Cvs Caremark Specialty Pharmacy Npi Assignment

National Provider Identifier (NPI)

What is an NPI?

A National Provider Identifier, or NPI, is a unique, ten-digit identifier that the Centers for Medicare & Medicaid Services (CMS) issues to all health care providers as mandated by the federal government in the Health Insurance Portability and Accountability Act of 1996 (HIPAA). NPIs eliminate the need for multiple identifiers from different health plans. Any provider covered under HIPAA must obtain one or more NPIs in order to conduct standard transactions.

To ensure successful claims submission, please complete the following steps:

  1. Get your NPI from CMS.
  2. Register your NPI with Independence Blue Cross (Independence).
  3. Enable electronic claims submission for your billing provider NPI.

You may also continue reading below for more information on each step.

Get Your NPI

Providers may apply for an NPI from CMS in one of two ways:

  • Online. The National Plan and Provider Enumeration System (NPPES), developed by CMS, includes an online application that takes approximately 20 minutes to complete.
  • By mail. You can request a paper application by calling the NPI Enumerator call center at 1-800-465-3203.

Once an NPI application has been processed successfully, the applicant will receive a confirmation notice and assigned NPI from CMS. Online applicants will receive confirmation by email, and paper applicants will receive confirmation by standard mail.

Register Your NPI with Independence

All NPIs that identify the billing provider, rendering provider, referring provider, and service facility on claims must be registered with Independence.*

All providers (participating and nonparticipating) may register using the NPI Provider Registration Web Form. Participating providers may also register by mail, using the form that has been included in mailings to participating provider offices.

*Referring providers on claims also must be identified using their CMS-assigned NPI.

Enable Your NPI for Electronic Claims Submission

For electronic claims submission, the NPI that identifies your billing organization must be affiliated with the entity that submits your electronic claims, also known as a trading partner. Please contact your billing software vendor, clearinghouse vendor, or third-party billing service for instructions on how to affiliate your NPI with the appropriate trading partner.

If you are your own trading partner, go to the Trading Partner Business Center to affiliate your NPI to your profile.

For electronic claims submission, please affiliate only the NPI that identifies the billing provider, not individual NPIs for rendering providers.

Use a Valid NPI for All Claims

If claims are submitted with NPIs that do not comply with the above guidelines, they will be rejected automatically.

Common reasons why claims are rejected include:

  • One or more NPIs are not registered with Independence.
  • The billing NPI is not affiliated with the electronic submitter (i.e., trading partner).
  • One or more NPI fields on the claim do not contain an NPI.
  • The NPI is entered incorrectly and does not match the registered NPI.

Please refer to the CMS-1500 claims submission toolkit or the UB-04 claims submission guide for more information about proper electronic and paper claims submissions.

Additional NPI Resources

NPI Frequently Asked Questions

General NPI Information

What is a National Provider Identifier (NPI)?

Is a health care provider required to obtain an NPI?

Why do health care providers need NPIs?

How can health care providers obtain an NPI?

How many NPIs do health care providers need?

How can hospitals notify Independence of their NPIs?

What is my Primary Provider Taxonomy Code?

How long will it take to receive an NPI?

How can health care providers report NPIs to Independence Blue Cross?

Where can I obtain additional information on the National Provider Identifier?

Enumeration

How do I enumerate; and does Independence require different NPIs when there are currently different provider numbers?

Claims/Billing

Where are the Independence billing instructions and companion guides?

What happens if a claim comes in without an NPI?

Will Independence allow providers to bill legacy and/or NPI?

Will Independence require NPIs on paper claims?

Will Independence require Tax ID in addition to NPI on paper claims?

If Independence is requiring NPI for all provider fields, will claims be denied/rejected if the NPI is not provided for ordering and/or referring providers?

If providers choose to enumerate their subparts further than they currently have today with payer legacy numbers, will Independence require enrollment of their additional subparts?

Payer Readiness

Does Independence currently require different NPIs when there are different provider numbers?

How can hospitals notify Independence of their NPIs?

Does Independence plan to validate [meet CMS NPI formula] and verify [Dr. Smith’s NPI is truly Dr. Smith’s] provider NPI?

What happens in Independence’s system if an invalid NPI is received in any provider field?

Does Independence plan to give providers access to their NPIs in provider directories?

Are NPIs required when using the interactive voice response (IVR) system?

