1.0 BACKGROUND AND PROVISIONS
On January 23, 2004, Health
and Human Services (HHS) published the Final Rule 45 Code of Federal
Regulations (CFR) Part 162, known as “HIPAA Administrative Simplification:
Standard Unique Health Identifier for Health Care Providers,” establishing
the National Provider Identifier (NPI) as the standard unique health
identifier for HCPs (both individuals and organizations). The implementation
specifications contained in the rule shall be met by “covered entities”
which include health plans, clearinghouses, and providers who submit
HIPAA-compliant standard electronic transactions, as defined by
the HIPAA regulations at 45 CFR 160.103. The compliance date for
all covered entities was May 23, 2007.
2.0 PROVIDERS
2.1 HHS defines
a HCP in Section 1861(u) of the Act, 42 United States Code (USC)
1395X(u), as a provider of medical or health services, which is
also defined in section 1861(s) of the Act, 42 USC 1395X(s). Generally,
a provider is a person or organization who furnishes, bills, or
is paid for health care in the normal course of doing business.
2.2 For the
purposes of the applicability of the rule to Defense Health Agency
(DHA), see the TRICARE Policy Manual (TPM),
Chapter 11, Section 1.1, for a listing of
authorized provider types.
2.3 HCPs are defined in two categories
for enumeration purposes:
• Entity Type 1. Individual.
Includes, but is not limited to, those human beings who provide
care such as, physicians, Nurse Practitioners (NPs), dentists, chiropractors,
pharmacists, and Physical Therapists (PTs).
• Entity Type 2. Organizational.
Includes, but is not limited to, non-person providers such as hospitals,
Home Health Agencies (HHAs), clinics, laboratories, suppliers of
Durable Medical Equipment (DME), pharmacies, and groups.
2.4 Foreign
Providers
2.4.1 A foreign provider is defined
as a provider who is not a citizen of the United States (US), regardless
of the country in which the provider is practicing.
2.4.1.1 Foreign providers may be authorized
TRICARE providers, however, they are not required to obtain an NPI
(due to limited ability to comply with the application requirements),
but may choose to do so voluntarily.
2.4.1.2 Electronic transactions (e.g.,
claims transactions) submitted by foreign providers for adjudication
may be submitted using legacy identifiers for provider identification
purposes; however, if a foreign provider obtains an NPI, they are
encouraged to use the NPI as the primary provider identifier on
the electronic transaction.
2.4.2 Providers
who are citizens of the US, practicing outside the 50 US and the
District of Columbia. (e.g., Puerto Rico), are not considered to
be foreign providers.
2.4.2.1 If the provider practicing
outside the 50 US and the District of Columbia is a US citizen and
meets the HHS definition of a covered entity, the provider is required
to obtain an NPI for the submission of HIPAA-compliant electronic
standard transactions and comply with the Final Rule.
2.4.2.2 Electronic transactions submitted
by “covered entities”, who are US citizens, that are not HIPAA- compliant
shall be denied as appropriate.
2.5 Subpart
Enumeration
2.5.1 Subpart enumeration is the
responsibility of the organizational provider.
2.5.2 In accordance
with the Final Rule, organizational providers will determine to
what extent subpart enumeration is required and identify which of
the subparts, if any, of their organizational entity will be identified
via a separate enumerator.
2.5.3 The organizational
provider will also determine how the various enumerators obtained
will be used for billing purposes.
3.0 CONTRACTOR
RESPONSIBILITIES
3.1 The contractor shall comply
with provisions of the HIPAA Final Rule for HIPAA Administrative Simplification:
Standard Unique Health Identifier for HCPs Final Rule.
3.2 The contractor
shall accept National Provider Identifiers (NPIs) when submitted
by providers and use the NPI as the primary identifier to identify
HCPs in all HIPAA-compliant electronic standard transactions in
accordance with the transaction Implementation Guide.
3.3 The contractor
shall deny all claims transactions that do not meet the requirements
of the Final Rule.
3.4 Since the National Uniform
Billing Committee (NUBC) and the National Uniform Claims Committee (NUCC)
have modified the Centers for Medicare and Medicaid Services (CMS)
1450 UB-04 and the CMS 1500 Claim Form to accommodate the use of
the NPI on the paper forms.
3.5 The contractor
shall accept and use the NPI if submitted on the paper form for
provider identification and claims adjudication.
3.6 The contractor
shall verify NPIs using the check digit algorithm in accordance
with the Final Rule, 45 CFR Part 162.
3.7 The contractor
shall maintain the NPI in their internal provider file. Upon direction
of the Contracting Office (CO) and future revision of the TRICARE
Systems Manual (TSM),
Chapter 2 to
address the NPI requirements for the TRICARE Encounter Provider
(TEPRV) records and TRICARE Encounter Data (TED) record.
3.8 The contractor
shall create and submit to DHA a new TEPRV record when a provider
submits their NPI to the contractor.
• Type 1 NPI for professional
providers.
• Type 2 NPI for organizational
providers.
• Type 2 NPI for subparts of
organizational providers that have been separately enumerated, e.g.,
different NPIs for different departments within an institution,
the contractor shall list the Type 2 NPI for each subpart identified
by the provider.
3.9 Covered
Individual (Type 1) HCPs
3.9.1 The contractor shall ensure
that HIPAA transactions received identify the provider’s NPI on
all HIPAA-compliant electronic standard transactions in accordance
with the Implementation Guide for the transaction.
