NRPM: Standard Health Care Provider Identifier. 3. Health care provider.


As defined by section 1171(3) of the Act, a “health care provider” is a provider of services as defined in section 1861(u) of the Act, a provider of medical or other health services as defined in section 1861(s) of the Act, and any other person who furnishes health care services or supplies. Our regulations would define “health care provider” as the statute does and clarify that the definition of a health care provider is limited to those entities that furnish, or bill and are paid for, health care services in the normal course of business.

The statutory definition of a health care provider is broad. Section 1861(u) contains the Medicare definition of a provider, which encompasses institutional providers such as hospitals, skilled nursing facilities, home health agencies, and comprehensive outpatient rehabilitation facilities. Section 1861(s) defines other Medicare facilities and practitioners, including assorted clinics and centers, physicians, clinical laboratories, various licensed/certified health care practitioners, and suppliers of durable medical equipment. The last portion of the definition encompasses any appropriately licensed or certified health care practitioners or organizations, including pharmacies and nursing homes and many types of therapists, technicians, and aides. It also includes any other individual or organization that furnishes health care services or supplies. We believe that an individual or organization that bills and is paid for health care services or supplies is also a health care provider for purposes of the statute.

Section 1173(b)(1) of the Act requires the Secretary to adopt standards for unique identifiers for all health care providers. The definition of a “health care provider” at section 1171(3) includes all Medicare providers and “any other person furnishing health care services and supplies.” These two provisions require that provider identifiers may not be limited to only those health care providers that bill electronically or those that bill in their own right. Instead provider identifiers will eventually be available to all those that provide health services. Penalties for failure to use the correct identifiers, however, are limited to those that fail to use the identifiers or other standards in the nine designated electronic transactions. As we discuss under a later section in this preamble,III. Implementation of the NPI, we do not expect to be able to assign identifiers immediately to all health care providers that do not participate in electronic transactions.

Our proposed definition of a health care provider would not include health industry workers who support the provision of health care but who do not provide health services, such as admissions and billing personnel, housekeeping staff, and orderlies.

We describe two alternatives for defining general categories of health care providers for enumeration purposes. In the first, we would categorize health care providers as individuals, organizations, or groups. In the second, we would categorize health care providers as individuals or organizations, which would include groups. The data to be collected for each category of health care provider are described in the preamble in section IV. B. Data Elements. We welcome your comments on whether group providers need to be distinguished from organization providers.

Individuals are treated differently than organizations and groups because the data available to search for duplicates (for example, date and place of birth) are different. Organizations and groups may need to be treated differently from each other because it is possible that a group is not specifically licensed or certified to provide health care, whereas an organization usually is. It may, therefore, be important to be able to link the individual members to the group. It would not be possible to distinguish one category from another by looking at the NPI. The NPS would contain the kinds of data necessary to adequately categorize each health care provider.

The categories are described as follows:

Individual--A human being who is licensed, certified or otherwise authorized to perform medical services or provide medical care, equipment and/or supplies in the normal course of business. Examples of individuals are physicians, nurses, dentists, pharmacists, and physical therapists.

Organization--An entity, other than an individual, that is licensed, certified or otherwise authorized to provide medical services, care, equipment or supplies in the normal course of business. The licensure, certification, or other recognition is granted to the organization entity. Individual owners, managers, or employees of the organization may also be certified, licensed, or otherwise recognized as individual health care providers in their own right. Each separate physical location of an organization, each member of an organization chain, and each subpart of an organization that needs to be identified would receive its own NPI. NPIs of organization providers would not be linked within the NPS to NPIs of other health care providers. Examples of organizations are hospitals, laboratories, ambulance companies, health maintenance organizations, and pharmacies.

In the first alternative for categorizing health care providers, as described above, we would distinguish a group from an organization. We would define a group as follows:

Group--An entity composed of one or more individuals (as defined above), generally created to provide coverage of patients’ needs in terms of office hours, professional backup and support, or range of services resulting in specific billing or payment arrangements. It is possible that the group itself is not licensed or certified, but the individual(s) who compose the group are licensed, certified or otherwise authorized to provide health care services. The NPIs of the group member(s) would be linked within the NPS to the NPI of the group. An individual can be a member of multiple groups. Examples of groups are (1) two physicians practicing as a group where they bill and receive payment for their services as a group and (2) an incorporated individual billing and receiving payment as a corporation.

The ownership of a group or organization can change if it is sold, consolidated, or merged, or if control changes due to stock acquisition. In many cases, the nature of the provider itself (for example, its location, staff or types of services provided) is not affected. In general, the NPI of the provider should not change in these situations unless the change of ownership affects the nature of the provider. (Example: If a hospital is acquired and then converted to a rehabilitation center, it would need to obtain a new NPI.) There may also be circumstances where a new NPI should be issued. (Example: a physicians’ group practice operating as a partnership dissolves that partnership and another partnership of physicians acquires and operates the practice.) We solicit comments on rules to be applied.

We discuss the enumeration of health care providers in more detail, in III. Implementation of the NPI, later in this preamble.