Physician NPI complete overview

New Compliance Contingency Guidance FAQs – CMS has posted the following new FAQs related to the previously posted NPI Compliance Contingency Guidance:

  • What are the exact dates for the NPI contingency plan?
  • If a complaint is filed against me for not being in compliance with the NPI after May 23, 2007, what will happen?
  • What happens if a complaint for not being in compliance with the NPI is filed against me after May 23, 2008?
  • Is it acceptable for a health plan to announce their NPI contingency now?
  • Is the NPI contingency plan voluntary?
  • Am I allowed to give my NPI to other providers as well as to the health plans with whom I exchange transactions?

To view these FAQs, providers should (1) Go to the CMS dedicated NPI Web page at, (2) scroll down to the section that says "Related Links Inside CMS" and (3) click NPI Frequently Asked Questions. To find the latest FAQs, click the arrows next to "Date Updated". Look for the word "NEW" in red font to appear beside the most recent FAQs.

Obtain Information on Contingency Plans – CMS strongly urges providers to pay attention to information from the health plans they bill so that they are aware if, and when, a specific health plan announces its own contingency plan.

Reminder – Sharing NPIs – Once providers have received their NPIs, they should share their NPIs with other providers with whom they do business, and with health plans that request their NPIs. In fact, as outlined in current regulation, providers who are covered entities under HIPAA must share their NPIs with any entities that need them for billing purposes, including those who need them for designation of ordering or referring physician. Providers should also consider letting health plans, or institutions for whom they work, share their NPIs for them.

Reminder – Enumerating a Group Practice – A group practice that conducts any of the HIPAA standard transactions is a covered health care provider (a covered entity under HIPAA) and, must obtain an NPI. The physicians employed by the group practice, on the other hand, are furnishing services at the group office(s) but they are not conducting any of the HIPAA standard transactions (such as submitting claims, checking eligibility and claim status). As such, the physicians would not be covered health care providers and are not required by the NPI Final Rule to obtain NPIs. However, as the employer, the group could require these physicians to obtain NPIs and use the NPIs to identify them as the rendering providers in the claims that the group submits. If these physicians prescribe medication, the pharmacies may require their NPIs in the claims that the pharmacies submit to health plans.  Additionally, health plans can require enrolled physicians to obtain NPIs in order to participate in that plan. Medicare is an example of a health plan with this requirement.

Reminder – Applying for an NPI Does Not Enroll a Health Care Provider in
a Health Plan –
Applying for an NPI and enrolling in a health plan are two completely separate activities. Having an NPI does not guarantee payment by any health plan.

When to Contact the NPI Enumerator for Assistance – Providers should remember that the NPI Enumerator can only answer/address the following types of questions/issues:

  • Status of an application.
  • Forgotten/lost NPI.
  • Lost NPI notification letter (i.e., for those providers enumerated via paper or Web-based applications).
  • Trouble accessing NPPES.
  • Forgotten password/User ID.
  • Need to request a paper application.

Need clarification on information that is to be supplied in the NPI application? Providers needing this type of assistance may contact the NPI Enumerator at (800) 465-3203, TTY (800) 692-2326, or e-mail the request to Note: The NPI Enumerator's operation is closed on the following federal holidays: New Year's Day, Independence Day, Veterans Day, Christmas Day, Martin Luther King's Birthday, Washington's Birthday, Memorial Day, Labor Day, Columbus Day and Thanksgiving.

Important Information for Medicare Providers –  Medicare has announced its contingency plan. View the associated CR at and the related MLN Matters article at Please note that these materials were recently revised so be sure to visit the links above for the latest information. This information will also be available shortly on CMS' dedicated NPI Web page. A national NPI Roundtable on the Medicare FFS Contingency Plan is scheduled for May 10, 2007, from 2–3:30 p.m. (ET). Registration details to follow.

Reporting a Group Practice NPI on Claims – Medicare has identified instances where the Multi-Carrier System (MCS) is correcting billing or pay-to provider data on Part B claims submitted by group practices. As of May 18, 2007, the MCS Part B claims processing systems will no longer correct claims submitted by group practices that are reporting the individual rendering Provider Identification Number (PIN) or individual rendering NPI in either the billing or pay-to provider identifier fields. Groups should enter either their group NPI or group NPI and legacy PIN number pair in either of these fields.

Reminder – Medicare Extending Date for Accepting Form CMS-1500 (12-90) – While Medicare began to accept the revised Form CMS-1500 (08-05) on January 1, 2007, and was positioned to completely cutover to the new form on April 1, 2007, it has recently come to our attention that there are incorrectly formatted versions of the revised form being sold by the Government Printing Office (GPO). After reviewing the situation, the GPO has determined that the source files they received from the NUCC's authorized forms designer were improperly formatted. The error resulted in the sale of both printed forms and negatives which do not comply with the form specifications. However, not all of the new forms are in error. Given the circumstances, CMS is extending the acceptance period of the Form CMS-1500 (12-90) version beyond the original April 1, 2007, deadline while this situation is resolved. Medicare contractors will be directed to continue to accept the Form CMS-1500 (12-90) until notified by CMS to cease. At present, CMS is targeting June 1, 2007, as that date. During the interim, contractors will be directed to return, not manually key, any Form CMS-1500 (08-05) forms received which are not printed to specification. By returning the incorrectly formatted claim forms back to providers, they will become aware of the situation so communications can begin with their form suppliers. For more details, and to learn how to identify the proper version of the new form, visit a recent MLN Matters article at

Still Confused? Not sure what an NPI is and how you can get it, share it and use it?  As always, more information and education on the NPI can be found at the CMS NPI Web page at Providers can apply for an NPI online at or call the NPI enumerator to request a paper application at (800) 465-3203. Getting an NPI is free - not having one can be costly.

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