TRICARE Operations Manual 6010.62-M, April 2021
Health Insurance Portability and Accountability Act (HIPAA) of 1996
Chapter 19
Section 4
HealthInsurance Portability And Accountability Act (HIPAA) Standard UniqueHealth Identifier For Health Care Providers (HCPs) Final Rule
Revision:
1.0BACKGROUND AND PROVISIONS
On January 23, 2004, Healthand Human Services (HHS) published the Final Rule 45 Code of FederalRegulations (CFR) Part 162, known as “HIPAA Administrative Simplification:Standard Unique Health Identifier for Health Care Providers,” establishingthe National Provider Identifier (NPI) as the standard unique healthidentifier for HCPs (both individuals and organizations). The implementationspecifications contained in the rule shall be met by “covered entities”which include health plans, clearinghouses, and providers who submitHIPAA-compliant standard electronic transactions, as defined bythe HIPAA regulations at 45 CFR 160.103. The compliance date forall covered entities was May 23, 2007.
2.0PROVIDERS
2.1HHS definesa HCP in Section 1861(u) of the Act, 42 United States Code (USC)1395X(u), as a provider of medical or health services, which isalso defined in section 1861(s) of the Act, 42 USC 1395X(s). Generally,a provider is a person or organization who furnishes, bills, oris paid for health care in the normal course of doing business.
2.2For thepurposes of the applicability of the rule to Defense Health Agency(DHA), see the TRICARE Policy Manual (TPM), Chapter 11, Section 1.1, for a listing ofauthorized provider types.
2.3HCPs are defined in two categoriesfor enumeration purposes:
•Entity Type 1. Individual.Includes, but is not limited to, those human beings who providecare such as, physicians, Nurse Practitioners (NPs), dentists, chiropractors,pharmacists, and Physical Therapists (PTs).
•Entity Type 2. Organizational.Includes, but is not limited to, non-person providers such as hospitals,Home Health Agencies (HHAs), clinics, laboratories, suppliers ofDurable Medical Equipment (DME), pharmacies, and groups.
2.4ForeignProviders
2.4.1A foreign provider is definedas a provider who is not a citizen of the United States (US), regardlessof the country in which the provider is practicing.
2.4.1.1Foreign providers may be authorizedTRICARE providers, however, they are not required to obtain an NPI(due to limited ability to comply with the application requirements),but may choose to do so voluntarily.
2.4.1.2Electronic transactions (e.g.,claims transactions) submitted by foreign providers for adjudicationmay be submitted using legacy identifiers for provider identificationpurposes; however, if a foreign provider obtains an NPI, they areencouraged to use the NPI as the primary provider identifier onthe electronic transaction.
2.4.2Providerswho are citizens of the US, practicing outside the 50 US and theDistrict of Columbia. (e.g., Puerto Rico), are not considered tobe foreign providers.
2.4.2.1If the provider practicingoutside the 50 US and the District of Columbia is a US citizen andmeets the HHS definition of a covered entity, the provider is requiredto obtain an NPI for the submission of HIPAA-compliant electronicstandard transactions and comply with the Final Rule.
2.4.2.2Electronic transactions submittedby “covered entities”, who are US citizens, that are not HIPAA- compliantshall be denied as appropriate.
2.5SubpartEnumeration
2.5.1Subpart enumeration is theresponsibility of the organizational provider.
2.5.2In accordancewith the Final Rule, organizational providers will determine towhat extent subpart enumeration is required and identify which ofthe subparts, if any, of their organizational entity will be identifiedvia a separate enumerator.
2.5.3The organizationalprovider will also determine how the various enumerators obtainedwill be used for billing purposes.
3.0CONTRACTORRESPONSIBILITIES
3.1The contractor shall complywith provisions of the HIPAA Final Rule for HIPAA Administrative Simplification:Standard Unique Health Identifier for HCPs Final Rule.
3.2The contractorshall accept National Provider Identifiers (NPIs) when submittedby providers and use the NPI as the primary identifier to identifyHCPs in all HIPAA-compliant electronic standard transactions inaccordance with the transaction Implementation Guide.
3.3The contractorshall deny all claims transactions that do not meet the requirementsof the Final Rule.
3.4Since the National UniformBilling Committee (NUBC) and the National Uniform Claims Committee (NUCC)have modified the Centers for Medicare and Medicaid Services (CMS)1450 UB-04 and the CMS 1500 Claim Form to accommodate the use ofthe NPI on the paper forms.
3.5The contractorshall accept and use the NPI if submitted on the paper form forprovider identification and claims adjudication.
3.6The contractorshall verify NPIs using the check digit algorithm in accordancewith the Final Rule, 45 CFR Part 162.
3.7The contractorshall maintain the NPI in their internal provider file. Upon directionof the Contracting Office (CO) and future revision of the TRICARESystems Manual (TSM), Chapter 2 toaddress the NPI requirements for the TRICARE Encounter Provider(TEPRV) records and TRICARE Encounter Data (TED) record.
3.8The contractorshall create and submit to DHA a new TEPRV record when a providersubmits their NPI to the contractor.
•Type 1 NPI for professionalproviders.
•Type 2 NPI for organizationalproviders.
•Type 2 NPI for subparts oforganizational providers that have been separately enumerated, e.g.,different NPIs for different departments within an institution,the contractor shall list the Type 2 NPI for each subpart identifiedby the provider.