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General NPI Information

What is a National Provider Identifier (NPI)?
An NPI is a unique, ten-digit, intelligence-free, numeric identifier. Intelligence-free means that the numbers do not carry information about health care providers, such as the state in which they practice, their provider type, or their specialization.

NPIs replace health care provider identifiers used for standard transactions under the Health Insurance Portability and Accountability Act (HIPAA). Those numbers included payer-specific IDs and Medicare legacy IDs (e.g., UPIN, OSCAR, PIN, and National Supplier Clearinghouse).

A provider’s NPI will not change. It will remain with the provider regardless of job or location change(s).

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Is a health care provider required to obtain an NPI?
Yes. Under the National Provider Identifier Regulation (published in the Federal Register on January 23, 2004), a health care provider who is a covered entity, as defined in 45 C.F.R. § 160.103, and who transmits any health information in connection with a HIPAA standard transaction in electronic form, is required to obtain an NPI.

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Why do health care providers need NPIs?
HIPAA requires the adoption of a standard unique identifier for health care providers.

NPIs allow for simpler electronic transmission of HIPAA standard transactions.

The NPI is the only health care provider identifier that can be used for identification purposes in standard transactions by covered entities. Covered entities include health plans, health care clearinghouses, and those health care providers who transmit any health information in electronic form in connection with a transaction for which the Secretary of Health and Human Services has adopted a standard.

NPIs are being used to identify health care providers on prescriptions and in internal files to link proprietary provider identification numbers and other information, coordination of benefits between health plans, patient medical record systems, program integrity files, and other ways as well.

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How can health care providers obtain an NPI?
Providers who have not yet obtained their NPI may apply in one of the following ways:

  • through an easy, Web-based application process that takes approximately 20 minutes to complete online;
  • by calling the National Provider Identifier enumerator call center at 1-800-465-3203 to request a paper application;
  • through an electronic file submitted by an organization. You must have the permission of the health care provider to apply for an NPI by using this method.

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How many NPIs do health care providers need?
An individual is eligible for a single NPI. An individual cannot have subparts and cannot designate subparts. In terms of NPI assignment, an individual is an Entity Type 1.

A sole proprietor/sole proprietorship is eligible for a single NPI. A sole proprietor/sole proprietorship cannot have subparts and cannot designate subparts. In terms of NPI assignment, a sole proprietor/sole proprietorship is an Entity Type 1 (Individual).

Organizations must also apply for a single NPI. In terms of NPI assignment, organization health care providers who are covered entities under HIPAA must apply for NPIs as Entity Type 2 (organization). Organization health care providers are corporations/partnerships or other types of businesses that are considered separate from an individual by the state in which they exist. Subparts of such organization health care providers who apply for NPIs are also Entity Type 2.

  • A subpart must have its own NPI if it conducts any of the HIPAA standard transactions separately from the covered organization health care provider of which it is a part. If your organization has subparts, please ensure that they have their own NPIs.
  • Example: A hospital owns ten home health agencies that all operate under the Tax Identification Number of the hospital. Because the hospital and each of the ten home health agencies is separately surveyed and enters into its own provider agreement with Medicare, 11 different NPIs should be obtained in total — one by the hospital and one by each of the ten home health agencies.
  • For further clarification regarding entity types and subparts, visit the
    Centers for Medicare & Medicaid Services website.

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How can hospitals notify Independence of their NPIs?

Registering your NPI with Independence is easy. Once you have obtained your NPI, you may register online by completing and submitting one of our NPI Provider Registration Forms.

Different online registration forms are available for all types of providers (participating and nonparticipating).

Contact your Network Coordinator with questions regarding the online Provider Registration Forms.

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What is my Primary Provider Taxonomy Code?
The Provider Taxonomy is an alphanumeric code, ten characters in length, that allows a single provider (individual, group, or institution) to identify its specialty category. Information on Provider Taxonomy Codes is available through the Washington Publishing Company.

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How long will it take to receive an NPI?
The Centers for Medicare & Medicaid Services (CMS) cannot predict the amount of time it will take to obtain an NPI. There are several reasons for that. Such factors CMS considers include:

  • volume of applications being processed at a given time;
  • whether the application is submitted electronically or on paper;
  • whether the application is complete and free of errors. When gathering information for the application, be sure that all provider information, such as social security number and federal employer identification number, are correct.

CMS estimates that, in general, a health care provider who submits a properly completed, electronic application could have an NPI within ten days.

