The Health Insurance Portability and Accountability Act (HIPAA) of 1996 requires the adoption of a standard unique identifier for health care providers. The NPI Final Rule issued January 23, 2004, adopted the NPI as this standard. The following resources will help you understand and deal with the NPI and its impact on Arkansas Medicaid.

For general information about NPI, see the CMS website and the NPPES website.

NPI Numbers and Electronic Transactions

Arkansas Medicaid will only accept the National Provider Identifier (NPI) number anywhere a provider number is required on electronic transactions. Some examples would be the billing, performing, requesting, attending, referring and prescribing provider number as appropriate for the transaction submitted. The NPI must also be used on electronic eligibility verification transactions.

Enrolled providers must report their NPI to Arkansas Medicaid. In order to report your NPI, log on the Health Care Provider Portal by entering your user ID and password. Proceed by following the steps to report your NPI. If you have already reported your NPI number to Arkansas Medicaid, your NPI information has been successfully linked to your Arkansas Medicaid Provider number.

If you have any questions or problems regarding your NPI, contact Provider Enrollment at (501) 376-2211 (local) or at (800) 457-4454 (toll free).

Providers who are not eligible for an NPI will continue to use their Arkansas Medicaid provider ID as always.

If you submit paper claims, you must use your Arkansas Medicaid Provider ID. Paper claims submitted with only an NPI will be returned for correction.

NPI Registry and Downloadable File Available at NPPES website

National Plan & Provider Enumeration System (NPPES) health care provider data that is disclosable under the Freedom of Information Act (FOIA) will be disclosed to the public by the Centers for Medicare & Medicaid Services (CMS). In accordance with the e-FOIA Amendments, CMS has disclosed the data via the Internet. Data is available in two forms:

• A query-only database, known as the NPI Registry.
• A downloadable file.

The NPI Registry and downloadable data file are available at the NPPES website. Links to the Registry and the NPPES data file have been added to the “Helpful Information for Providers” menu for quick access. The Registry and the downloadable NPPES data file allow you to search for providers’ NPI numbers. Prescribers’ and referring physicians’ NPI numbers are necessary for electronic billing.

Go to the NPPES website to view or use the NPI Registry.
Go to the NPPES website to download the data file.
More information about NPPES Data Dissemination.

NPI Reporting Using the Crosswalk Tool

If you are a typical provider, you are required to report your NPI to Gainwell Technologies. If you submit claims without having reported your NPI, your claims will be denied with the error code “provider not on file.” Gainwell Technologies developed a reporting crosswalk tool to help providers communicate their National Provider Identifiers to Arkansas Medicaid. The reporting crosswalk tool will step you though entering the necessary data so Arkansas Medicaid can recognize your new ID number. Please note that your physical address could be used to help determine who you are when submitting claims electronically with your NPI, so make sure you verify the physical billing address we have on file for you.

To verify your address and report your NPI online, log on the Health Care Provider Portal . Select “Demographics Update.” Verify that we have your correct demographic information on file. From Available Tools select “Report NPI.”

For assistance reporting your NPI, please contact the Provider Enrollment Unit. For billing related issues with your NPI, contact the Provider Assistance Center (PAC). You may reach Provider Enrollment or PAC by calling toll-free (800) 457-4454 or local (501) 376-2211. Select option 0 for “Other inquiries” and then option 3 for “Provider Enrollment” when prompted or option 2 for “Provider Assistance Center” when prompted.

What is the National Provider Identifier (NPI)?

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 requires the adoption of a standard unique identifier for health care providers. The NPI Final Rule issued January 23, 2004, adopted the NPI as this standard.

The NPI is a 10-digit, intelligence-free numeric identifier (10-digit number). Intelligence-free means the numbers do not carry information about health care providers, such as the state in which they practice or their provider type of specialization.

The NPI replaces health care provider identifiers in use today in HIPAA standard transactions. Those identifiers include the Arkansas Medicaid provider number otherwise known as the legacy provider identifier (LPI) and Medicare legacy provider identifier such as the unique physician/provider identification number (UPIN); Online Survey, Certification, and Reporting (OSCAR); physician/provider identification number (PIN); and National Supplier Clearinghouse (NSC).

