HIPAA Provider Identifier Rule
Provider identifier rule strives to simplify red tape
By: Greg Alterton
With most of the attention and effort regarding compliance with the Health Insurance Portability and Accountability Act directed toward the privacy rule in 2003, and now the security rule in 2005, what is often lost on the regulated community is that the basic intent of Congress in passing HIPAA was to simplify the administration of health care.
HIPAA does this by encouraging the use of electronic transactions between health care providers and payers, and by standardizing the data necessary for specified transactions. This standardization was embodied in the transaction and code sets rule that went into effect in October last year. The U.S. Department of Health and Human Services adopted another regulation in January of this year related to this simplification goal: the national provider identifier standard rule. The rule goes into effect May 23, 2005, and has a final compliance date two years later – May 23, 2007.
Currently, dental plans assign an identifying number to each provider with whom they conduct electronic transactions, e.g., electronic claims. Since providers typically work with several dental plans, they are likely to have a different ID number for each plan, i.e., separate numbers for Medicaid, Blue Cross, Blue Shield, TriCare and various other commercial plans.
The standard provider identifier rule, also called the national provider identifier, will ensure that one unique ID number will be assigned to each provider and will be used in transactions with all health plans. The HIPAA rule requires that national provider identifiers be used by all regulated providers and accepted by all clearinghouses and health plans in connection with the electronic transactions that are covered by HIPAA.
Providers who are “covered entities” within HIPAA will receive their unique identifier number by applying for the number to the U.S. Department of Health and Human Services. ADA plans to assist member dentists in applying for their identifiers. However, no provider need apply to Health and Human Services for the number until May 23, 2005, the effective date of the regulation. That is the earliest date that any application will be accepted by Health and Human Services.
Again, HIPAA defines a “covered entity” as a health care provider who conducts certain specified transactions electronically with third-party payers. However, while the national provider identifier requirement only applies to HIPAA “covered entities,” and because the regulation establishes a national provider identifier system, third-party payers may require all providers – those under HIPAA, and those who are not – to submit claims using a Health and Human Services-assigned provider identification number after May 23, 2007.
The HIPAA-required national provider identifier will be permanent; it’s one number for use on HIPAA-compliant transaction forms, for all time. The identifier will not include coded information about the health care provider. Karen Trudel of the Health and Human Services’ Centers for Medicare and Medicaid Services, which promulgated the rule, said, “If the [national provider identifier] were to include intelligence, that is, coded information about the health care provider, as part of the identifier, a new [national provider identifier] would have to be issued any time the coded information about the provider changed. This would undermine the lasting nature of the [identifier].”
For further information on the national provider identifier rule, or other HIPAA requirements, contact Greg Alterton at (800) 736-7071, Ext. 8870. Dentists may also e-mail an inquiry to grega@cda.org, or to the ADA at hipaa@ada.org.