National Provider Identifier (NPI)
The National Provider Identifier (NPI) is a standard required under HIPAA. The NPI is a unique, 10-digit identification number for health care providers that is free of any personal or identifying information. Covered health care providers, health plans, and health care clearinghouses must use the NPI in administrative and financial transactions (e.g., claims submission) that are adopted under HIPAA. The NPI replaces all other existing provider identifiers. For more information, please visit the CMS NPI web site. You may search the NPI Registry for a provider's National Plan & Provider Enumeration System (NPPES) information.
Effective May 17, 2008, Availity began requiring all connected health plans to process X12 HIPAA standard electronic transactions according to one of the following options.
- Legacy ID required
- NPI allowed
- Legacy identifier required
- Dual ID (Allows all of the following scenarios)
- NPI only
- Legacy identifier only
- NPI and Legacy identifiers
- NPI per mandate
- NPI required per mandate under HIPAA regulations
- Legacy identifier not allowed
- NPI per mandate. Legacy ID also allowed.
- NPI required per mandate under HIPAA regulations
- Legacy identifier also allowed
As noted above, all payers either accept or mandate use of the NPI. Rejection of claims can affect timely payment of your claims. Please communicate with your health plans and pay attention to information you receive from them.
- If you send a transaction without an NPI to a payer who is following Option 3 or 4, the transaction will be rejected.
- If you send a transaction with a Legacy ID to a payer who is following Option 3, the transaction will be rejected.
- Tax ID is not considered a Legacy ID when used to identify the provider as a taxpayer for reporting to the IRS. Please be aware when this ID is required.
Availity’s NPI validation rules
In order to support each health plan’s NPI readiness, Availity validates transactions according to Option specific rules. Options 3 and 4 are new and currently active.
All web transactions are formatted according to the health plan’s NPI readiness. If an NPI is required by the health plan, the NPI field will be required on the screen.
Availity will not manipulate EDI/B2B transactions in order to make them compliant for the health plan’s requirements. Availity will validate all incoming EDI transactions according to the health plan’s NPI readiness. Availity will reject transactions if identification numbers do not follow the payer’s requirements.
- If a health plan requires an NPI, Availity will not add a provider’s NPI and submit to the plan.
- If a health plan does not allow Legacy IDs, Availity will not strip the Legacy ID and submit to the plan.
Rest assured that Availity does not remove legacy identifiers from transactions to ensure that our customers' data is secure, accurate, and in the format required by our participating health plans.
Register your NPI with health plans
Providers must ensure they have correctly registered their NPI with any applicable health plans prior to including them on any health care transactions. Availity is not responsible for registering individual NPI numbers or verifying the accuracy of the NPI registered for a given provider. Additionally, it is also imperative to include the XX qualifier in any transactions which require the NPI.
Availity will continue to accept the existing legacy identifier as the primary identifier for atypical providers. Atypical providers are non-health care providers who are not eligible to obtain an NPI, such as taxi and construction companies. Such providers will need to register their identifiers with Availity. Availity will maintain a database of registered identifiers and refer to it to determine if an NPI is required for the submitting provider.
- Web - Atypical providers submitting via the web must complete the ID tab within the Maintain Provider function by selecting the option indicating that they are not required to have an NPI and completing the ID field for their primary identifier. This functionality is currently available.
- Non-Web (EDI/B2B) - Transactions submitted by or on behalf of atypical providers without an NPI will be rejected unless they are registered as an atypical provider with Availity. You may contact Client Services for assistance in registering atypical providers. If you wish to contact Availity on behalf of your atypical providers, we request that you send a list of atypical providers and their primary identifiers to email@example.com ahead of time. This will ensure a smooth transition for the atypical providers, and avoid rejections and possible claim delays.
This registration allows Availity to relax the NPI requirement in order to properly pass the transaction to the health plan. Availity has no way of knowing every impacted health plan, and therefore cannot notify health plans of a provider’s atypical status. Atypical providers should notify applicable health plans of their status so that transactions are not rejected by the payer for a missing NPI.