The National Provider Identifier, known as the NPI, was brought in with the aim to improve and simplify all electronic transactions. Given that healthcare Providers work with several health plans, they are likely to have a different identifier for each plan. The NPI thus ensures that each provider has one unique identifier to be used in transactions across all health plans
All HIPAA (Health Insurance Portability and Accountability Act) covered healthcare Providers that are covered entities under HIPAA are required to obtain an NPI, whether individuals or organizations for all HIPAA standard transactions, for instance like the NCPDP format for retail prescription drugs and the X12N837 for pharmacy professional services, Part B drugs and supplies, and DMEPOS. The NPI remains with the provider regardless of job or location changes.
If a Pharmacy sends or receives HIPAA covered transactions the pharmacy must obtain an NPI and holds true for a pharmacist. But if the healthcare provider does not conduct HIPAA-covered transactions, but is a healthcare Provider under HIPAA's definition (as are pharmacies and pharmacists), then the provider "may", but is not required to obtain an NPI .
However, when the pharmacy is the billing entity, they are required to submit an NPI as the identifier. Here it is very clear that depending on the payor, a pharmacist NPI may or may not be required on a HIPAA transaction. If a pharmacist NPI has been requested on a claim transaction, then it is usually to identify the Rendering Provider, i.e Billing Provider, to whom the claim should be paid to. Such a situation may occur when using the X12N 837 claims format or the CMS form 1500.
It is also noteworthy to bear in mind that if a pharmacy is involved in both traditional Over the counter dispensing (OCD) of medication as well as long term care services, they could obtain an NPI for both business components. Also pharmacies that are DME suppliers may choose to use only one NPI.
In certain scenarios where it involves Medicare patients and where pharmacists are not recognized as Medicare Part B providers and are restricted to billing at the 99211 code level & can only bill "incident-to" the physician supervising in the practice or clinic, here only the NPI of the Medicare Provider (i.e. physician or Medicare Part B-approved practitioner) must be used on the paper or electronic CMS 1500 claim form. But, for non-Medicare patients, the clinic or non-Medicare payer may require the pharmacist to use their NPI number. This could be mainly used for internal tracking purposes or dependant on the contract signed or state Medicaid rules.
The pharmacy billing for DSMT (Diabetes Self-Management Training) could be done under the pharmacy's NPI number assigned to the DSMT program. Many pharmacies already bill services to Medicare either as a DME supplier or Part D provider, but the pharmacy must submit Form CMS-855B application to become a Part B provider. Pharmacy must submit the Prescriber's NPI for all Medicare Part D claims.
For a claim to be accepted, especially where the prescription is for a controlled substance, the Prescriber's DEA number is essential to include on the prescription hard copy submitted to the pharmacy or pharmacist. If the Prescriber did not include their NPI/DEA number(s) on the prescription hard copy, then the pharmacy is responsible for acquiring the Prescriber ID either from the pharmacy's claim system or by contacting the Prescriber. The participating pharmacy must document the correct Prescriber ID on the prescription hard copy or on a prescription label, affixed to the back of the prescription hard copy.
It is also pertinent to note that under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), signed into law on April 16, 2015, Section 507 requires that for plan year 2016 and thereafter, claims for covered Part D drugs must include a valid prescriber NPI. More specifically, Section 507 of MACRA amends Section 1860D–4(c) of the Social Security Act (42 U.S.C. 1395w–104(c)) by requiring that pharmacy claims for covered Part D drugs include prescriber NPIs that are determined to be valid under procedures established by the Secretary in consultation with appropriate stakeholders.
Overall, all online claims must be submitted with the Pharmacy NPI. Online claims submitted with the Pharmacy NCPDP number tend to be rejected.