Quality Reviews and NPI Data

Check an NPI number

Frequently Asked Questions

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What’s an NPI?

An NPI is a 10-digit numeric identifier. It doesn’t carry information about you, such as the state where you practice, your provider type, or your specialization. Your NPI won’t change, even if your name, address, taxonomy, or other information changes.

In HIPAA standard transactions, providers must use the NPI in place of other provider identifiers, such as a Provider Transaction Access Number (PTAN), Quality Improvement Evaluation System (QIES), Certification and Survey Provider Enhanced Reporting (CASPER), and National Supplier Clearinghouse (NSC).

Who May Get an NPI?

All health care providers (physicians, suppliers, hospitals, and others) may get an NPI. Health care providers are individuals or organizations that render health care as defined in 45 Code of Federal Regulations (CFR) 160.103.

Who May Not Get an NPI?

Any entity that doesn’t meet the definition of a health care provider as defined in 45 CFR 160.103 may not apply for an NPI. Such entities include billing services, value-added networks, repricers, health plans, health care clearinghouses, non-emergency transportation services, and others.

Do You Need an NPI to Enroll in Medicare?

Yes. If you apply for enrollment in Medicare, you must have an NPI and put it on your enrollment application. The NPI Enumerator will reject enrollment applications without an NPI.

What are the Health Care Provider NPI Categories?

Two categories of health care providers exist for NPI enumeration purposes: Entity Type 1 (Individual) and Entity Type 2 (Organization).

Who Must Get an NPI?

All health care providers who are HIPAA-covered entities, whether individuals or organizations, must get an NPI. A HIPAA-covered entity is a:

  • Health care provider that conducts certain transactions in electronic form
  • Health care clearinghouse
  • Health plan (including commercial plans, Medicare, and Medicaid)
Under HIPAA, you’re a covered health care provider if you electronically transmit health information in connection with a HIPAA standard transaction, even if you use a business associate to do so.

Who is considered a Health Care Provider/Practitioner?

Under federal regulations, a "health care provider" is defined as: a doctor of medicine or osteopathy, podiatrist, dentist, chiropractor, clinical psychologist, optometrist, nurse practitioner, nurse-midwife, or a clinical social worker who is authorized to practice by the State and performing within the scope of their practice as defined by State law, or a Christian Science practitioner. A health care provider also is any provider from whom the University or the employee's group health plan will accept medical certification to substantiate a claim for benefits.