Recently, CMS published a final rule that requires prescribers who are not covered entities themselves to obtain an individual (Entity Type 1) National Provider Identifier (NPI) and disclose it when needed for a pharmacy claim. This is pursuant to certain relationships prescribers have with covered organization health care providers such as hospitals and group practices. Covered organization health care providers must direct prescribers to obtain an individual NPI by May 6, 2013. This means that virtually all prescribers must now obtain an individual NPI (Entity Type 1).
Just so you know the NPI is free of charge. It only takes approximately twenty (20) minutes to complete the application, and the NPI can be obtained online at https://nppes.cms.hhs.gov/NPPES/Welcome.do. You can also obtain an NPI via paper application. The paper NPI Application/Update Form (CMS-10114) can be downloaded and printed at http://glossary.guide/wp-content/uploads/2020/06/CMS-10114-12-19-18.pdf The vast majority of prescribers already have individual (Entity Type 1) NPIs. However, if you are one of the few prescribers who do not, you are required to obtain an individual NPI unless a very narrow exception applies to you, such as you are a health care provider in sole practice who accepts only cash for payment. Please keep in mind that failure to obtain an NPI may be considered an act of non-compliance with the NPI regulation by you or an organization covered health care provider (e.g., hospital or group practice) with which you have an employment, contractual, or member relationship. A complaint may be filed against covered entities that do not comply with this rule.
The vast majority of prescribers already have individual (Entity Type 1) NPIs. However, if you are one of the few prescribers who do not, you are required to obtain an individual NPI unless a very narrow exception applies to you, such as you are a health care provider in sole practice who accepts only cash for payment. Please keep in mind that failure to obtain an NPI may be considered an act of non-compliance with the NPI regulation by you or an organization covered health care provider (e.g., hospital or group practice) with which you have an employment, contractual, or member relationship. A complaint may be filed against covered entities that do not comply with this rule.
For those prescribers who already have an individual (Entity Type 1) NPI, please be sure to keep your NPI information up-to-date to ensure that the data reflects current and correct information. Covered health care providers (including prescribers) are required to update their NPI information within 30 days of the effective date of the change. Failure to provide updated information may be considered an act of non-compliance with the NPI Final Rule, and a complaint may be filed against covered health care providers who do not comply with this provision of the final rule.
Most updates and changes to NPI information can be made by health care providers over the web. If you applied on paper, you can submit updates or changes over the web by creating an account. Access the NPPES record at https://nppes.cms.hhs.gov/NPPES/Welcome.do, follow the NPI hyperlink and select Login. The user will be prompted to enter the User ID and password that he/she previously created.
If the health care provider has forgotten the password, enter the User ID and click the “Reset Forgotten Password” button to navigate to the Reset Password Page. If the health care provider enters an incorrect User ID and Password combination three times, the User ID will be disabled. Please contact the NPI Enumerator at 1-800-465-3203 if the account is disabled or if the health care provider has forgotten the User ID.
You can also obtain an NPI or submit changes to your NPI information via paper application. The paper NPI Application/Update Form (CMS-10114) can be downloaded and printed at http://glossary.guide/wp-content/uploads/2020/06/CMS-10114-12-19-18.pdf
As part of meeting the requirement to update information in NPPES, you should check that the taxonomy you selected in NPPES still correctly describes you as a health care provider. There is increased focus on the NPI as a health care provider identifier, particularly for oversight purposes, and certain NPPES data is available to the public (see further below for more information) and is used for research purposes. If you obtained an NPI while a student and properly selected “student” taxonomy and then later become a full licensed provider without updating the taxonomy, then your NPI information is not updated and accurate as required by the NPI Final Rule. Similarly, if prior to becoming a licensed physician, you were a health care paraprofessional, and properly selected a taxonomy code to reflect your paraprofession, this taxonomy would not be updated and accurate as required, if you are currently practicing as a physician. Moreover, an analysis of the data in NPPES may characterize you as a student or paraprofessional when this is no longer accurate and lead to unnecessary inquiries about your credentials in light of your current health care practice.
If a health care provider wishes to just view his or her NPPES information as is available to the public before logging in to the NPPES website, you may do so by accessing the NPI Registry at https://nppes.cms.hhs.gov/NPPES/NPIRegistryHome.do. The NPI Registry gives the health care provider an online view of Freedom of Information Act (FOIA)-disclosable NPPES data. The health care provider can search for its information using the name or NPI as the criterion. Information regarding NPPES data that are FOIA-disclosable can be found at http://www.cms.hhs.gov/NationalProvIdentStand/ by selecting ‘Data Dissemination’.
Please note: Business Mailing Address and Business Practice location information (full address and corresponding telephone numbers) are key data elements that are FOIA-disclosable. Health care providers should not report their residential address unless it is their Business Mailing Address or Business Practice Location. The NPPES data appearing on the NPI Registry cannot be deleted; however, it can be updated or changed.
The NPI Enumerator can assist you with the following topics:
Health care providers needing this type of assistance may contact the NPI Enumerator at 1-800-465-3203, TTY 1-800-692-2326, or email the request to the NPI Enumerator at CustomerService@NPIenumerator.com. For general information regarding the NPI, please review the NPI Booklet at http://glossary.guide/wp-content/uploads/2020/06/NPI-Booklet.pdf
Remember: Getting an NPI is free – not having one can be costly
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