.com/taxonomy.

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Is taxonomy required for the billing provider?

The taxonomy is NOT required but strongly recommended for the billing provider on CMS-1500 and UB-04 claims. Taxonomy is not necessary for dental or pharmacy claims. Please note that the provider is not restricted to using the taxonomy that was used to request an NPI number.

Is taxonomy required for the rendering (servicing) provider on dental and professional claims?

Taxonomy is not required for the rendering (servicing) provider on professional claims or dental claims. However, the NM Medicaid fee-for-service program does recommend that taxonomy be used when a rendering provider is entered on a professional claim. Please note that the provider is not restricted to using the taxonomy that was used to request an NPI number.

Is taxonomy required for the attending and other providers on an institutional claim?

Taxonomy is NOT required for the attending provider on an institutional claim.

How does a provider that provides health care services for the HCBS waiver program and also provides health care services for the "regular" Medicaid fee-for-service program submit claims with only one NPI?

One of the most important uses of the taxonomy will be when a provider has a single NPI number for both HCBS waiver services and non-waiver services. The provider must use different taxonomies to distinguish between the two kinds of claims. For waiver services the provider must use the taxonomy 174400000X (other service provider- specialist) in order to identify that the service is under the HCBS waiver. On non-waiver claims, the provider would use their normal healthcare taxonomy, such as "physical therapist", for example.

What happens if I submit a paper or electronic claim with my NM Medicaid provider number and NOT my NPI after NM Medicaid requires the NPI?

A delay in payment and/or claim denial can result if you are a health care provider and submit a claim without your NPI after the deadlines requiring an NPI.

Can I submit a paper claim with an NPI on it now?

Do not submit paper claims with the NPI on it. The new forms are not being accepted. An NPI on the old form would not be recognized and the claim would deny for an unknown provider number. The denied claim would not show up on your remittance advice.

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Can I submit an electronic claim with an NPI now?

Yes, but you need to have your NM Medicaid provider ID on it as well or Conduent will not be able to identify who submitted the claim.

Will my NM Medicaid provider number go away?

No. You will still retain your NM Medicaid provider number.

What is a "Medicaid proprietary" provider number?

This term is used to describe the Medicaid ID number you were assigned by the NM Medicaid fee-for-service program.

If a provider has an NPI and wants to be a NM Medicaid provider, does the provider still have to enroll in the NM Medicaid program?

Even if you have an NPI, you are still required to be enrolled in the NM Medicaid fee-for-service program and you will still be assigned a NM Medicaid provider number.

Can an NPI be associated with more than one NM Medicaid fee-for-service provider number?

Yes, as long as the providers share the same tax ID. That's why it is so important to use taxonomy and location zip code on the claim. An example of this is a home health agency that also renders hospice services. Currently the provider has a Medicaid ID number for home health services and one for hospice. However, the provider can use just one NPI number because the "taxonomy" stated on the claim by the provider will inform the Medicaid Program who provided the service.

Are providers required to "share" their NPI with other providers?

When providers order services (such as lab and radiology), prescribe drugs, admit patients to hospitals, make referrals, etc., they must provide their NPI number to lab, pharmacy, hospital, or other provider. This is necessary because in many instances, the provider rendering the ordered or prescribed service or item must have the practitioner's NPI to file their own claim. In the past, Medicaid numbers or DEA numbers were often used in place of the NPI. Now the NPI number must be used.

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Will the claim be processed using the NPI number or the Medicaid proprietary number?

The NPI number, taxonomy code and zip code will be used to find the correct NM Medicaid provider number in the claims processing system. The claim will then be processed based on the information associated with that NM Medicaid provider number. The remittance advice will have the NM Medicaid provider number and the NPI on it.

Will the Children's Medical Services (CMS) provider number for our inpatient hospital still work?

Hospitals have sometimes been given a Medicaid ID number that begins with a "C" to use only for their claims for Children's Medical Services. Those numbers will be cancelled. The hospital should now bill with their regular hospital NPI number. The claim can still be recognized as a CMS claim because of the authorization number on the claim.

Does the NPI go on a prior authorization or level of care request?

When requesting a prior authorization or level of care determination from one of the contractors to the Medicaid Program, the provider may request the prior authorization either under the Medicaid ID number or under the NPI number including the taxonomy which will be used when later filing the claim for the service.

What should a provider do to get ready for the change to the NPI?

  • Register for an NPI
  • Inform Conduent of NPI number using NPI Submission on website
  • Prepare systems to (1) use new paper claim forms when billing on paper; and (2) report NPI, taxonomy, and ZIP code on paper and electronic claim forms
  • Ask questions on special situations
  • Attend Conduent training sessions
  • Develop the capability to bill electronically to minimize problems.

Who do I contact if my NPI question is not answered here?

Please call the Consolidated Customer Service Center (CCSC) at 800-299-7304.

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Is there a link to the NPI supplement that HSD has issued and mailed to providers?

Yes. http://www.hsd.state.nm.us/mad/pdf_files/Supplements/REG_S_07-01.pdf

Where can I get my other NPI questions answered?

If your question still is not answered after checking all the NPI FAQs, please contact the Consolidated Customer Service Center (CCSC) at 800-299-7304.

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