Covered entities under HIPPA must use NPI’s to identity health care providers in HIPPA standard transactions. The NPI number is required to submit claims or conduct other transactions specified by HIPPA. By definition, a health care provider” is an individual, group or organization that provides medical or other health service or supplies.”  This would include physicians an other practitioners, physician/practitioner groups, institutions such as hospitals, laboratories and nursing homes, health maintenance organizations and suppliers such as pharmacies and DME companies. However, it does not include health industry workers such as admissions and billing personnel, housekeeping staff, orderlies and those who support the provision of health care, but do not provide health care services.  

The issuance of an NPI does not:

1.   Change or replace a current Medicare enrollment or certification process
2.  Enroll the person in a health plan
3.  Ensure the person is licensed or credentialed
4.  Ensure the person or entity is not excluded by the OIG or state Medicaid exclusion agency
5.  Guarantee payment or reimbursement from a health plan or CMS

An interesting fact:

Did you know that the OIG List of Excluded Individuals and Entities (LEIE) only has approximately 5 percent of NPI’s as a key identifier. 

You might also enjoy:
What every compliance plan should answer
Avoiding risks in your compliance plan
Legal jargon in healthcare compliance plans
How to get off the OIG exclusion list

Michael Rosen, Esq.

Written by Michael Rosen, ESQ
ProviderTrust Co-Founder, mrosen@providertrust.com

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
Connect with Michael on Linkedin

New Call-to-action