NPI & Payer Codes FAQs

Expand All | Collapse All

What are National Provider Identifiers (NPIs)?

Answer: National Provider Identifiers (NPIs) are unique identification numbers that are required for all eligible health care providers. A single 10-digit NPI number will replace your current provider identification number(s) used to conduct standard transactions with health plans.

To learn more about the National Provider Identifier standard, visit the dedicated NPI section of the Centers for Medicare and Medicaid Services (CMS) website.

To apply for an NPI:

  • Log on to the National Plan and Provider Enumeration System (NPPES) and apply online; or
  • Obtain a copy of the paper NPI Application/Update Form (CMS-10114) by contacting the NPI Enumerator in one of three ways:
  • Then, mail the completed, signed application to the NPI Enumerator located at the mailing address above.
Who should get an NPI?

Answer: All eligible health care providers. There are two types of providers:

  • Type 1 - Health care providers who are individuals (practitioners), including physicians, dentists, and all sole proprietors. If you represent an unincorporated solo practice and have received only a Type 1 NPI, please do not submit that NPI as a Type 2 Organizational NPI. Instead, submit the NPI as the practitioner’s NPI.
  • Type 2 - Health care providers who are organizations, including physician groups, hospitals, nursing homes, and the corporation formed when an individual incorporates him/herself. Other examples include independent laboratories, ambulatory surgery centers, multiple physician practices or incorporated solo practices.

Example: If a practice has five practitioners, each practitioner will need an NPI number (Type 1). The group will also need an NPI number (Type 2).

Should paper billers obtain an NPI number?

Answer: Yes, all eligible health care providers, regardless of their participation in electronic submissions, should obtain an NPI.

What is a sub-part?

Answer:There is no strict definition of a sub-part as part of the HIPAA regulations. It appears that this was left ambiguous to provide some flexibility for businesses. Below are the parameters of a sub-part:

  • Only organizations, group practices, health systems (Type 2) can subpart
  • A sub-part is simply a unique or distinct part of a larger business, organization or practice
  • An NPI that has been issued to a sub-part does not behave any differently than any other NPI
  • An organization may choose to sub-part for any number reasons including:
    • Different specialties or departments
    • Different locations
    • Unique contractual arrangements with health plans
  • Not all organization providers have sub-parts
    • The way an organization sub-parts and obtains NPI numbers is entirely up to that organization. CareFirst is not equipped to offer advice or guidance regarding the number of NPIs an organization should request.
Does my NPI replace my Tax Identification Number (TIN)?

Answer: No, the NPI does not replace the TIN.

How should I send my NPI number(s) to CareFirst?

Answer:If at any time your provider or practice information changes, you will need to let CareFirst know. NPI numbers can be accepted from providers in a variety of formats. You can:

  • update your information online by logging into the Provider Portal (CareFirst Direct),
  • submit a Change in Provider Information Form – Professional,
  • send your NPI information directly to our Provider Information and Credentialing Department using the NPI Submission form, or
  • send your NPI Submission form or spreadsheet by fax to (410) 505-2959 or by mail to:

    CareFirst BlueCross BlueShield/CareFirst BlueChoice, Inc.
    Provider Information and Credentialing
    10455 Mill Run Circle
    PO Box 825 Mailstop CG-41, ATTN: NPI
    Owings Mills, MD 21117
Why do I need to send my Social Security number on the NPI Submission form? If CareFirst has my Tax ID, why do they need my Social Security number?

Answer: A provider’s Social Security number is just another one of the data elements we are using to verify that the NPI submitted is linked to the appropriate legacy provider ID number for the purpose of our crosswalk and our provider files.

Should I continue to use legacy or proprietary ID numbers on electronic or paper claims and inquiries?

Answer: CareFirst requires the NPI be submitted on all claims (electronic and paper). Submission of your legacy provider number is up to you but is no longer required. Providers are required to submit their NPI on the current CMS 1500 (02/12) version of the professional claim form and the UB-04 version of the institutional claim form.

Expand All | Collapse All