National Provider Identifier (NPI)
The information contained in this page is not intended as legal advice. It is a general description of prohibitions and permissions. For rulings on specific circumstances, individual legal counsel should be sought. ASHA does not and cannot offer legal counsel.
The Health Insurance Portability and Accountability Act (HIPAA) established a simplification standard for claims processing known as the National Provider Identifier (NPI). Clinicians do not need to be HIPAA-covered entities to obtain an NPI, but HIPAA-covered entities must obtain an NPI. NPIs are now required on all claims and are recommended for use on superbills so that patients can successfully submit claims to their health insurer for out-of-network reimbursement. The Centers for Medicare and Medicaid (CMS) NPI Enumerator manages the NPI system. For questions about NPIs or applications, contact the NPI Enumerator. ASHA cannot provide direct assistance managing a provider’s NPI account. A provider can find their own NPI number, or an individual can search for a provider’s NPI number here.
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National Provider Identifier (NPI) Overview
HIPAA legislation initiated the National Provider Identifier (NPI) standard; this legislation requires that all HIPAA-covered entities obtain NPIs. Some individuals who are not HIPAA-covered entities also choose to obtain an NPI. An NPI is a 10-digit number that is assigned to an individual or a business entity used for billing purposes. It is different from a state license—note that providers must also maintain a state license in order to legally practice. Once an individual obtains an NPI, this identifier remains the same even if the individual’s name, taxonomy, address, license, or other information changes. The NPI does not indicate your provider type, specialty, or state where you practice. The purpose of the NPI system is to create a standard provider identifier system that can be used across payers. Obtaining an NPI does not enroll you with any health insurance companies but can be used for enrollment. Since the act was established, NPI has become a common billing requirement for both in-network and out-of-network billing. It is generally recommended that all providers obtain an NPI. All health care providers or organizations can obtain an NPI as defined in Title 45 Code of Federal Regulations (CFR) Section 160.103.
There are two different types of NPI numbers:
- Entity Type 1: For individual health care providers
- Entity Type 2: For organization or group health care providers
The Type 1 NPI represents an individual provider and is required on all claims to indicate the individual who rendered the service. The Type 2 NPI represents a health care business or organization and can be used for billing purposes. A Type 2 NPI directs the reimbursement monies to the business rather than to the individual provider. Sole proprietors can use their personal Type 1 NPI for billing purposes but have the option of also obtaining a Type 2 NPI that represents the practice/business. For practices that take insurance of any type, all rendering providers still need to be credentialed with payers under their personal Type 1 NPI but can bill under the practice Type 2 NPI once enrolled. Some inpatient settings do not require all individual providers to be credentialed with the payers under their Type 1 NPI, but this varies, so providers should follow the guidance of their facility management. CMS provides helpful background information about NPI and general guidance regarding its uses and types.
Applying for and Managing Your NPI
CMS provides a helpful resource titled, NPI: What You Need to Know [PDF]. The NPPES Provider Info page includes a step-by-step guide and indicates all the information that providers and organizations need to complete the application. There are three ways to apply for an NPI:
- Apply online through the National Plan and Provider Enumeration System (NPPES). Individual providers should first create a username and password through the Identity & Access Management (I&A) System and then log in to NPPES using that username and password.
- Send a paper application using Form CMS-10114, NPI Application/Update Form. The mailing address is listed on the form. The NPI Enumerator will provide a printed copy if providers contact them directly by phone at 800-465-3203 or TTY 800-692-2326, or providers can send an email to customerservice@npienumerator.com.
- Work with an Electronic File Interchange Organization (EFIO) to send application data through a bulk enumeration process.
The NPPES FAQs page offers guidance on a number of frequently asked questions about NPI applications and management.
Protecting Your NPI: Supervision and Credentialing
Once you have received an NPI, you can create a log-in to manage your NPI profile and monitor use of your NPI. It is important to remember that your Type 1 NPI represents you as an individual provider and should not be used by other parties unless a payer gives explicit permission. Even when someone is under supervision, most payers do not allow their services to be billed under someone else’s NPI—so, it is important to check the payer’s policies about billing another clinician under your NPI. This is often called “incident to” billing or “billing under the direction of” another provider. Medicaid and private insurance policies are highly variable, so it is important to check with them directly. Medicare does not allow clinicians in outpatient settings to bill under the direction of an audiologist or speech-language pathologist (SLP) supervisor unless they are providing 100% over-the-shoulder supervision. For more information on considerations for billing when supervising another clinician, see the ASHA webpage on Supervision.
When practices are credentialing new clinicians with their insurance payers, it is important to follow the payer’s requirements for billing during the credentialing process. Medicare does not allow clinicians to bill services until their credentialing process is completed, and they cannot bill under the NPI of another provider during this time. Some Medicaid programs and private insurance payers may allow clinicians to provide services during the credentialing process, but this should be verified with the payer directly. The credentialing contract usually indicates how billing should be managed during the credentialing process. This contract is a legal document, and providers are obligated to follow all procedures outlined in the contract. Billing other providers’ services under your NPI without permission from the payer can be considered fraudulent billing. It is vital to follow all payer requirements and ensure that your NPI is always used appropriately.
