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National Provider Identifier (NPI) Glossary

Covered Entity – means:

  1. A health plan
  2. A health care clearinghouse
  3. A health care provider who transmits any health information in electronic form in connection with a transaction covered HIPAA

Covered Health Care Provider – means a provider of medical or health services and any other person or organization who furnishes, bills, or is paid for health care in the normal course of business.

CMS Centers for Medicare & Medicaid Services (CMS) - (formerly known as HCFA) the Department of Health and Human Services (HHS) agency responsible for Medicare and parts of Medicaid. CMS has historically maintained the UB-92 institutional EMC format specifications, the professional EMC NSF specifications, and specifications for various certifications and authorizations used by the Medicare and Medicaid programs. CMS also maintains the HCPCS medical code set and the Medicare Remittance Advice Remark Codes administrative code set.

EIN – See Employer Identification Number

Employer Identification Number (EIN) – The number assigned by the Internal Revenue Service (IRS) for tax purposes. The Tax Identification Number is also known as TIN.

Entity Type Code – The type of health care provider that is being assigned an NPI. Codes are as follows:

Entity Type Code 1 (A Person) – Individuals who render health care or furnish health care supplies to patients; e.g., physicians, dentists, nurses, chiropractors, pharmacists, physical therapists. Note: Individuals who have incorporated may also have the corporation obtain an NPI as a Type 2 organization. Entity Type Code 2 (A Non-Person) – Organizations other than an individual that render health care services or furnish health care supplies to patients; e.g., hospitals, home health agencies, ambulance companies, health maintenance organizations, durable medical equipment suppliers, pharmacies, group practices.

Enumerator – An organization under contract with the Department of Health and Human Services to assign NPIs. The enumerator is responsible for the following:

  • Receive and process National Provider Identifier (NPI) applications; 
  • Notify health care providers of their NPIs;
  • Use the National Plan and Provider System (NPPES) to ensure the unique identification of a health care provider; 
  • Answer questions about the processes of applying for and obtaining NPIs;  
  • Furnish providers with updates; 
  • Collect information via the applications and updates;
  • Maintain the NPPES database containing NPIs and information about the health care providers to which they are assigned; and 
  • Furnish information upon request and in accordance with established guidelines.

Health Care Clearinghouse – Under HIPAA, this is an entity that processes or facilitates the processing of information received from another entity in a nonstandard format or containing nonstandard data content into standard data elements or a standard transaction, or that receives a standard transaction from another entity and processes or facilitates the processing of that information into nonstandard format or nonstandard data content for a receiving entity.

Health Information - means any information, whether oral or recorded in any form or medium, that:
  • Is created or received by a health care provider, health plan, public health authority, employer, life insurer, school or university, or health care clearinghouse; and
  • Relates to the past, present, or future physical or mental health or condition of an individual, the provision of health care to an individual, or the past, present, or future payment for the provision of health care to an individual.

    HIPAA – The Health Insurance Portability and Accountability Act - This Federal law has several components that provide for

    • Portability of health care coverage
    • Standards to be used when transmitting health information electronically
    • Medical and administrative code sets to be used within those standards 
    • Identifiers to be utilized by providers, health plans, employers and individuals 
    • Measures required to protect the security and privacy of personally identifiable health care information.

    Individual Health Care Provider – Health care providers who are human beings.  These providers are considered entity type code 1. Examples are physicians, dentists, nurses, chiropractors, pharmacists and physical therapists.

    IRS – Internal Revenue Service

    IRS Individual Taxpayer Identification Number (IRS ITIN) – The tax identification number assigned by the Internal Revenue Service to individuals/entities who are not eligible for a Social Security Number (SSN).

    National Provider Identifier (NPI) – A 10-position, intelligence-free numeric identifier (10-digit number). This means that the numbers do not carry other information about healthcare providers, such as the state in which they live or their medical specialty. Beginning May 23, 2007 (May 23, 2008, for small health plans), the NPI must be used in lieu of legacy provider identifiers.

    • Legacy provider identifiers include:
    • Online Survey Certification and Reporting (OSCAR) system numbers;
    • National Supplier Clearinghouse (NSC) numbers;
    • Provider Identification Numbers (PINs); and
    • Unique Physician Identification Numbers (UPINs) used by Medicare
    • Blue Cross Blue Shield Numbers used by BCBS

    They do not include taxpayer identifier numbers (TINs) such as:

    • Employer Identification Numbers (EINs); or
    • Social Security Numbers (SSNs)

    National Provider System (NPS) – Now known as National Plan and Provider Enumeration System (NPPES).

    National Plan and Provider Enumeration System (NPPES) – The administrative system for supporting a national plan and provider registry. This is a comprehensive uniform system for identifying and uniquely enumerating health care providers and plans at the national level.

    Nonhealth Care Services – Atypical or nontraditional services that are indirectly related to health care but do not fall within the definition of health care services. These could include taxi, home and vehicle modifications or insect control.

    NPI – See definition for National Provider Identifier

    NPPES – National Plan and Provider Enumeration System

    NPS – National Provider System; now known as NPPES

    Organization Health Care Provider – Health care providers who are not individuals (persons). These providers are classified as entity type code 2 providers. Examples are hospitals, home health agencies, clinics, nursing homes, residential treatment centers, laboratories, ambulance companies, group practices, suppliers of durable medical equipment, supplies related to health care, prosthetics and orthotics, and pharmacies.  The organization health care provider is responsible for determining if its subparts must be assigned NPIs and is ultimately responsible for complying with the HIPAA rules and for ensuring that its subparts and/or health care components are in compliance.

    Payer – In health care, an entity that assumes the risk of paying for medical treatments. This can be a health plan, a self-insured employer, or an HMO. 

    SSA – Social Security Administration

    SSN – Social Security Number

    Social Security Number (SSN) – A number assigned by the Social Security Administration (SSA) to the individual being identified.

    Subpart – A health care provider that is an organization may be comprised of components that function as health care providers somewhat independently of the “parent” (the covered organization health care provider of which they are a part). These components, which are referred to as  “subparts” in the regulation,  might conduct their own HIPAA standard transactions, might be certified by the State separately from their “parent,” or might be located at the same or different location as/from, their “parent”. The covered organization health care provider needs to determine if it consists of any such subparts, and, if it does, it must determine if any of those subparts need to have their own unique NPIs in order to be identified in HIPAA standard transactions. Many providers that are enrolled in Medicare are actually subparts. Examples of subparts may include different components of an organization health care provider, such as different departments of a hospital or separate physical locations of an organization health care provider.

    Tax Identification Number (TIN) – The number assigned by the Internal Revenue Service (IRS) for tax purposes. Also known as the Employer Identification Number.

    Taxonomy Code – An administrative code set that classifies health care providers by type, classification and specialization.

    TIN – Tax Identification Number

    TPA (Third Party Administrator) - An entity that processes health care claims and performs related business functions on behalf of another organization.  They may be engaged by a health plan, self-insured group, or others to perform the functions of or be the point of contact with a health plan.

    Transaction - means the transmission of information between two parties to carry out financial or administrative activities related to health care. It includes the following types of information transmissions:

    1. Health care claims or equivalent encounter information.
    2. Health care payment and remittance advice.
    3. Coordination of benefits.
    4. Health care claim status.
    5. Enrollment and disenrollment in a health plan.
    6. Benefit Eligibility / Coverage with a health plan.
    7. Health plan premium payments.
    8. Referral certification and authorization.
    9. First report of injury.
    10. Health claims attachments

    UPIN – Unique Physician Identification Number