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How can health care providers report NPIs to Independence?
Registering your NPI with Independence is easy. Once you have obtained your NPIs, you may register online using our NPI Provider Registration Web Form. All providers (participating and nonparticipating) may register using the appropriate online form.

Participating providers may also register their NPIs with us by mailing their completed custom NPI submission form. This form has been included in mailings to participating provider offices.

Contact your Network Coordinator with questions regarding the new Provider Registration Web form or your custom NPI submission form.

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Where can I obtain additional information on the National Provider Identifier?
The Centers for Medicare & Medicaid Services website is an excellent resource for detailed information on the National Provider Identifier.

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Enumeration

How do I enumerate?
While keeping NPI enumeration requirements in mind, Independence strongly encourages providers to enumerate with NPIs in the same configuration as they are now enumerated with IBC using Corporate Provider IDs.

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Claims/Billing

Where are the Independence billing instructions and companion guides?
Billing information can be found in our Claims submission toolkit for proper electronic and paper claims submissions as well as in our companion guides. Additional information can be found in issues of Partners in Health Update as well as in the current Provider Manual for Participating Professional Providers.

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What happens if a claim comes in without an NPI?
An NPI is required by HIPAA regulations. If a claim is submitted without a valid, registered NPI, the claim will reject.

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Will Independence allow providers to bill legacy and/or NPI?
In accordance with the CMS mandate, providers must use the NPI as the primary identifier on the claim, and Independence will reject claims with invalid NPIs.

For purposes of processing a claim, you must submit your registered National Provider Identifier (NPI). In accordance with the reimbursement terms of your provider contract, you may continue to provide your 10-digit legacy number. Only a valid NPI will be accepted by us as the primary identifier on the claim.

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Will Independence require NPIs on paper claims?
Yes. Paper claims must be submitted with an NPI as the primary identifier.

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Will Independence require Tax ID in addition to NPI on paper claims?
Yes. Tax ID is required for all claims.

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If Independence is requiring NPI on all provider fields, will claims be denied/rejected if an NPI is not provided for ordering and/or referring providers?
Some of these providers may not have an NPI, and others we may not be able to obtain. Independence requires NPI identifiers in the following four provider fields:

  • Billing provider
  • Rendering provider
  • Service Facility provider
  • Referring provider

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Is Independence planning on requiring a nine-digit zip code on the claim form?
The nine-digit zip code is currently not required.

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If providers choose to enumerate their subparts further than they currently have today with payer legacy ID numbers, will Independence require enrollment of their additional subparts?
No, Independence will not require enrollment of all subparts. However, Independence will not accept health care transactions using these NPIs if they are not registered with Independence.

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Payer Readiness

Does Independence require different NPIs when there are currently different provider numbers?
While keeping NPI enumeration requirements in mind, Independence strongly encourages providers to enumerate with NPIs in the same configuration in which they are now enumerated with Independence using corporate provider IDs. Otherwise, issues may occur with your claim payments and internal business and reporting procedures. Independence recommends that you take a close look at your current provider number configuration and plan wisely when obtaining your NPIs.

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How can hospitals notify Independence of their NPIs?
Registering your NPIs with Independence is easy. Once you have obtained your NPIs, you may register online using our NPI Provider Registration Web Form. All providers (participating and nonparticipating) may register using the appropriate online form.

Contact your Network Coordinator with questions regarding the new Provider Registration Web Form.

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Does Independence plan to validate [meet CMS NPI formula] and verify [Dr. Smith’s NPI is truly Dr. Smith’s] provider NPIs?
Independence validates provider NPIs through the NPPES database provided by CMS. However, unless we are 100 percent sure of a provider match, we will not enter that NPI into our systems. Therefore, it is important to submit your NPIs to Independence so that your NPIs can be registered.

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What happens in Independence’s system if an invalid NPI is received in any provider field?
Each claim must pass an NPI check-digit validation to ensure that it has a valid NPI. To date, many claims are not passing this check-digit validation. The most common reasons why claims are not passing the NPI check-digit validation are:

  • the wrong provider identifier is entered in an NPI field;
  • the NPI is entered incorrectly;
  • the number entered is not a valid NPI.

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Does Independence plan to give providers access to NPIs in provider directories?
Independence does not currently plan to publish provider’s NPIs in its provider directory.

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Are NPIs required when using the interactive voice response (IVR) system?
Because the IVR system is not covered under the CMS mandate, providers are permitted to use either an NPI or 10-digit legacy ID number and tax ID to access the IVR.

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