Medicare Prgram Integrity Manual Chapter 14 - Natinal Prvider Identifier Transmittals fr Chapter 14 Table f Cntents (Rev. 270, 10-05-08) 14.1 - Access t Natinal Plan and Prvider Enumeratin System (NPPES) and Unique Physician Identificatin Number (UPIN) Data 14.2 - Privacy Act Requirements 14.2.1 - NPI 14.2.2 - UPIN 14.2.3 - Adding Physician/Health Care Practitiner/Grup Practice Setting 14.3 - Access t NPI Data 14.3.1 - NPI Registry 14.3.2 - NPI Dwnladable File 14.4 - Access t UPIN Data 14.5 NPIs fr Secndary Prviders 14.7.4 - T-Mail
14.1 - Access t Natinal Plan and Prvider Enumeratin System (NPPES) and Unique Physician Identificatin Number (UPIN) Data With the implementatin f the Natinal Prvider Identifier (NPI), the Centers fr Medicare & Medicaid Services (CMS) discntinued assigning UPINs in June 2007. Effective May 23, 2008, Medicare will use the NPI as bth a primary and secndary identifier. 14.2 - Privacy Act Requirements 14.2.1 - NPI The CMS has established a Privacy Act system f recrds ntice titled the Natinal Plan and Prvider Enumeratin System (NPPES). The primary purpse f the ntice is t cllect infrmatin needed t uniquely identify individual/rganizatinal health care prviders, t assign an NPI t thse health care prviders, t maintain and update the infrmatin abut the health care prviders, and t disseminate health care prvider infrmatin in accrdance with the prvisins f the Privacy Act f 1974. CMS published the NPPES Data Disseminatin ntice n May 30, 2007. In accrdance with the e-foia Amendments, CMS has disclsed these data via the Internet. 14.2.2 - UPIN The CMS has established a Privacy Act system f recrds titled the Unique Physician/Practitiner Identificatin Number (UPIN). The infrmatin in the UPIN database is subject t the prvisins f the Privacy Act. CMS published a system f recrds ntice in the Federal Register n Nvember 15, 2006. This ntice specified the purpse fr cllecting the infrmatin maintained in this system and rutine uses which permit disclsure withut the prir written cnsent f the individual t whm the recrd pertains. 14.2.3 - Adding Physician/Health Care Practitiner/Grup Practice Setting (Rev. 141, Issued: 02-24-06; Effective/Implementatin: N/A) T add a practice setting t an established UPIN (base number), prvide: Recrd Cde "1" in Field 1; The physician/health care practitiner/grup practice prvider number in Field 33, a different lcal PIN fr the new lcatin (Create a new PIN t satisfy this requirement); UPIN in Field 34; Yur carrier number in Field 36; Y in Field 39; and
All ther data elements fr the specific MPIER recrd including the revised infrmatin in the apprpriate fields. 14.3 - Access t NPI Data Infrmatin abut the NPI can be fund at: (1) a query-nly database, knwn as the NPI Registry at https://nppes.cms.hhs.gv/nppes r (2) a NPPES dwnladable file at http://nppesdata.cms.hhs.gv/cms_npi_files.html 14.3.1 - NPI Registry The NPI registry allws users t perfrm simple queries t retrieve read-nly infrmatin frm NPPES. Fr example, users may search by the NPI r legal business name t lcate the NPPES recrds and search fr an individuals r rganizatins. The NPI Registry will return the results f the query t the user, and the user will click n the recrd(s) he/she wants t view. 14.3.2 - NPI Dwnladable File The dwnladable files cntain the data fr health care prviders wh have been assigned NPIs. There is n charge t dwnlad the files cntaining the NPPES FOIA-disclsable health care prvider data. User IDs and passwrds are nt needed t dwnlad these files. 14.4 - Access t UPIN Data T btain a cpy f the UPIN file, cntact CMS directly by writing t: CMS Public Use Files 7500 Security Bulevard, N1-15-03 Baltimre, MD 21244-1850 The fllwing infrmatin is releasable fr physicians and nn-physician practitiners: Full name; Credentials (e.g., MD); UPIN; State; ZIP Cde; and Specialty cde. The UPIN Registry at www.upinregistry.cm will nt be available after May 23, 2008. 14.5 NPIs fr Secndary Prviders
