Step-by-Step Procedure to Obtain YOUR (individual) or your Organization's NPI:

STEP 1:

1-Individual Health Care Providers – (Entity Type 1 – No sub-parts)

If you are an individual providing health care services and billing for them to government funded health plans as an individual, e.g. a physician, you will apply for an NPI as an individual practitioner. Subpart delegation does not affect health care providers who are enrolled in Medicare as individual practitioners or sole proprietors. For purposes of NPI assignment, these are Entity Type 1 health care providers.

2-Organizational Health Care Provider – (Entity Type 2 - sub-parts by definition)

A health care provider that is an organization may have components that function as health care providers somewhat autonomously of the provider of which they are a part, and will need a separate NPI to meet Federal regulatory requirements for participation in Medicare. These components, called íƒ˙subpartsíƒ˘, might conduct their own HIPAA standard transactions, might be certified by the State separately and might be located at a different location from their parent. Covered organizational health care providers are responsible for determining if they have subparts that need NPIs. If there are subparts that need NPIs, the covered health care providers must ensure that the subparts obtain their own NPIs, or must obtain them for the subparts.

Many providers that are enrolled in Medicare are actually subparts, such as different departments of a hospital, and the different locations of the members of a provider network. Medicare providers that apply for NPIs as Organizations (Entity Type 2) are all affected by the subpart concept. These organizations include hospitals, nursing homes, DME suppliers, supplier groups, home health agencies, ambulatory surgical centers, ambulance companies, and many others - some of which may be subparts of others.

SUB-PARTS Fact Sheet – Guidance on Sub-Part Determination

The National Provider Identifier (NPI) will replace health care provider identifiers in use today in Health Insurance Portability and Accountability Act (HIPAA) of 1996 standard transactions. All health care providers who are HIPAA covered providers must obtain an NPI to identify themselves in HIPAA standard transactions. Covered organization health care providers are responsible for determining if they have subparts that need NPIs. If there are subparts that need NPIs, the covered health care providers must ensure that the subparts obtain their own NPIs, or must obtain them for the subparts.

1. What Is a Subpart?
   HIPAA-covered entities are legal entities. Often, a health care provider that is an organization may be comprised of components that function as health care providers somewhat independently of the parent(the covered organization health care provider of which they are a part). These components, which we call subpartsí, might conduct their own HIPAA standard transactions, might be certified by the State separately from their parentí, or might be located at the same location as, or a different location from, their parent. The covered organization health care provider needs to determine if it consists of any such subparts, and, if it does, it must determine if any of those subparts need to have their own unique NPIs in order to be identified in HIPAA standard transactions. Many providers that are enrolled in Medicare are actually subparts. Examples of subparts may include different components of an organization health care provider, such as different departments of a hospital, and separate physical locations of an organization health care provider, such as the different locations of the members of a chain.


2. Why Is Subpart Determination Necessary?
   Subpart determination ensures that entities within a covered organization health care provider that need to be uniquely identified in HIPAA standard transactions obtain unique NPIs for that purpose. The NPI Final Rule provides guidance to covered organization health care providers in determining subparts and whether or not they should have NPIs. A subpart that conducts any of the HIPAA standard transactions separately from the parent must have its own unique NPI. If Federal regulations exist that require an entity to have its own unique identification number for purposes of billing Federal health plans, such as Medicare, the covered organization health care provider would need to ensure that, if it was composed of subparts that were affected by such regulations, each subpart obtained its own NPI in order to be compliant with those regulations. This is because NPIs will eventually replace the billing numbers that had been assigned by Medicare. Medicare Durable Medical Equipment (DME) suppliers must obtain NPIs for each physical location in order to comply with such Federal regulations. No similar Federal regulations exist for other types of Medicare providers.


3. Who Is Affected by Subpart Delegation?
   Medicare providers that apply for NPIs as Organizations (Entity Type 2) are affected by the subpart concept. Organizations include hospitals, nursing homes, DME suppliers, supplier groups, home health agencies, ambulatory surgical centers, ambulance companies, and many others—some of which may be subparts of others. Subpart delegation does not affect health care providers who are enrolled in Medicare as individual practitioners or sole proprietors (for purposes of NPI assignment, they are Entity Type 1 health care providers). Individuals are considered legal entities, cannot designate subparts, and cannot be considered subparts.