The provider’s NPI does not change and remains with the provider regardless of job or location changes.

What is the purpose of the NPI?

The NPI is a single identification number assigned to health care providers. It is intended to improve the efficiency of the health care system and help to reduce fraud and abuse. The intent of the NPI is to eliminate the need for payers and providers to keep numerous identifiers and in turn simplify transaction processing between entities.

Who is eligible for an NPI?

In order to get an NPI, a provider must be a health care provider as defined under HIPAA. A “covered entity” is defined as a health care provider, clearinghouse or health plan who conducts standard electronic transactions. The Final Rule for NPI requires a “covered entity” health care provider to get an NPI. These “covered entities” must use the standards when conducting any of the defined transactions covered under HIPAA.

Covered entities are further described as:

• Private sector health plans including:
  • Managed care organizations (MCOs)
  • Employee Retirement Income Security Act (ERISA) plans, excluding some small self-administered health plans
• Government health plans including:
  • Medicare
  • State Medicaid programs
  • Military Health System (for active duty and civilian personnel)
  • Veterans Health Administration
  • Indian Health Service programs
• Health care clearinghouses
• Health care providers that choose to submit or receive electronic transactions

With the exception of atypical providers, Arkansas Medicaid requires all health care providers (individual, organization, and subparts of an organization) submitting electronic claims to obtain an NPI. Atypical providers conducting services like transportation or carpentry may not be considered health care services and therefore may be ineligible to get an NPI.

What is the definition of an atypical provider and how will Gainwell Technologies handle those transactions?

An individual or business that is not a health care provider and does not meet the definition of a health care provider according to the NPI Final Rule. “Atypical” means non-traditional medical services. Examples are pest control, remodeling, chore services, non-emergency transportation providers, and so forth.

Gainwell Technologies will continue to identify providers that are not eligible for an NPI with their Arkansas Medicaid Provider ID.

For Arkansas Medicaid, atypical providers include

• 06 Autism Specialty AV intensive intervention (group only)
• 06 Autism Specialty AW consultant
• 06 Autism Specialty AX lead-line therapist
• 06 Autism Specialty AZ clinical services specialist (group only)
• 15 Transportation Specialty TC non-public transportation
• 15 Transportation Specialty TD NET transportation broker
• 23 Specialty X2 optical dispensing contractor
• 32 Personal Care Specialty P1 private care agency or health agency
• 32 Personal Care Specialty PA Area Agency on Aging
• 32 Personal Care Specialty PD DDS
• 32 Personal Care Specialty PE weekend
• 32 Personal Care Specialty PG level 1 assisted living
• 32 Personal Care Specialty PS public school or education services
• 32 Personal Care Specialty R3 residential care facility
• 51 ARChoices adult family home
• 53 ARChoices Specialty E7 home delivered meals
• 53 ARChoices Specialty EC frozen home delivered meals
• 54 ARChoices personal emergency response systems
• 55 ARChoices adult day care
• 56 ARChoices adult day health care
• 57 ARChoices respite
• 67 ACS waiver supported living
• 70 Medicare Health Advantage Plan eligibility only
• 71 ACS waiver consultation services
• 72 ACS waiver environmental modifications—adaptive equipment
• 73 ACS waiver specialized medical supplies
• 74 ACS waiver case management services
• 75 ACS waiver-supported employment
• 82 ACS waiver organized health care delivery system
• 84 APD environmental adaptations
• 85 ACS waiver crisis intervention
• 86 non-Medicaid provider DDS non-Medicaid
• 87 Independent choices
• 95 Registered, Noncredentialled Providers Specialty BP board certified behavior analyst paraprofessional
• 95 Registered, Noncredentialled Providers Specialty CS community support staff
• 95 Registered, Noncredentialled Providers Specialty NT qualified behavioral health provider (QBHP)/personal care aide/non credentialed
• 95 Registered, Noncredentialled Providers Specialty NU resident
• 95 Registered, Noncredentialled Providers Specialty NV physician assistant
• 95 Registered, Noncredentialled Providers Specialty NW non-independently licensed clinicians
• 95 Registered, Noncredentialled Providers Specialty RS certified peer recovery support specialist BH/SU
• 97 Specialty AT ARChoices traditional agency attendant care
• 97 Specialty VS ARChoices in home care
• 98 ARChoices counseling case management

Can an atypical provider send standard transactions electronically?

