All physicians, providers, and healthcare organizations who are covered under the Health Insurance Portability and Accountability Act (HIPAA) are required to apply for a National Provider Identifier (NPI). This unique identification is an industry standard for providers, health plans, prescribers, healthcare clearinghouses, business associates, and more to submit or process health insurance claims.
Because of how elaborate and dynamic the U.S. healthcare system operates, it is essential to have a well connected and accessible database to reference provider information in a timely manner. Whether you’re new to searching the NPI Registry (NPPES) or perform these actions on a reoccurring basis, let’s take a look at how to lookup NPI numbers for providers and healthcare organizations.
The National Plan and Provider Enumeration System (NPPES)
Individuals or organizations apply for NPIs through the CMS National Plan and Provider Enumeration System (NPPES). The NPPES is a database administered by the Centers for Medicare and Medicaid Services (CMS) to “improve the efficiency and effectiveness of the electronic transmission of health information” by standardizing the format of unique identification for healthcare providers and health plans.
CMS makes periodic updates to the NPPES system to help make it easier for a better overall experience. Here are some of the latest feature improvements to the database for enhanced NPI lookup for physicians and healthcare organizations.
NPI Type 1 and Type 2 Providers
The Centers for Medicare and Medicaid Services (CMS) provided an important document that helps clearly identify many factors surrounding National Provider Identifiers – CMS | The Who, What, When, Why & How of NPI: Information for Healthcare Providers. According to CMS, there are two types of healthcare providers in terms of NPI – Type 1 and Type 2 providers.
Type 1 Providers
Healthcare providers who are individuals, including physicians, dentists, and all sole proprietors. An individual is eligible for only one NPI.
Type 2 Providers
Healthcare providers who are organizations, including physician groups, hospitals, nursing homes, and the corporation formed when an individual incorporates him/herself.
How to Lookup and Verify Providers and Healthcare Organizations
The NPPES NPI Registry is a free directory provided by CMS to lookup all active National Provider Identifier information. In addition to the online searchable database, CMS also supplies an active NPI list as a file download, or through an Application Programming Interface (API).
Looking up a physician or healthcare organization on the NPPES NPI Registry is pretty straight forward, but when referencing any database for the first time, a small learning curve can exist. For NPI validation, you will need to quickly associate which type of provider you are looking to reference – either an individual or an organization.
Next, it’s beneficial to have a taxonomy description to help provide more context for search results. Once you have entered all of your information, the NPI Registry will then deliver a few results. CMS only publish the parts of an NPI record that have public relevance – including the provider’s name, specialty (taxonomy), and practice address.
*Note* Provider NPIs for individuals do not change over time, even with a change in name, location, organization, etc.
NPI Lookup Search Results
Once you enter lookup information, the database will reveal multiple results. The following below information will be presented in a table view from the NPI Registry.
- NPI: The NPI Number is the unique, 10-digit National Provider Identifier assigned to the provider. The NPI Number is a hyperlink, navigating to the NPI Details page when selected.
- Name: The Legal Business Name associated with the Provider. For Individual Providers, the Name column consists of the Individuals First and Last Names.
- NPI Type: Identifies if the Provider is a Type 1 Individual Provider or a Type 2 Organizational Provider .
- Primary Practice Address: The address of the Practice Location is displayed.
- Phone: The Phone number associated with the Practice Location is displayed.
- Primary Taxonomy: The description of the primary taxonomy for the provider is displayed. If a primary taxonomy does not exist for the provider, the Taxonomy column will display “No Primary Taxonomy”. All taxonomies for the provider will be displayed on the Details page regardless of the primary taxonomy status.
The NPI Registry details page shows the user an individual provider’s or organization’s NPPES healthcare provider data. Only the Freedom of Information Act (FOIA) data related to the selected record is viewable. Information associated with NPIs is updated daily. If the record being viewed has any changes pending, the pending information will not be presented.
Reasons to Lookup Physicians and Healthcare Organizations with an NPI
Since the National Provider Identifier (NPI) replaced the Unique Physician Identification Number (UPIN) in 2007, there have been vast improvements in a more clear and concise way for validating provider information for administrative and financial transactions for multiple parties including health plans, healthcare clearinghouses, health systems, business associates, and more. To gather more context on how to utilize the NPI, take a look at our Quick Guide to Understanding National Provider Identifiers (NPI).
