The NPI is a 10-digit identifier lacking personal details like state, provider type, or specialization. It remains constant despite information updates. Providers replace other identifiers like PTAN, QIES, CASPER, and NSC in HIPAA transactions with the NPI.
Who Needs an NPI?
Every HIPAA-covered entity, individual, or organization must obtain an NPI. Covered entities include healthcare providers, clearinghouses, and health plans. You're considered a covered healthcare provider if you electronically transmit health information for HIPAA transactions, even through a business associate.
What are Health Care Provider NPI Categories?
NPI enumeration categorizes healthcare providers into Entity Type 1 (Individual) and Entity Type 2 (Organization). Entity Type 1: Individual providers, including sole proprietors, obtain NPIs. Sole proprietors apply using their SSN, regardless of having an EIN. Each sole proprietor gets one NPI, unaffected by factors like office locations or employees. Incorporated individuals conduct business under a corporation, distinct from sole proprietors. Being a solo practitioner doesn't necessarily imply sole proprietorship, and vice versa. Entity Type 2: Organization providers with varying employee numbers receive NPIs. Even if an incorporated individual is the sole employee, they're considered an organization. Some organization providers have subparts operating semi-independently, offering diverse healthcare services or in separate locations. Subparts aren't legal entities but are part of the organization. They can obtain their NPIs if conducting individual HIPAA transactions. This ensures unique identification in transactions. For instance, a hospital's acute care, laboratory, pharmacy, and rehabilitation services may each require individual NPIs for transactions with health plans.