Yes, an atypical provider such as a non-emergency transportation provider may use electronic data interchange (EDI). Using EDI does not determine if the provider is providing health care services or not. Since a non-emergency transportation provider cannot get an NPI, the current Arkansas Medicaid Provider ID must be used.

A typical health care provider must use a valid NPI on electronic claims. An atypical provider does not use an NPI; this type of provider must use the Arkansas Medicaid provider number on electronic claims.

Who will issue NPI numbers?

The National Plan and Provider Enumeration System (NPPES) was elected by the Centers of Medicare & Medicaid Services (CMS) to assign the NPI to eligible health care providers. The NPPES also stores the information about enumerated providers.

There is no cost to apply and providers may apply for an NPI in one of three ways:

• Providers may apply through an easy web-based application process at https://nppes.cms.hhs.gov.
• The electronic file interchange (EFI) process, also referred to as “bulk enumeration”, allows a health care provider or group of providers to have a particular electronic file interchange organization (EFIO) apply for the NPI on their behalf. In other words, rather than having a provider or group of providers submit a paper or Web NPI application, the EFIO obtains an NPI for them via the submission of an electronic file. More information on EFI can be found at https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/NationalProvIdentStand/efi
• Arkansas Medicaid will not bulk enumerate on behalf of its providers.

Providers must furnish any updates to the NPPES within 30 days of the change if any of the required data submitted on the application changes.

Will NPIs automatically be issued?

No. If a provider wants to obtain an NPI, the provider is responsible for either applying directly for an NPI, or as part of another organization’s bulk enumeration process.

How long does it take to obtain an NPI?

As reported on the CMS website, “We cannot predict the amount of time it will take to obtain a National Provider Identifier (NPI) because several factors come into play. Such factors include the volume of applications being processed at a given time, whether the application was submitted electronically or on paper, and whether the application was complete and passed all edits. We expect that a health care provider who submits a properly completed electronic application could have its NPI in 10 days.”

Where may I learn more about NPI?

Medicare NPI policy and recommendations are available on the CMS website at https://www.cms.gov/regulations-and-guidance/administrative-simplification/nationalprovidentstand.

Where may I learn more about the NPI Application and Enumeration?

Information about NPI Application and Enumeration is available from the NPPES website.

Where may I find additional NPI information from CMS?

To get additional information from CMS, go to https://www.cms.gov/regulations-and-guidance/administrative-simplification/nationalprovidentstand.

What is the link to the NPI application process on the CMS website?

To apply for an NPI through the Internet, go to the NPPES website.

Will Arkansas Medicaid accept claims with both NPI and Arkansas Medicaid Provider IDs?

Arkansas Medicaid will read only the NPI on claims unless the provider is atypical. Atypical providers must continue to use their Arkansas Medicaid provider ID. Your Arkansas Medicaid provider ID may be given in the REF segment but your NPI will take precedence in our hierarchy.

Arkansas Medicaid only accepts the National Provider Identifier (NPI) number anywhere a provider number is required on electronic transactions. Some examples would be the billing, performing, requesting, attending, referring and prescribing provider number as appropriate for the transaction submitted. The NPI must also be used on electronic eligibility verification transactions.

Will a provider’s NPI ever change?

In most cases no. The following is a list of situations that could occur for a covered entity with an NPI:

• If a health care provider is deceased, the NPI will be deactivated.
• If a health care provider goes out of business, the NPI will be deactivated.
• If a health care provider moves to a different geographical location, it will not affect the NPI. The provider will maintain the same NPI for life.
• If a health care provider’s NPI is used in the case of fraud, a new NPI will be issued.

NOTE: Deactivated NPIs will never be issued to other health care providers.

How can I be sure my Medicaid claims won’t be rejected due to my NPI number?