3.9.2 The contractor
shall ensure electronic transactions submitted by business associates
of the individual provider use their NPIs and NPIs of other HCPs
and subparts appropriately for the submission of HIPAA-compliant electronic
standard transactions in accordance with the Implementation Guide
for the Transaction.
3.10 Covered
Organizational (Type 2) HCPs
3.10.1 The contractor shall ensure
that transactions submitted by the organizational entity or its
subparts use the NPI on HIPAA-compliant electronic standard transactions.
3.10.2 The contractor shall ensure
that transactions submitted by the organizational subparts comply
with the NPI implementation specifications.
3.10.3 The contractor shall ensure
that business associates of the organizational entity or its subparts
use their NPIs and NPIs of other HCPs and subparts appropriately
for the submission of HIPAA-compliant electronic standard transactions.
3.11 Application
Of NPI To TRICARE Processes And Systems
3.11.1 The contractor shall use the
NPI as the primary provider identifier for all TRICARE authorized
providers who meet the HHS definition of “covered entities” and
submit HIPAA-compliant electronic standard transactions.
3.11.2 The contractor shall also accept
the NPI as the primary identifier on paper claims from providers.
3.11.3 The contractor shall use the
NPI, as appropriate, for the identification of providers in the
Defense Enrollment and Eligibility Reporting System (DEERS).
3.11.4 Upon direction of the CO and
future revision of the TSM,
Chapter 2,
the NPI shall be used as the primary provider identifier for TEPRV
and TED records, for HCPs who meet the HHS definition of covered
entity and submit HIPAA-compliant electronic standard transactions.
The NPI will also be used as the primary provider identifier on the
TEPRV and TED record for providers who obtain an NPI and submit
paper claim forms.
3.11.5 TED records will identify both
the individual or organizational provider NPI as appropriate. For providers
who are part of a group or clinic practice, the TED record will
reflect the NPI for the group or clinic as well as the NPI of the
individual provider. TED records submitted for Institutional claims
shall include the NPI for the Organizational (Type 2) entity. Individual
NPIs shall not be submitted on institutional TED records.
3.11.6 NPI shall be used for the identification
of providers on referrals and authorizations as appropriate.
3.12 NPI
Usage In HIPAA Adopted Standard Transactions
3.12.1 The contractor shall collect,
use, and retain NPI’s for activities such as the processing and
resolution of claims, duplicate claims identification, medical utilization,
fraud investigation, third party claim submissions and claim reporting.
• Accredited Standards Committee
(ASC) X12N 837 - Health Care Claim: Professional, Institutional,
Dental. The NPI shall be employed in accordance with the usage specifications
of the HIPAA Implementation Guide, guide addenda or errata, and
any companion documents.
• ASC X12N 270/271 - Health Care
Eligibility Benefit Inquiry and Response. The NPI shall be employed
in accordance with the usage specifications of the HIPAA Implementation
Guide, guide addenda or errata, and any companion documents. DEERS
will capture and maintain the NPI for individual providers to facilitate Health
Care Eligibility Inquiry and Response transactions and has the capability
to capture and maintain the NPI for organizational providers.
• ASC X12N 278 - Health Care
Services Review - Request for Review and Response. The NPI shall
be employed in accordance with the usage specifications of the HIPAA
Implementation Guide, guide addenda or errata, and any companion
documents.
• ASC X12N 276/277 - Health Care
Claims Status Request and Response. The NPI shall be employed in
accordance with the usage specifications of the HIPAA Implementation
Guide, its addend, errata, and any companion documents. When required,
the NPI shall be used in the electronic standard exchange between
entities requesting health care claim status, organizations sending
the health care claim status response and other business partners
affiliated with the health care claim status request and response.
• ASC X12N 834 - Benefit Enrollment
and Maintenance. DMDC will modify Government furnished web-based system/application
to include the NPI where appropriate and in compliance with the
HIPAA Implementation Guide, its addenda, errata, and any companion
documents.
• ASC X12N 835 - Health Care
Claim Payment/Advice. The NPI shall be submitted in accordance with
the usage specifications of the HIPAA Implementation Guide, its
addenda, errata, and any companion documents. The NPI will be used
when communicating the status of a health care claim payment.
• National Council for Prescription
Drug Program (NCPDP) latest HIPAA adopted version. This NCPDP transaction and
the latest HIPAA adopted NCPDP Batch Standard version may be used
for eligibility checking as well as for claims-related transmissions.
3.12.2 The contractor shall utilize
the NPI and any other pertinent identifiers to correctly credit
and debit the provider.
3.12.3 The contractor shall utilize
the NPI in the transaction as defined in NCPDP guidance for the implementation
and use of the transactions. For retail pharmacy, the contractor
shall comply with the standards adopted in the implementation specifications,
as directed in current HIPAA adopted Final Rules.
3.12.4 The contractor shall modify
Companion Guides to provide specific guidance with regard to the
NPI and its corresponding entity type code for use as the primary
provider identifier, as appropriate.
3.13 Web
Server Technology
3.13.1 The contractor may choose to
utilize the NPI for other provider identification purposes, at no
cost to the Government and at their own discretion, on contractor
developed and maintained web applications.
3.13.2 However, this is not to be
construed as instruction from DHA to develop, operate, modify, or
maintain contractor web applications.
3.13.3 Use of the NPI on contractor
web applications shall be in accordance with the requirements of
the HIPAA Final Rules.