3.9CoveredIndividual (Type 1) HCPs
3.9.1The contractor shall ensurethat HIPAA transactions received identify the provider’s NPI onall HIPAA-compliant electronic standard transactions in accordancewith the Implementation Guide for the transaction.
3.9.2The contractorshall ensure electronic transactions submitted by business associatesof the individual provider use their NPIs and NPIs of other HCPsand subparts appropriately for the submission of HIPAA-compliant electronicstandard transactions in accordance with the Implementation Guidefor the Transaction.
3.10CoveredOrganizational (Type 2) HCPs
3.10.1The contractor shall ensurethat transactions submitted by the organizational entity or itssubparts use the NPI on HIPAA-compliant electronic standard transactions.
3.10.2The contractor shall ensurethat transactions submitted by the organizational subparts complywith the NPI implementation specifications.
3.10.3The contractor shall ensurethat business associates of the organizational entity or its subpartsuse their NPIs and NPIs of other HCPs and subparts appropriatelyfor the submission of HIPAA-compliant electronic standard transactions.
3.11ApplicationOf NPI To TRICARE Processes And Systems
3.11.1The contractor shall use theNPI as the primary provider identifier for all TRICARE authorizedproviders who meet the HHS definition of “covered entities” andsubmit HIPAA-compliant electronic standard transactions.
3.11.2The contractor shall also acceptthe NPI as the primary identifier on paper claims from providers.
3.11.3The contractor shall use theNPI, as appropriate, for the identification of providers in theDefense Enrollment and Eligibility Reporting System (DEERS).
3.11.4Upon direction of the CO andfuture revision of the TSM, Chapter 2,the NPI shall be used as the primary provider identifier for TEPRVand TED records, for HCPs who meet the HHS definition of coveredentity and submit HIPAA-compliant electronic standard transactions.The NPI will also be used as the primary provider identifier on theTEPRV and TED record for providers who obtain an NPI and submitpaper claim forms.
3.11.5TED records will identify boththe individual or organizational provider NPI as appropriate. For providerswho are part of a group or clinic practice, the TED record willreflect the NPI for the group or clinic as well as the NPI of theindividual provider. TED records submitted for Institutional claimsshall include the NPI for the Organizational (Type 2) entity. IndividualNPIs shall not be submitted on institutional TED records.
3.11.6NPI shall be used for the identificationof providers on referrals and authorizations as appropriate.
3.12NPIUsage In HIPAA Adopted Standard Transactions
3.12.1The contractor shall collect,use, and retain NPI’s for activities such as the processing andresolution of claims, duplicate claims identification, medical utilization,fraud investigation, third party claim submissions and claim reporting.
•Accredited Standards Committee(ASC) X12N 837 - Health Care Claim: Professional, Institutional,Dental. The NPI shall be employed in accordance with the usage specificationsof the HIPAA Implementation Guide, guide addenda or errata, andany companion documents.
•ASC X12N 270/271 - Health CareEligibility Benefit Inquiry and Response. The NPI shall be employedin accordance with the usage specifications of the HIPAA ImplementationGuide, guide addenda or errata, and any companion documents. DEERSwill capture and maintain the NPI for individual providers to facilitate HealthCare Eligibility Inquiry and Response transactions and has the capabilityto capture and maintain the NPI for organizational providers.
•ASC X12N 278 - Health CareServices Review - Request for Review and Response. The NPI shallbe employed in accordance with the usage specifications of the HIPAAImplementation Guide, guide addenda or errata, and any companiondocuments.
•ASC X12N 276/277 - Health CareClaims Status Request and Response. The NPI shall be employed inaccordance with the usage specifications of the HIPAA ImplementationGuide, its addend, errata, and any companion documents. When required,the NPI shall be used in the electronic standard exchange betweenentities requesting health care claim status, organizations sendingthe health care claim status response and other business partnersaffiliated with the health care claim status request and response.
•ASC X12N 834 - Benefit Enrollmentand Maintenance. DMDC will modify Government furnished web-based system/applicationto include the NPI where appropriate and in compliance with theHIPAA Implementation Guide, its addenda, errata, and any companiondocuments.
•ASC X12N 835 - Health CareClaim Payment/Advice. The NPI shall be submitted in accordance withthe usage specifications of the HIPAA Implementation Guide, itsaddenda, errata, and any companion documents. The NPI will be usedwhen communicating the status of a health care claim payment.
•National Council for PrescriptionDrug Program (NCPDP) latest HIPAA adopted version. This NCPDP transaction andthe latest HIPAA adopted NCPDP Batch Standard version may be usedfor eligibility checking as well as for claims-related transmissions.
3.12.2The contractor shall utilizethe NPI and any other pertinent identifiers to correctly creditand debit the provider.
3.12.3The contractor shall utilizethe NPI in the transaction as defined in NCPDP guidance for the implementationand use of the transactions. For retail pharmacy, the contractorshall comply with the standards adopted in the implementation specifications,as directed in current HIPAA adopted Final Rules.
3.12.4The contractor shall modifyCompanion Guides to provide specific guidance with regard to theNPI and its corresponding entity type code for use as the primaryprovider identifier, as appropriate.
3.13WebServer Technology
3.13.1The contractor may choose toutilize the NPI for other provider identification purposes, at nocost to the Government and at their own discretion, on contractordeveloped and maintained web applications.
3.13.2However, this is not to beconstrued as instruction from DHA to develop, operate, modify, ormaintain contractor web applications.
3.13.3Use of the NPI on contractorweb applications shall be in accordance with the requirements ofthe HIPAA Final Rules.
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