(Rev. 270; Issued: 10-05-08; Effective Date: 05-23-08; Implementatin Date: 09-26-08) When a prvider identifier is reprted n a paper r electrnically submitted Medicare claim t identify an rdering/referring /attending/perating/supervising/purchased service/ther/service facility prvider (in the x12n 837 claims transactins) r prescriber (in the NCPDP 5.1 retail drug claim transactin), that identifier must be an NPI. Fr Medicare purpses, this requirement is effective fr claims received n and after May 23, 2008. If the entity t be identified as the rdering/referring/attending/perating/supervising/purchased service/ther/service facility prvider r prescriber des nt furnish an NPI at the time f the rder/referral/purchase r time f service, the billing prvider must attempt t btain that NPI in rder t use it in the claim. The billing prvider may use the NPI Registry r may need t cntact the rdering/referring/ attending/perating/supervising/purchased service/ther/service facility r prescriber in rder t btain the NPI. While the Implementatin Guides fr the X12N claims transactins permit the reprting f the Scial Security Number (SSN) fr sme secndary prviders if there is n NPI, we d nt believe the billing prvider will be successful in the btaining the SSN. If unable t btain the NPI f the entity t be identified in the service facility lcatin lp (in the X12 N 837 transactin), n identifier shuld be reprted in that lp. If unable t btain the NPI f the rdering/referring/attending/perating/supervising/purchased service/ther r prescriber, the billing prvider (in the X12N 837 transactins) r the service prvider (in the NCPDP 5.1 transactins) shall use its wn NPI t identify thse secndary prviders. Medicare will nt pay these claims if these secndary prviders are nt identified by NPIs. Effective May 23, 2008, the NPI will replace the UPIN as the unique identifier fr all physicians, as defined in 1861 (r) f the Scial Security Act, as well as nurse practitiners, clinical nurse specialists, physician assistants, licensed clinical scial wrkers, clinical psychlgists, and certified nurse midwives. The nly types f prviders eligible t refer/rder services r items fr Medicare beneficiaries are physicians and the nn-physician practitiners mentined abve. 14.7.4 - T-Mail (Rev. 141, Issued: 02-24-06; Effective/Implementatin: N/A) Facilitates the flw f infrmatin between yu and the Registry. It prvides a means t transmit, receive, and file messages. Lengthy, detailed r technical messages can be sent directly instead f thrugh third parties. Messages can be sent regardless f the time difference. The Registry assigns a T-MAIL ID and passwrd. T-MAIL passwrds d nt expire. Hwever, the Registry ccasinally changes passwrds fr security reasns. A menu lists all ptins and expedites transmissin f yur message. T-MAIL displays messages psted t yu and allws yu t send a respnse. If mre than ne T-MAIL message is psted, they are displayed in the sequence they are sent. Yu can select a specific T-MAIL message. They remain n yur menu until yu purge them.
T-MAIL hurs are 4 a.m. - midnight (Pacific Cast Time) Mnday thrugh Friday.
HU HU HU HU Transmittals Issued fr this Chapter Rev # Issue Date Subject Impl Date CR# R270PI 10/15/2008 Reprting Natinal Prvider Identifiers (NPIs) fr 09/26/2008 6093 Secndary Prviders R267PI 09/12/2008 Reprting Natinal Prvider Identifiers (NPIs) fr 09/26/2008 6093 Secndary Prviders Rescinded and replaced by Transmittal 270 R263PI 07/25/2008 The Natinal Prvider and Plan Enumeratin 08/08/2008 6036 System (NPPES) and the Unique Physician Identificatin Number (UPIN) Data R141PI 02/24/2006 Mdificatin t the UPIN Prcess N/A 4191