Obtaining a National Provider Identifier (NPI) number is to have a lot on your plate as an individual medical professional or healthcare organization.

As a healthcare provider, you are required to use your NPI number for administrative and financial transactions.

An NPI is used as your unique identity that will make it easy for payers to identify you, or your practice during claims and payment processing.

For example, a medical facility or an individual provider can submit a claim for billing the services and provide the NPI number for its identity. The payer will recognize the facility/individual and issue the payments according to the given details in the submitted claim.

If you are a new medical facility or opt to work as a solo physician anywhere in the US, then you must get an NPI number to send your healthcare data safely and quickly to receive payments for medical services you offer to your patients.

We will help you through this systematic guide to apply for a national identifier number.

What is A National Provider Identifier (NPI) Number?

National Provider Identifier or NPI is a 10-digit number given to healthcare providers and organizations in America by the government agency that runs Medicare (called the CMS). Any doctor, nurse or therapist who has to follow privacy laws called HIPAA and wants to bill Medicare for treating patients must have an NPI. This alphanumeric number stays the same over time and is meant to identify a person or place that gives healthcare. An NPI can go to someone who works at their own office, a hospital or fills in for other doctors. Groups such as clinics, pharmacies, schools and hospitals can also ask for NPI numbers.

Historical Background of NPI

The CMS published the NPI final rule on 23 January 2004 and mandated the providers to obtain an individual NPI by May 6, 2013.

According to CMS.gov, healthcare providers might use other means for their transactions like Provider Transaction Access Number (PTAN), Quality Improvement Evaluation System (QIES), Certification and Survey Provider Enhanced Reporting (CASPER), and National Supplier Clearinghouse (NSC).

However, the authority strongly recommends that medical professionals and providers use only their NPIs for HIPAA-covered transactions to get cash in their pockets without any setbacks.

The unique NPI number helps easily identify the providers during the billing process e.g. in claim processing and the transfer of the payments to the right entities.

Types of National Provider Identifier (NPI)

The National Identifier Number is categorized into two types according to the nature of the healthcare provider, whether a provider is offering its services as an individual or as an organization. These NPI types are: 

• NPI Type 1
• NPI Type 2

NPI-1

The NPI type-1 is issued to individual healthcare providers who are working as an independent and solo physician.

For example, a solo physician can apply for an NPI number to show their identity to the payers to receive payments.

The individual providers who can apply for NPI are:

• Medical Officers
• Gynecologists
• Physical Therapists
• Chiropractors 
• Psychiatrists 
• Pharmacists
• Physicians
• Nurses
• Radiologists, etc.

NPI-2

The Type-2 NPI also referred to as organizational NPI number is for group healthcare organizations that have multiple specialty doctors delivering their services under one roof or identified as an organization’s employees.

For example, in a hospital, a cardiologist sees patients with heart diseases, a physical therapist checks the patients with physical illnesses and a radiologist works for diagnosis.

They all owe allegiance to that hospital and receive the cost of services they provide to the patients.

In this case, the hospital will apply for NPI Type 2 as a main entity.

The CMS issues organizational NPI to the group providers like:

• Hospitals
• Small Practices
• Laboratories
• Residential treatment centers
• Durable Medical Equipment (DME) suppliers
• Health Maintenance Organizations (HMOs)
• Group Practices
• Home Health Agencies etc.

➜ NOTE: Remember your entity while submitting your details in the application form. Because there are two separate sections for both entities in the form. For example, if you are a solo physician, you will provide the required information and details as an individual. On the other hand, if you are applying as an organization, like a hospital, provide your relevant information and requirements as an organization while filling out the application form for NPI.

How to Apply for a National Provider Identifier?

Having an NPI number is one of the core responsibilities of a healthcare provider in the US, who wants to put their revenue cycle in motion. It helps the provider navigate the bottlenecks that hinder the workflow during claim processing and payment collection. This is because a payer may reject a provider’s claim request due to a missing or incorrect NPI number.

Since having an NPI officially issued by CMS is the need of the hour. So here is the step-by-step guide to having your NPI:

Step #1: Meet the Requirements to Fill the Application Form

Before applying for an NPI number, you must have to fulfill the requirements that are of utmost importance. For example, why are you applying for an NPI, your information, addresses, and others?

Here is a detail of the requirements that you are required to provide to the payers before applying for an NPI number:

1. Reason for Obtaining NPI

Your goals or reasons may be that you need to submit the claims and receive payments from Medicare or Medicaid and/or you are required to transmit your medical information to other HIPAA-covered payers.

You must have a reason to owe a National Identifier Number. For example, if you are a solo practitioner or an organization and submit medical claims to the payers, then you need an NPI which is why you are applying.

Furthermore, if you are even a medical student, intern, or any other medical professional and need HIPAA-covered transactions, then this may be another reason to get your NPI for successful transactions.

Therefore, in whatever category you fall, you will justify acquiring an NPI number.

2. Accurate SSN and ITIN

Providing the correct social security number (SSN) and/or your Taxpayer Identification Number (ITIN) is mandatory to receive an NPI number.

This information confirms that you are a country/state resident or citizen in the USA and helps CMS issue the NPI number.