Be sure to get your NPI and report it to Arkansas Medicaid using the Web-based NPI reporting crosswalk tool. Arkansas Medicaid only accepts the National Provider Identifier (NPI) number anywhere a provider number is required on electronic transactions. Some examples would be the billing, performing, requesting, attending, referring and prescribing provider number as appropriate for the transaction submitted. The NPI must also be used on electronic eligibility verification transactions.

For pharmacy providers, “NP” is no longer accepted for the prescriber ID. Pharmacy providers must use the prescriber’s NPI number. Pharmacy providers can obtain a prescriber’s Medicaid ID number by logging on the Health Care Provider Portal. You will need to enter your pharmacy Medicaid provider number and your federal tax number to obtain access to the Health Care Provider Portal.

If you do not process electronic transactions, do you need an NPI?

Yes. Arkansas Medicaid requires all health care providers (individual, organization, and subparts of an organization) who provide health care services and submit electronic or paper claims to obtain an NPI. If you refer a patient to a physician who submits claims electronically, your NPI will be required to complete their claims.

Do you need to use the NPI when billing claims?

Yes. If you are required to have an NPI for other transactions, you must also use it for billing claims.

Must all providers on the claim use their NPI numbers?

Yes, if a provider is required to get an NPI, it must be used on the claim for the billing, treating, referring, and attending providers.

What do I do if I am not eligible for an NPI and don’t have one?

You should continue to use your Arkansas Medicaid provider ID as you always have.

Should I use my NPI on paper claims?

Electronic billing has virtually eliminated the need for paper claims. If you submit paper claims, you must use your Arkansas Medicaid Provider ID. Paper claims submitted with only an NPI will be returned for correction. If you submit claims on paper, use the CMS-1500, CMS-1450, or dental claim form.

Do we have to get a different NPI for each service location?

No. The same NPI can be reported for different service locations; however, if the same NPI is reported, there must be a different taxonomy, zip code+4, or physical street address reported for the various locations.

How do I request a paper NPI application to apply for an NPI from the enumerator by telephone?

Call the NPPES Enumerator at 1-800-465-3203.

What standard transactions are affected by HIPAA?

As required by HIPAA, the Secretary of Health and Human Services is adopting standards for the following administrative and financial health care transactions:

• Health claims and equivalent encounter information
• Eligibility for a health plan
• Health care payment and Remittance Advice
• Health claim status
• Referral certification and authorization
• NCPDP

Where may I obtain Implementation Guides for standard transactions?

Implementation Guides are available from the CMS website or from Washington Publishing Company.

What are subparts?

Organization providers may have the option to obtain more than one NPI. Some components or subparts of an organization may be eligible to obtain separate NPIs. The following are examples of subparts:

• Certified separately
• Licensed separately by the State
• Required by Federal Regulations to have their own billing number

Subparts do not apply to individual providers. Only a provider can determine whether they need to apply for multiple IDs or subpart the provider’s organization.

Additional information about the types of providers and subparts may be obtained from the CMS website or the NPPES website.

What is the NPI reporting crosswalk tool?

The NPI reporting crosswalk tool is a Web-based application that allows providers to report their NPIs to Arkansas Medicaid.

If I’ve already received my NPI, why do I have to register it on the Provider Portal?

The federal government contractor hired to handle the NPI application and issue NPI numbers has not been given permission to release this information to Arkansas Medicaid or other payers. In order to link your NPI number with your Arkansas Medicaid provider ID, you must register your NPI with Arkansas Medicaid.

Does this website registration capture my NPI for all Arkansas health care payers?

No, only for Arkansas Medicaid.

What if I have questions about reporting NPI information to Arkansas Medicaid?

For assistance reporting your NPI, please contact the Provider Enrollment Unit. For billing related issues with your NPI, contact the Provider Assistance Center (PAC). You may reach Provider Enrollment or PAC by calling toll-free (800) 457-4454 or local (501) 376-2211. Select option 0 for “Other inquiries” and then option 3 for “Provider Enrollment” when prompted or option 2 for “Provider Assistance Center” when prompted.

Is information that you input using the NPI reporting crosswalk tool updated in real-time or in batch mode?

