National Provider Identifier (NPI)
Page last Modified on January 24, 2008
DMAS - NPI Compliance - May 23, 2008
NPI Updates
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| Taxonomy Code Information |
| Upcoming NPI WebEx Sessions |
| Frequently Asked Questions |
| General |
| Prior Authorizations |
| Billing |
| Taxonomy |
Health Care Providers
Atypical Providers
NPI Billing
Contact Information
NPI Disclosure
Resource Link
The National Provider Identifier (NPI) is part of the HIPAA Administration Simplification Regulations. The Final Rule, published January 23, 2004, established a standard unique identifier for all covered entities under HIPAA. HIPAA defined a covered entity as a health care provider, clearinghouse or health plan that conducts standard electronic transactions. The final rule requires a covered entity to obtain an NPI. It is intended to simplify transactions, including claims and coordination of benefits (COB), and save money in the long term.
The NPI is a 10-digit number and the standard unique identifier for health care providers. It will replace the use of all legacy provider identifiers (e.g., UPIN, Medicaid Provider Number, Medicare Provider Number, Blue Cross and Blue Shield Numbers) in standard transactions as of the compliance date. In April of 2007, CMS extended the compliance date from May 23, 2007 to May 23, 2008. As of May 23, 2008, Virginia Medicaid will require all of its participating health care providers to obtain and use an NPI in lieu of their legacy Medicaid provider identification number (PIN) for all standard transactions (e.g. ARS, Claims, Prior Authorization), including paper claims.
"Health Care Provider" 45 CFR 160.103: Health care provider means a provider of services as defined in section 1861(u) of the Act, a provider of medical or other health services as defined in section 1861(s) of the Act, and any other person who furnishes or bills and is paid for health care in the normal course of business (63 FR 25325). If an individual or organization does provide those services, it is considered a health care provider and would be eligible for an NPI. The following table is a list of health care providers.
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Health Care Providers |
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| Ambulatory Surgical Center | Hospice | Physical Therapist (Medicare Crossover) |
| Audiologist | Hospital | Physician |
| Certified Professional Midwife | Independent Laboratory | Physician Assistant (Medicare crossover) |
| Chiropractor | Intermediate Care Facility | Podiatrist |
| Clinical Nurse Specialist | Licensed Clinical Social Worker | Private Mental Hospital |
| Clinical Nurse Specialist - Psychiatric only | Licensed Marriage and Family Therapist | Prosthetic Services |
| Clinical Psychologist | Licensed Professional Counselor | Psych Residential Inpatient Facility |
| Community Service Board | Long Stay Hospital | Rehab Agency |
| Dental Clinic | Nurse Anesthetist (Medicare Crossover) | Rehab Hospital |
| Dentist | Nurse Midwife | Renal Unit |
| Durable Medical Equipment/Supplies | Nurse Practitioner | Rural Health Clinic |
| Education Services | Occupational Therapist (Medicare Crossover) | Skilled Nursing Facility |
| Emergency Transportation | Optician | Skilled Private Duty Nursing |
| Federally Qualified Health Center | Optometrist | State Mental Hospital |
| Health Department Clinic | Outpatient Rehab Facility | Substance Abuse Clinic |
| Home Health Agency | Pharmacy | |
Atypical providers are individuals or businesses that bill Medicaid for services rendered, and do not meet the definition of a health care provider according to the NPI Final Rule 45 CFR 160.103 (e.g., carpenters, transportation providers, etc). As a result of the NPI final rule, DMAS elected to give Atypical Providers a 10-digit Atypical Provider Identifier (API) to replace their legacy Medicaid provider number. The following table is a sample of Atypical Providers:
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Atypical Providers |
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| Adult Day Health Care | Non-Health care Mental Health/Mental Retardation Services |
| Assisted Living | Personal Care |
| Case Management | Respite Care |
| Family Caregiver Training | Treatment Foster Care |
| Non-Emergency Transportation | |
Providers billing with an NPI and who have received a remittance advice, and do not have any lingering NPI billing issues may stop using the legacy provider number. Further guidance will be forthcoming in the providers final NPI compliance Memo in February 2008.
DMAS is mandating Group Practice Enrollment. Group Practice Enrollment allows multiple fee for service practitioners who share the same EIN (Fed Tax ID) number to be paid under one Group Practice NPI. All individual practitioners in the Group Practice must be enrolled in the Virginia Medicaid Program and have an individual NPI (Type1). In addition, the Group Practice must enroll in the Virginia Medicaid Program and have an organization NPI (Type 2). Providers must enroll with First Health Services as a group, and ensure receipt of confirmation verifying the information has been added to their provider file, prior to billing Medicaid. For more information regarding Group Practice Enrollments, please refer to the Group Billing Reminder Notice. http://www.dmas.virginia.gov/downloads/pdfs/npi-Grp_Billing.pdf
Effective June 1, 2007, the UB-92 was replaced with the UB-04, and the CMS-1500 12/90 version was replaced with the CMS-1500 08/05 version. Information related to billing, NPI related error codes and resolutions can be found at www.dmas.virginia.gov/downloads/pdfs/ DMAS will continue to update all of its Medicaid Manuals and billing forms to accommodate changes as they occur.
For NPIs that represent more than one service type, a taxonomy code will be required for claims submissions. Taxonomy Code Information.
It has been confirmed through Medicare that claims submitted to Medicare, will continue to be crossed over and sent to Medicaid. Therefore, any claim received by DMAS after the NPI compliance date of May 23, 2008 without an NPI, will be denied.
For questions related to provider enrollment please contact:
First Health Services Corporation -
Provider Enrollment Unit (PEU)
PO Box 26803
Richmond, VA 23261-6803
888-829-5373 (Toll free In-state)
804-270-5105 (Out of state only)
804-270-7027 (Fax)
For questions related to claims, covered services or other inquiries, please contact the Provider Helpline at:
(804) 786-6273 (Out of state only)
(800) 552-8627 (In-state only)
If you have questions or problems related to Virginia Medicaid’s NPI implementation, please visit our Frequently Asked Questions (FAQs). For further assistance, please email us at NPI@dmas.virginia.gov.
DMAS disseminated a Medicaid Memo dated May 8, 2007, notifying the provider community of NPI disclosure to other health care entities for the purpose of conducting health care transactions, pursuant to the Centers for Medicare & Medicaid Services (CMS) guidance. For additional information please visit CMS at: http://www.cms.hhs.gov