Provider FAQ
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What is a National Provider Identifier (NPI)?
The NPI is a unique identifier assigned to a health care provider for use in standard electronic transactions, such as health care claims. After May 23, 2007, standard electronic transactions may only contain the NPI to identify the provider.
Is a health care provider required to obtain an NPI?
Under the National Provider Identifier Regulation (that was published in the Federal Register on January 23, 2004), a health care provider who is a covered entity is required to obtain an NPI by May 23, 2007.
Do I need an NPI?
Please refer to the document titled “NPI Submittal Instructions” listed under Documents and Forms section of the GHP Web Portal. This document contains a table that lists the provider types and NPI requirements for each provider type for Georgia Medicaid.
Will a health care provider’s NPI ever change?
The NPI is meant to be a lasting identifier, and would not change based on changes in a health care provider’s name, address, ownership, membership in health plans or health care provider taxonomy classification. There may be situations where use of an NPI for fraudulent purposes results in a health care provider requesting a different NPI.
Will a health care provider have to pay for an NPI?
No. A health care provider will not be charged, nor have to pay, a fee in order to obtain an NPI.
What is the NPPES?
NPPES is the National Plan and Provider Enumeration System. The Centers for Medicare & Medicaid Services (CMS) has developed the National Plan and Provider Enumeration System (NPPES)to assign unique National Provider Identifiers (NPI).
How do I contact the enumerator?
By phone 1-800-465-3203
By email at customerservice@npienumerator.com
By mail at NPI Enumerator, PO Box 6059, Fargo, ND 58108
By web site at https://nppes.cms.hhs.gov/NPPES
Can I get an NPI online?
Yes, go to https://nppes.cms.hhs.gov/NPPES to apply for an NPI.
How long does it take to get an NPI?
A health care provider who submits a properly completed electronic application may expect to receive their NPI in 10 days although this may vary depending upon the volume of applications at any given time.
What information will I need to supply to get an NPI?
Please go to https://nppes.cms.hhs.gov/NPPES for this information. This requirement will vary depending if you are an individual health care provider or an organizational health care provider.
What are entity type 1s and types 2s?
Entity type 1 is an “individual health care provider”. Entity type 2 is an “organizational health care provider”. Please visit https://nppes.cms.hhs.gov/NPPES for more information on entity types.
What is an EIN?
An EIN is an Employer Identification Number assigned by the Internal Revenue Service. The EIN is furnished only on an NPI application from providers who are organizations.
What is a taxonomy code?
The Health care Provider Taxonomy codes are a HIPAA standard code set named in the implementation specifications for some of the standard HIPAA transactions. Please visit the web site https://nppes.cms.hhs.gov/NPPES for more information on taxonomy codes.
Where may I obtain a copy of provider taxonomy codes?
The Health Care Provider Taxonomy Code Set is available at no charge from the Washington Publishing Company’s website: www.wpc-edi.com.
I don’t know what my taxonomy code is. What should I do?
You will receive direction and assistance in determining your taxonomy code as part of the NPI application process at https://nppes.cms.hhs.gov/NPPES.
What is the format of an NPI?
The NPI is all numeric and is 10 positions in length. The first 9 positions are the identifier and the last position is a check digit. The check digit helps detect invalid NPIs. There is no embedded intelligence in the NPI with respect to the health care provider that it identifies.
I applied for an NPI and was refused. Now what do I do?
Continue to use your Medicaid ID for electronic transactions.
When do I need to use my NPI with Georgia Medicaid?
You must use your NPI on all electronic claims submissions. This includes claims submitted via WINASAP.
When do I need to use my Medicaid Provider Number?
You will need to use your Medicaid Provider Number in the following circumstances.
- Paper claims submission
- Resubmission of electronic claims on paper
- Submission of web claims
- IVR System inquiries
- Provider authentication
- All claim inquiries
- All other inquiries
- Telephone inquiries
- Provider authentication
- All claim inquiries
- All other inquiries
- Prior authorizations
- Requests
- Inquiries
- Referrals
- Request
- Inquiries
- Medicaid forms
When do I need both my NPI and my Medicaid Provider Number?
- Applying to be a Medicaid Provider
- Adding a location to my Provider record
- Changing my Provider information
- Written inquiries and correspondence
- E-mail and ‘Contact Us’ inquiries
Will I use any other identification number on electronic claims?
Yes. You will need to supply your Tax ID (also called Employer Identification Number or Social Security Number) on all electronic claims.
We have always been advised (through legal counsel and professional affiliations) that all Medicaid waiver services were “health care” in nature, thus the need to insure all service delivery was HIPAA compliant since we are HIPAA “covered entities.” The list of provider types and category of services we received showing that an NPI is only needed for a very limited number of CHSS and MRWP services seems to be in conflict with the information from the CMS web site. We are looking for assurance that given all waiver services are covered by HIPAA and that we do bill electronically, that an NPI is not needed for all waiver services-despite the fact that all the services provided are HIPAA covered services.
That is correct. If a service is considered a non-medical service (atypical service) and a claim is submitted to a health plan or payer in an electronic format, it (the electronic submission) is not required to be conducted as a standard transaction. Therefore a provider who renders an atypical service is not required to bill using an NPI number. For example, environmental modifications and vehicle adaptation are covered services, but are considered as atypical.
Given the requirement that there be a Medicaid provider number for all residential (each house) and day service settings, should we obtain an NPI for each of these locations as well-for the services from the Provider Type-Category of Service- Specialty Table? For example, if we provide MRWP SMS in all day and residential settings do we need to obtain a NPI for each of the 100+ locations?
DCH can not require a provider to obtain an NPI for each location; however we recommend that the provider maintain the same enrollment configuration as it currently does to minimize disruption in claims reimbursement.