3. Organizational/Individual Details

If you are running a small or large-scale medical practice, a hospital, or working as a solo provider, you have to provide the details, like name, location, and Employer identification number (EIN).

These details will allow CMS to recognize the existence and nature of your organization.

4. 10 Digit Taxonomy Code

A 10-digit taxonomy code is the identity of your practice or hospital. It tells about the type, category, and area of specialization.

This code will confirm that you are an active healthcare provider delivering medical services in your specific area of specialization.

After having all the above-mentioned requirements on the table, you will then proceed to the next phase to apply for an NPI number.

To get this job done, you may choose and go with one of three procedures as follows:

• Apply online on the National Plan and Provider Enumeration System’s website
• Apply manually using paper CMS-10114 Form
• Apply on behalf of the Electronic File Interchange (EFI) organization

Step #2: Apply Online on the National Plan and Provider Enumeration System NPPES website.

The first way to apply and obtain your National Identifier Number is through the National Plan and Provider Enumeration System NPPES website.

We recommend you use this method. It is a secure, easy, and smooth way to input your details and get an NPI number.

Additionally, you will receive the NPI quickly without any delays. Follow these steps to obtain and access NPI using the NPPES website:

Step #3: Apply Manually Using Paper CMS-10114 Form

If you are going to use the manual way to submit your application to acquire your NPI number, you will use a manual for entering your required details manually.

CMS provides a manual form to providers to complete their application. This form is known as CMS Form 10114.

The official CMS Form 10114 contains five sections with instructions outlined in it for guidelines. You must follow the instructions to fill the form with accurate information. 

Here is the breakdown of each section on CMS Form 10114 used for the manual NPI registration process:

• SECTION 1
• SECTION 2 
• SECTION 3
• SECTION 4
• SECTION 5

SECTION 1: Basic Information

In section 1 of the CMS Form 10114, you are required to provide your basic personal information.

• In Part A, mention the reason for your application. If you are applying for the first time, you will tick the initial application checkbox. The remaining three fields are related to change of information, deactivation, and reactivation respectively.
• In Part B of Section 1, specify your entity for example you are an organization or an individual provider.

SECTION 2: Identifying Information

Section 2 is dedicated to providing further details about an entity.

• Part A asks for individual provider details, you will provide name details, SSN, and ITIN.
• Part B is for organizations where it requires organization identity details with EIN.

*Do not provide SSN No in the EIN field.

SECTION 3: Business Addresses and Other Information

In Section 3 of CMS Form 10114, you are required the details of your business such as address, location, ZIP codes, Medicaid or Non Medicare ID No, etc.

• Part A requires mailing addresses
• Part B is for practice location (address)
• Part C asks for other provider information like Medicaid or Non-Medicare ID No.
• Part D is for the provider taxonomy number or license number. 

*Do not provide SSN, ITIN, or EIN in this section.

SECTION 4: Certification Statement

The Section 4 in CMS for 10114 requires the provider’s certifications and authorizations:

• Part A is specified for individual providers, where he will provide his name with signatures and date. 
• Part B is for organizations, where they will provide their basic information, authorized signature, and date.

💡 Remember ➜ The physicians cannot bill their services without completing their credentialing process. In addition, they are unable to complete their transactions using the NPI of another provider until they are credentialed. Some Medicaid programs and private insurance companies allow providers during the ongoing credentialing process, in case the payer directly verifies this.

SECTION 5: Contact Person

Section 5 in the CMS Form 10114 is given for the information about the contact person. This can be a provider head of an organization or an authorized person who manages your practice’s matters.

You need to provide the information in this section:

• Contact person’s name
• Designation/Position 
• Contact number
• E-mail address etc.

💡 Get NPI Manually ➜ Contact NPI Enumerator at 800-465-3203 or send an email to customerservice@npienumerator.com to get a hard copy at your mailing address.

STEP #4: Apply on Behalf of the Electronic File Interchange (EFI) Organization

The Electronic File Interchange (EFI) system allows authorized organizations to submit National Provider Identifier (NPI) application forms on a healthcare provider’s behalf. These organizations are called Electronic File Interchange Organizations (EFIOs). They receive official approval from the Centers for Medicare and Medicaid Services (CMS) and the NPI Enumerator by submitting a certification statement.

Once approved, the provider gives the EFIO the required information to apply for an NPI. The EFIO then uses the same procedures to submit NPI applications, like the National Plan and Provider Enumeration System (NPPES) website or CMS Form 10114. By using EFI or contacting the NPI Enumerator directly, the EFIO sends the application and obtains the NPI number for the provider’s practice.

Finally, you receive your NPI number on behalf of an EFIO. 

Conclusion

National Identifier Number is essential for healthcare providers to ensure smooth and fast transactions of their payments. This helps them avoid the unnecessary wait times in transaction process and allows receiving the payments for their claims on time.

The providers can apply for NPI numbers using three ways, which we have discussed in detail in the blog.

These are:

• Apply online on the NPPES website
• Apply manually using the CMS-10114 Form
• Apply on behalf of an EFI organization

*We recommend you use the online process via the NPPES website. This is the fast and secure way to get your NPI number from CMS.