Resources for Additional Information

• Additional information regarding subparts is available on the Medicare NPI Implementation page on the CMS website.
For more detailed information on subpart designation, visit the Medicare Subpart Expectations paper on the CMS website.
• The Medicare Learning Network (MLN) is the brand name for official CMS educational products and information for Medicare fee-for-service providers. For additional information visit the Medicare Learning Network's web page on the CMS website.

STEP 2: NPI application process for YOU (as an individual provider)

All individual health care providers (who are NOT employees providing health care in a Type 2 Entity) should apply immediately for an NPI, the sooner the better. This may be done in one of two ways:

1. By using the web-based process which has been available beginning May 23, 2005. Simply access the following website and you can access and complete the form and submit it, all online.
2. By filling out a paper NPI Application and mailing it to the Enumerator (see above). This process has been available beginning July 1, 2005. Simply access the following website, download the required form for your case, print it out, fill it in and mail to the enumerator.

STEP 3: NPI application - Electronic File Interchange (EFI) process

Beginning May 1, 2006 health industry organizations can submit health care providers' applications for National Provider Identifiers (NPIs) to the National Plan and Provider Enumeration System (NPPES) via Electronic File Interchange (EFI). With EFI, a CMS-approved health industry organization can submit the application data of many health care providers in a single electronic file in a CMS-specified format so the burden on both the provider community and CMS is greatly reduced when this process is utilized.

EFI is an alternative to web-based or paper NPI application. After the NPPES processes a file, it makes available to the organization a downloadable file containing the NPIs of the enumerated health care providers. The EFI materials are available from the CMS NPI page and from the NPPES page.

Step-by-Step EFI Application Process:

Electronic File Interchange Organization (EFIO) Registration

If an organization would like to become an EFIO, it must log onto https://nppes.cms.hhs.gov and follow the appropriate links to the EFIO registration page. Once there, a representative of the EFIO ("EOR") will enter certain information about himself/herself and the EFIO into the NPPES system. (This will include the EOR's selection of a user ID and password.) An authorized official of the EFIO must then download from https://nppes.cms.hhs.gov, complete and sign a certification statement and mail it to the CMS designated Enumerator:

NPI Enumerator
P.O. Box 6059
Fargo, North Dakota 58108-6059

EFIO Gathers and Formats Data from Providers

The EFIO will enter all of the relevant data from those providers on whose behalf the EFIO will act into an XML file for eventual submission to NPPES.

EFIO Submits the XML File to NPPES

The completed XML format file is uploaded electronically to NPPES. The EFIO will then receive two e-mails from NPPES. The first contains the NPPES-generated file name. The second indicates whether the file upload was successful.

NPPES Review and Feedback

   A file submitted to NPPES is in a "queue until the Enumerator is ready to have NPPES review it. Then each provider's record will be run against NPPES and its edits. Possible outcomes are:
A. The file passes all edits and validations. NPIs are then assigned for each provider. The NPIs will be in a return file that the EFIO downloads. The EFIO must then notify each provider of its NPI (the NPI belongs to the provider, not the EFIO.)
B. Most records pass through the edits, are properly validated, and NPIs are assigned. But some records require additional validation. NPPES will send the EFIO a downloadable return file indicating the status of each pending record, and the NPIs of those providers enumerated.
C.The entire file is rejected because too many records are deficient. No return file will be generated but the EFIO will receive an e-mail notification that the file was rejected. The EFIO may resubmit the entire file once the errors have been corrected.

STEP 4: NPI application process for individual employees in your organization: (non-EFI process)

• Verify health care provider employee NPI status
• Verify your organizationíon's legal authority to act on behalf of employee health care providers to complete NPI applications and update transactions on their behalf.
• Notify Health Care Providers of Collected Information: ensure
  - that employees are aware of the provider information being collected on the NPI form CMS-10114 from www.cms.hhs.gov/forms
  - that they understand the Penalties for Falsifying Information on the National Provider (NPI)
• Review NPI Application Data
• Ensure all employee data and update information is complete and correct.
• Keeping NPI Documents
  Ask the health care providers to sign a document indicating awareness that the above actions were taken on their behalf, and keeo those documents on file.
• Designate Contact Person for NPI Confirmation

The NPPES sends an e-mail to the organizational Contact Person whose name is on the health care providers NPI application submitted to the NPPES Enumerator over the web. This e-mail is the notification from NPPES that informs the Contact Person of the enumerated health care provider NPI. The Contact Person must forward the NPI notification and the actual NPI to the health care provider.