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HHS adopts HIPAA standard HPIDs, beefs up NPI requirements


A new HIPAA standard for national unique health plan identifiers will save primary care physicians money and time, according to the Centers for Medicare and Medicaid Services.

The U.S. Department of Health and Human Services (HHS) has adopted a Health Insurance Portability and Accountability Act (HIPAA) standard for national unique health plan identifiers (HPIDs) as part of its ongoing effort to “streamline healthcare administrative transactions, encourage greater use of standards by healthcare providers, and make existing standards work more efficiently."

The final rule announcing the change also addresses issues that occur when non-health plan and non-healthcare provider organizations, such as pharmacies, submit claims that lack the national provider identifier (NPI) of certain prescribing physicians in their claims.

In January 2004, HHS announced that it had adopted the NPI as the standard unique healthcare provider identifier. It also published physician requirements for obtaining and using the NPI. Since that time, however, pharmacies have had trouble submitting claims in cases where an NPI from a prescribing physician was missing from the pharmacy claim. Medicare Part D claims, in particular, have been problematic.

The new final rule addresses this issue by requiring non-covered healthcare providers who prescribe at covered healthcare provider organizations, such as hospitals, to obtain and provide an NPI. Doctors and other “covered entities” who do not currently possess an NPI are required to apply for one within 180 days from the final regulation’s effective date.

The Centers for Medicare and Medicaid Services (CMS) believes that the new NPI requirements will have little negative affect on the healthcare industry as a whole, because most physicians currently have and use NPIs. It is expected, however, to resolve the difficulties pharmacies have been having with rejected claims.

CMS also expects the new HIPAA HPID standard, announced as part of the final rule, to save the healthcare industry $1.3 billion to $6 billion over 10 years. Much of these savings, CMS says, will directly benefit primary care physicians in the form of a reduction in the time practice administrators will spend interacting with health plans, chasing down patient insurance eligibility information, and fixing rejected claims. In addition, CMS expects the automation of claims transactions that until now had to be completed manually to result in significant savings for physicians.

The final rule also includes a new data element to be used as an “other entity” identifier (OEID). The OEID is used when entities that are not health plans, healthcare organizations, or individual healthcare providers, must, nevertheless, be included on an insurance claim.

In the final rule, HHS also adopted a 1-year delay (from October 1, 2013, to October 1, 2014) for requiring covered entities to adopt the International Classification of Diseases, 10th Edition, or ICD-10, as previously reported by Medical Economics.

CMS has posted a

fact sheet


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