The information you enter into the NPI Reporting Tool is updated in real-time for viewing data but in batch mode for claims processing.

Will the NPI reporting crosswalk tool be the only way to report your NPI?

No. You can request a paper NPI Reporting Form to report your NPI. Using the Web-based NPI reporting crosswalk tool is quicker and more efficient. However, if you want to use a paper application, you may print a NPI Reporting Form or a NPI Change Form from Section V of your provider manual. When the NPI Reporting Form is received, Gainwell Technologies will enter the information into the system from the paper document.

How will rendering providers report their NPI to Arkansas Medicaid?

Groups are allowed to obtain NPIs from their rendering providers and report them to Arkansas Medicaid on the rendering providers’ behalf.

How do we remove rendering providers from our group using the NPI reporting crosswalk tool?

You cannot remove a rendering provider with the tool. If the NPI reporting crosswalk tool identifies a rendering provider that is no longer in your group, contact Provider Enrollment to disassociate the rendering provider. Provider Enrollment can be reached toll-free at (800) 457-4454 or local at (501) 376-2211. Select option 0 for “Other inquiries” and then option 3 for “Provider Enrollment” when prompted.

Will the rendering providers who are linked to the group display?

Yes. When a group logs into the NPI reporting crosswalk tool, all active rendering providers affiliated with the group are accessible under each group’s service locations. Groups are allowed to obtain the NPI from their rendering providers and report it to Arkansas Medicaid on the rendering providers’ behalf.

Can you do anything besides reporting your NPI on the NPI reporting crosswalk tool?

No. You can only report your NPI and associate your Taxonomy codes using this tool.

Can a rendering provider’s NPI be reported without reporting the group in the NPI reporting crosswalk tool?

Yes. An individual provider may report their NPI independently.

How can I remove a rendering physician that is showing linked to our group?

You must contact Provider Enrollment to disassociate the rendering provider. Provider Enrollment can be reached toll-free at (800) 457-4454 or local at (501) 376-2211. Select option 0 for “Other inquiries” and then option 3 for “Provider Enrollment” when prompted.

How do I link the Individual NPI to the group NPI?

If the Medicaid Provider numbers were previously linked, registering the NPIs will not affect those linkages. Registering your NPI will only create a one-to-one match between the Arkansas Medicaid Provider ID and the NPI. It will not affect individual-group provider relationships.

How do I correct errors made on the NPI reporting crosswalk tool?

Once an entry is submitted using the NPI reporting crosswalk tool, all changes require Gainwell Technologies intervention. Provider Enrollment can be reached toll-free at (800) 457-4454 or local at (501) 376-2211. Select option 0 for “Other inquiries” and then option 3 for “Provider Enrollment” when prompted.

How do I update our address in the NPI reporting crosswalk tool?

You cannot change your address using the NPI reporting crosswalk tool. To change your demographic information, submit an address change form. If you have questions, contact Provider Enrollment toll-free at (800) 457-4454 or local at (501) 376-2211. Select option 0 for “Other inquiries” and then option 3 for “Provider Enrollment” when prompted.

How can I tell if the NPI was successfully reported in the NPI reporting crosswalk tool?

In each provider subsection of the NPI reporting crosswalk tool, the provider number (nine-digit number) displays in the green, red, or blue header, and the status of the provider/NPI record. Before any NPI is reported the header will be Blue (not reported), an unsuccessful entry will be Red (conflict), and a successfully reported NPI will have a Green (Active) header.

Can I fax the NPI Reporting Form instead of mailing it?

Yes. You may fax the NPI Reporting Form to (501) 374-0746 or
mail it to
Medicaid Provider Enrollment Unit – NPI
Gainwell Technologies
P.O. Box 8105
Little Rock, AR 72203-8105

Can I report my NPI over the phone?

No, but you may fax the NPI Reporting Form to (501) 374-0746. If you have questions about reporting NPI information, please contact Provider Enrollment toll-free at (800) 457-4454 or local at (501) 376-2211. Select option 0 for “Other inquiries” and then option 3 for “Provider Enrollment” when prompted.

Can we enter more than 1 taxonomy code?