Here are a few examples of how leveraging the NPI database can help with operations across various types of healthcare organizations:
Health Plans and Pharmaceuticals
- Prescriber lookup and validation
- Billing entity or physician group validation
- Screening providers during contracting and enrollment
- Ongoing monthly exclusions monitoring and verification
- Credentialing providers as part of an ongoing credentialing and monitoring cycle
- Screening non-par or “out-of-network” providers prior to processing and reimbursing a claim
- Credentialing for providers and vendors
- Ongoing monthly exclusions monitoring and verification
- Monitoring provider referral networks and claims from referring providers
Having a centralized electronic database has improved quality standards and compliance for many healthcare professionals as it relates to validating provider and healthcare organization credentials for a more modern and integrated system for value-based care. However, gaps in information, processes, and user knowledge still can present some challenges for all parties involved.
For example, many NPI registrants are not aware of how frequently their information has been updated to reflect new changes or if any errors or inconsistencies apply to their record. Due to these constraints, more advanced tools that help provide better context and present more actionable workflows are an invaluable asset to organize and manage healthcare information.
CMS Medicare Enrollment Process
There are still quite a few steps and hoops to jump through in the Medicare enrollment process. One of the biggest challenges for both CMS and providers is ensuring the latest information is on file and that each party has the appropriate access to relevant and timely information. For instance, Medicare enrollment for providers and suppliers requires the creation of a Provider Enrollment, Chain, and Ownership System (PECOS) account in addition to registering for an NPI. PECOS allows registered users to electronically submit and manage their Medicare enrollment information.
If you are a physician or practitioner looking to complete enrollment, here is a helpful PECOS checklist for what is required for sign up. Many times, enrolled providers will need to update their information. Below is a helpful video to learn how to update Medicare enrollment if you are an individual provider. Over time, some providers choose to end their enrollment in the federal program altogether, known as a Medicare Opt-Out Affidavit.
The Value of Smarter NPI Data
Although an NPI is just a common healthcare identifier and technically only provides basic information like Name, NPI, Address, Phone, Taxonomy, there is more than meets the eye as far as functionality. The National Provider Identifier has the ability to be a game changer as it relates to supplementing data for other helpful and even critical healthcare functions in compliance, human resources, credentialing, procurement, claims processing, and more.
Because healthcare in the U.S. can be pretty complex and highly regulated, many times the requirement of unique innovation is necessary to perform key tasks each day. When it comes to upholding the integrity of federal healthcare programs, the government has put together quite a few databases and online directories to help aid in delivering care and providing transparency for the general public to each provider’s information.
Unfortunately, as you can imagine, the system is not flawless and due to inefficient reporting from each state, as well as confidentiality requirements, pertinent healthcare information can be hard to come by without the use of enhanced tools and datasets to help aggregate the right information to build a consistent provider and healthcare organization profile.
Here’s an example: If a Maryland State Medicaid exclusion record only contains a First Name, Last Name, a Single Address, and an Exclusion Effective Date but no NPI number, is your organization able to verify that your provider is or is not excluded?
Good news…it’s possible. We can help.
Although there are many different types of NPI lookup software online, many of these low-cost options only scratch the surface of utilizing the versatility of NPI validation and verification. We believe that many processes can be improved by leveraging NPI data with other unique identifiers across various online registries. Our software solutions help organize these types of data to then produce a more comprehensive profile for physicians, healthcare organizations, and more.
Healthcare Database Screening and Exclusions Monitoring
Completing employee and organization profiles with augmented data (like NPI and SSN) helps create a smarter exclusion monitoring program for your organization to eliminate errors and insufficient information gaps. Using both the NPI and screening against all exclusion lists (OIG LEIE, SAM.gov, all state Medicaid lists) is a great step in identifying where to address potential disqualifications of services provided by healthcare staff, vendors, volunteers, referrals, business associates, and more.
Help keep your company safe with the tools you need to more accurately and efficiently search and validate with NPI verification and exclusions screening software.
Do you have any questions about the NPI (National Provider Identifier), how to verify, or how to utilize the latest software for ongoing provider and healthcare organization monitoring, exclusions screening, claims processing, or more?
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Written by Michael Rosen, Esq.
Michael brings over 20 years of experience founding and leading risk mitigation businesses, receiving numerous accolades such as Inc. Magazine’s Inc. 500 Award and Nashville Chamber of Commerce Small Business of the Year.