Understanding the National Provider Identifier
We're here to help you understand the National Provider Identifier (NPI) process. Here are some guidelines and information about the regulation and its requirements.
About the NPI
Every health care provider transmitting health information in connection with a standard transaction in electronic form must obtain an NPI. An NPI is required by HIPAA for electronic transactions.
- 10-digit numbers unique to each health care provider or organization.
- Random numbers that contain no coded information about the provider or organization.
- Permanent identifiers that do not change over time or expire.
- A replacement for other identifying numbers currently used in electronic transactions, such as the Medicaid, Blue Cross and Blue Shield, UPIN, CHAMPUS and other certain "legacy" numbers.
- Not a replacement for social security numbers, DEA numbers, taxpayer ID numbers, taxonomy (specialty) numbers or state license numbers.
- Issued by the government through a third-party group, the National Plan & Provider Enumeration System (NPPES), which is responsible for processing applications and assigning numbers.
All individual health care providers (including dentists) and organizations such as clinics and group practices are eligible to obtain an NPI.
Who Needs an NPI?
If you answer "yes" to any one of the following questions, you are considered a "covered entity" under the NPI standard and are required by federal law to obtain an NPI.
- Do you submit claims electronically?
- Do you use a clearinghouse?
- Do you submit claims attachments electronically?
- Do you use the Internet to verify eligibility or check on the status of claims?
Value to You and Your Practice
- One simple identifier eliminates the need to maintain and match identification numbers to specific payers for transactions.
- Allows you to relocate your practice or change specialties without requiring new identifiers from multiple payers.
- Helps reduce costs and simplify health care transactions.
The Application Process
- Visit https://nppes.cms.hhs.gov
- Complete the application and follow instructions to submit either online or by mail. Faxes are not accepted.
- After confirmation of the receipt of your application, you should receive your NPI via e-mail within one to five business days if you submitted the application online. Mailed applications may require up to 20 days to process.
Report Your NPI to Delta Dental
- Check with your local Delta Dental member company and ask how they prefer to receive it. (Simply submitting it on a claim will not ensure that it's entered into our system.)
- Once you've reported your NPI, you can begin using it on claims.
- Use new claim forms that accommodate the NPI by providing a specific space for the NPI. (This might require you to upgrade your software.)
If any data related to your NPI changes (name, address, etc.), you are responsible for submitting an update to the NPPES within 30 days of the change.
Type 1 or Type 2 — which NPI is right for you?
There are two types of NPIs: Type 1, for individual health care providers, such as dentists and hygienists, and Type 2 for incorporated businesses, such as group practices and clinics.
- Type 1 is for the provider. This is the only type of NPI you will need if you receive payments in your name or under your social security number as a solo practitioner. For practices with multiple dentists, obtain a Type 1 NPI for each dentist.
- Type 2 is for group practices, incorporated dental practices or other business entities paid under their business or corporate name, or under their employer identification number (EIN).
On claims, the Type 2 NPI identifies the payee, and may be submitted in conjunction with a Type 1 NPI to identify the dentist who provided the treatment. For example, on a standard ADA Dental Claim Form (#J400), the treating dentist's NPI is entered in field 54 and the billing entity's NPI is entered in field 49.
Do You Need Type 1, Type 2, or Both?
|Practice Type||NPI Type|
|Solo practitioner||Type 1 only, if claims are transmitted in the dentist's name and social security number.|
|Individual dentist at one practice location||Type 1 for the dentist and Type 2 for the practice, if claims are transmitted in the practice's name and Tax Identification Number (TIN)|
|Multiple dentists, one practice location||Type 1 for each dentist and Type 2 for the practice, if claims are transmitted in the practice's name and TIN|
|Multiple dentists, multiple practices||Type 1 for each dentist and Type 2 for each practice with a separate TIN|
Frequently Asked Questions
I submit paper claims and don't use the Internet to check patient eligibility and benefits. Do I still need an NPI?
If you don't conduct any electronic transactions governed by HIPAA, you aren't required to obtain an NPI. However, we strongly encourage you to get one, because you can use it as a single unique identifier with all payers.
How is the NPI determined?
NPIs are issued by the National Plan & Provider Enumeration System (NPPES). The NPI contains no embedded intelligence — no coding that would identify the dentist's state or license number, for example. It is simply a random number that does not expire.
How will the NPI affect other numbers I've used in the past?
The NPI replaces other identifying numbers used in electronic transactions, such as:
- Blue Cross and Blue Shield
- Certain other legacy numbers
The NPI will not replace these numbers, which are used for purposes other than general identification:
- Social security
- Taxpayer Identification
- Your state license
Where can I get help with the NPI application?
The NPI Enumerator will help you with your NPI application and to update your information in the NPPES.