No. The NPI reporting crosswalk tool will only allow a user to enter 1 taxonomy code.

Do I have to report my NPI using both the NPI reporting crosswalk tool and the paper reporting form?

No. Use only one method, either the paper form or the Web-based NPI reporting crosswalk tool. You do not need to use both. Best is the online tool, since it will print an immediate receipt to confirm the proper reporting of your NPI.

Do I need to report the NPI if the physician is deceased?

If a physician is deceased, and electronic claims or adjustments will be submitted on his behalf after the NPI compliance deadline, an NPI must be reported for the physician.

Arkansas Medicaid only accepts the National Provider Identifier (NPI) number anywhere a provider number is required on electronic transactions. Some examples would be the billing, performing, requesting, attending, referring and prescribing provider number as appropriate for the transaction submitted. The NPI must also be used on electronic eligibility verification transactions.

Do we have to report an NPI for all provider locations?

Yes. Unless you plan to discontinue services at a location, every service location must have an NPI reported.

Do we have to report contact information for each provider number?

No. Contact information is required only once for each time a user logs into the system to report NPIs. If a user logs out of the system and logs back in, contact information will be required.

Do we have to report our NPI if we do not file electronic claims?

Yes. If you refer a patient to a physician who submits claims electronically, your NPI will be required to complete their claims.

If a provider is no longer part of our practice, do we still need to report their NPI if they are showing up on the NPI reporting crosswalk tool?

If electronic transactions will continue to be submitted by the practice for that provider, it will be necessary to report the provider’s NPI.

Arkansas Medicaid only accepts the National Provider Identifier (NPI) number anywhere a provider number is required on electronic transactions. Some examples would be the billing, performing, requesting, attending, referring and prescribing provider number as appropriate for the transaction submitted. The NPI must also be used on electronic eligibility verification transactions.

If I don’t know the NPI for all of our rendering doctors, can I go back and report them later?

Yes. You can log back into the NPI reporting crosswalk tool at any time to report the NPI for providers.

If a batch of claims is submitted and one is missing the NPI, will the batch be rejected?

No. The batch will be accepted, the individual claim with the missing NPI will not.

Arkansas Medicaid only accepts the National Provider Identifier (NPI) number anywhere a provider number is required on electronic transactions. Some examples would be the billing, performing, requesting, attending, referring and prescribing provider number as appropriate for the transaction submitted. The NPI must also be used on electronic eligibility verification transactions.

Do I have to bill the rendering NPI on the electronic claims transactions?

Yes. The rendering NPI will be required on electronic claims transactions.

What is the definition of a Taxonomy code?

The health care provider Taxonomy code is a unique, 10-character, alphanumeric code that allows a provider to identify a specialty category. Providers applying to NPPES for an NPI are required to submit their Taxonomy codes. Providers may have one or more Taxonomy codes associated to them. If a provider is required to report a Taxonomy code when using the Web-based NPI reporting crosswalk tool, only one Taxonomy can be chosen regardless of how many taxonomies were reported to NPPES. Arkansas Medicaid will use a Taxonomy code only to match an NPI to a legacy Arkansas Medicaid provider ID during EDI processing. No payment processing will be completed using the taxonomy code.

Does the Taxonomy code need to be reported on claims?

Providers that are required to report their Taxonomy code in the NPI reporting crosswalk tool are also required to report their Taxonomy code on claims.

Are all waiver providers atypical?

Not all waiver providers are atypical providers. Workgroup for Electronic Data Interchange (WEDI) developed a white paper that may assist in determining an atypical provider. This white paper can be found on the WEDI website at http://www.wedi.org.

Will Gainwell Technologies offer a directory of NPIs for other providers?

Gainwell Technologies will not offer a directory of NPIs; however, the National Provider Identifier (NPI) Registry is available now at the National Plan & Provider Enumeration System (NPPES) website. A link to the Registry has been added to the “Provider information” menu for quick access from the Arkansas Medicaid website. The Registry allows you to search for providers’ NPI numbers. NPI numbers for referring physicians or prescribers are necessary for electronic billing. There is no charge to use the NPI Registry. Go to the NPPES website to view or use the Registry.