What is an NPI number and who needs one?
January 23, 2023
Accurate details are key when billing insurance or submitting a superbill for insurance reimbursement. One of the most common reasons health insurers reject claims is an incorrect or missing NPI number. At SuperBill, we hate seeing health insurance claims rejected, so we want to clear up any confusion about who needs an NPI number and why they matter.
First off, what does NPI mean? An NPI number is a unique ten-digit ID number that helps insurers identify U.S. healthcare providers and organizations. NPI numbers are an essential part of any insurance claim.
As a healthcare provider, you may have questions about NPI numbers. Questions like: What is NPI short for? Who needs an NPI number? How do you apply for an NPI number? And what is an NPI number used for? We’ll answer all these and more below.
NPI number meaning
An NPI number, short for National Provider Identifier, is given to every covered healthcare professional in the United States to streamline information transferred between providers, clearinghouses, and insurers.
You can think about NPI numbers like you would social security numbers. The IRS gives each person a unique social security number to more efficiently monitor their tax history. It is attached to you individually to protect your identity, and is used by credit card companies and other financial institutions to identify you.
In the same way, NPI numbers are an identification number used by multiple health care organizations. In addition to the Center for Medicare and Medicaid Services (CMS), all health insurers and healthcare clearinghouses use NPI numbers to process claims. It is impossible to file a successful claim or to bill insurance without an NPI. Meaning medical claims will not be reimbursed if the provider’s NPI number is missing or incorrect.
Who Needs an NPI Number?
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires anyone who transmits patient health information to have a provider NPI. Meaning providers and adjacent healthcare professionals and organizations need an NPI number. And according to the Department of Health and Human Services (HHS’s) 2003 addition to HIPAA, The Security Rule, as patient health data continues to move into electronic systems, HIPAA compliance is more important than ever.
Common HIPAA-covered providers and organizations include:
- Clinical Social Workers
- Speech Language Pathologists
- Lab Testing Clinics
- Pain Management Clinics
- Plastic Surgeons
- Family Physicians
- Lactation Specialists
- Fertility Clinics
- Physical Therapists
- Occupational Therapists
- Massage Therapists
- Physician Assistants
- Registered Nurses
- Nurse Practitioners
Who does not need an NPI number?
According to CMS.gov, any entity that does not meet the definition of a health care provider as defined in 45 CFR 160.103 may not apply for an NPI. This includes:
● Billing services
● Value-added networks
● Health plans
● Health care clearinghouses
● Non-emergency transportation services
Why is HIPAA compliance such a big deal?
HIPAA protects patients’ privacy. If you are not HIPAA-compliant, from a legal standpoint, you are violating your patients’ privacy and could be subject to a lawsuit. For a full list of HIPAA-covered entities, refer to the CMS Are You a Covered Entity? webpage.
Note: even out-of-network providers who do not accept insurance need an NPI number in order to be HIPAA-compliant! Many out-of-network providers support their patients by using SuperBill for insurance reimbursement claims. We make out-of-network benefits easier for your patients to understand and use. If you have an NPI, SuperBill would be happy to handle your patient’s out-of-network claims filing and tracking, as well as handling any denied claims. Read our post on How SuperBill Helps You Acquire New Patients to learn more.
What is an NPI number used for?
To reiterate, an NPI number is used for identification. It’s an ID number for providers that insurers use when they process medical claims. As a provider, you will enter your NPI number anytime you file a claim or generate a superbill. In today’s world of automated electronic claims filing systems, a provider’s entire medical claims history is linked to their NPI number.
NPI numbers are a pretty significant improvement to the insurance billing system. Before the 1996 HIPAA law went into effect, health insurers made their own ID numbers for each provider. Every insurer had its own system of ID numbers, meaning providers had to use a different ID for each insurance plan that processed their claims. After years of headache, the U.S. government established the NPI system we know today.
NPI numbers are consistent no matter what insurance plans you accept. They are as unique and universal as social security numbers, and they last for life.
How to apply for an NPI number
Applying for an NPI number is easy. The online form usually takes fewer than 20 minutes. To apply for an NPI, healthcare providers should go to the National Plan & Provider Enumeration System (NPPES) website and follow the steps below.
- First, make an Identity and Access Management System (I&A) account. Select ‘Create or Manage an Account’ to get started.
- Follow the steps to complete your I&A registration, then return to the NPPES homepage to sign in to your account with your new user ID and password.
- Select ‘Submit a New NPI Application’ to apply. Follow the instructions on screen.
Another option is to apply by mail. To apply with a paper form, read the CMS instructions for mail-in applications.
NPI number example and look-up
The NPPES has a registry where you can look up any registered provider by name or NPI number. To use their NPI look-up, just enter whatever information you have for the provider and click Search. You can search by NPI number, NPI type, taxonomy, name, organization, or address.
From there, select the provider you’re searching for from the list, and you can see a summary of their pertinent information, like the NPI number example below.
Clicking the NPI number link will take you to a page with more information about the provider, including medical license history and additional addresses.
How long does it take to get an NPI number?
According to CMS, online applications for an NPI number should take around 10 days. You may receive the number in fewer than 10 days if the processing center is not too busy. If it takes longer than 15 days, we recommend contacting them to check on your application status.
If you apply by mail, the CMS reports the average wait time is around 20 days. If you mail in your application and wait more than 30 days for your NPI number, contact CMS.
If you are still asking yourself “what is an NPI number going to do for me?” we suggest looking through CMS.gov’s FAQ page. After all, they are the agency in charge of issuing your NPI number, meaning they tend to have the most current information available.
If you already have an NPI number and would like free out-of-network billing assistance, check out SuperPay, a patient payments solution powered by SuperBill. This service gives you and your patients access to all of SuperBill’s claim filing and tracking services for free. We also have some helpful resources for providers on the SuperBill blog, like a guide to CPT and ICD-10 coding.