Social Workers and the National Provider Identifier

Many social workers will need to obtain and use a National Provider Identifier (NPI) number by May 23, 2007, the federal deadline for compliance. This Legal Issue of the Month article reviews basic information about the NPI, including contingency plans, and  identifies available resources for assistance.   

What is the NPI?

The NPI is a 10-digit number that will be used to uniquely identify health providers and health plans for purposes of conducting the standard electronic transactions defined by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) regulations. The Centers for Medicare and Medicaid Services (CMS) have developed the National Plan and Provider Enumeration System (NPPES) to assign the NPI.

Who Must Obtain an NPI?

Social workers who file electronic claims for reimbursement must obtain an NPI, as well as social workers who are Medicare providers. All social workers in clinical practice who seek reimbursement from third-party payors should obtain an NPI.   

What is the Application Process?

There are several ways to access the five-part NPI application:

Information Required for Individual Providers
  • Provider Name
  • SSN (or individual tax identification number (ITIN) if not eligible for SSN)
  • Provider Date of Birth
  • Country of Birth
  • State of Birth (if Country of Birth is U.S.)
  • Provider Gender
  • Mailing Address
  • Practice Location Address and Phone Number
  • Taxonomy (Provider Type)
  • State License Information
  • Contact Person Name (for organizational applicants)
  • Contact Person Phone Number and Email

The NPI has created two entity types:  Type 1 includes individual practitioners and Type 2 includes organizational providers, group practices, or incorporated individuals. 

In addition to entity type, social workers will need to identify a taxonomy code for their practice.  The taxonomy code for clinical social workers is 1041C0700X.

In the application process for the NPI, CMS urges health care practitioners to include legacy identifiers, not only for Medicare but for all payers. If reporting a Medicaid number on the application, social workers should include the name of the State. The goal is to enable payers and providers to transition from prior legacy identifiers to a system that uses only the NPI.

What Will Happen After the May 23, 2007 Deadline?

After May 23, 2007 providers with an NPI (including clinical social workers) may only use the NPI to identify themselves in standard electronic transactions.  There is an additional year for small health plans to comply. Standard transactions are those related to electronic claims, including referrals, remittance advices, eligibility, and claim status inquiries. According to CMS, non-NPI provider identifiers may be used for internal organizational purposes.

The NPI is meant to be a permanent identifier; however, some of the information provided in the initial application may change, such as a social worker’s name, address, business ownership, provider status with health plans, or Healthcare Provider Taxonomy classification.  The NPI may be changed in very limited circumstances, if necessary to correct fraudulent usage.

CMS has provided guidance regarding a contingency period for non-compliance after the May 23, 2007 deadline and the agency’s enforcement approach. After providing notice to the entity about an alleged NPI violation, CMS will provide an opportunity to: “1) demonstrate compliance, 2) document its good faith efforts to comply with the standards, and/or 3) submit a corrective action plan.”  (CMS, Guidance on compliance with the HIPAA national provider identifier (NPI) rule, after the May 23, 2007, implementation deadline).  In addition, there will be some period after May 23, 2007 when Medicare fee for service will permit the use of the NPI and legacy numbers, but not after May 23, 2008. (CMS, NPI question resources).

Timeframe for Complete Compliance
  • Once a provider obtains an NPI, it is estimated that it will take 120 days to do the remaining work to use it.  This includes working on internal billing systems, coordinating with billing services, vendors, and clearinghouses, testing with payers. 
  • Social workers must also share the NPI with other providers, health plans, clearinghouses, and any entity that may need it for billing purposes. 
  • Social workers who delay applying for the NPI risk their cash flow and that of their health care partners as well. (CMS, National provider identifier standard (NPI), Overview).
NASW Activity

NASW has published several practice documents, referenced below, regarding the NPI.  In addition, information is available on the NASW “HIPAA Highlights for Social Workers” Web page, available at www.socialworkers.org/hipaa. Finally, an NPI Hotline is available at NASW by calling (202) 408-8600, ext. 497.

Resources
Centers for Medicare & Medicaid Services (CMS) (undated). Guidance on compliance with the HIPAA national provider identifier (NPI) rule, after the May 23, 2007, implementation deadline. [Online]. Available at http://www.cms.hhs.gov/NationalProvIdentStand/Downloads/NPI_Contingency.pdf (last visited, April 27. 2007).
Centers for Medicare & Medicaid Services (CMS) (undated). National provider identifier standard (NPI), Overview. [Online]. Available at http://www.cms.hhs.gov/NationalProvIdentStand/ (last visited, April 30, 2007).
Centers for Medicare & Medicaid Services (CMS) (undated). NPI question resources. [Online]. Available at http://www.cms.hhs.gov/NationalProvIdentStand/07_Questions.asp#TopOfPage (last visited April 30, 2007).
Centers for Medicare & Medicaid Services (CMS) (undated). NPI Resource Sheet. [Online]. Available at http://www.cms.hhs.gov/NationalProvIdentStand/Downloads/NPI_Resource_Sheet.pdf (last visited, April 30. 2007).
National Association of Social Workers (July 2004). National provider identifier and the clinical social worker. Clinical Social WorkPractice Update.  [Online]. Available at http://www.socialworkers.org/practice/clinical/csw0704.pdf (last visited, April 30, 2007).
National Association of Social Workers (2005). National provider identifier, Practice News Alert. [Online]. Available at https://www.socialworkers.org/practice/clinical/csw052005.asp (last visited, April 30, 2007).
National Association of Social Workers (October 2006). Deadline approaching for national provider identifier, Practice Bulletin. [Online]. Available at https://www.socialworkers.org/practice/clinical/csw102606.asp (last visited, April 30, 2007).

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6/25/2017
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