NRPM: Standard Health Care Provider Identifier. A. Data Elements

05/07/1998

The NPS would collect and store in the NPF a variety of information about a health care provider, as shown in the table below. We believe the majority of this information is used to uniquely identify a health care provider; other information is used for administrative purposes. A few of the data elements are collected at the request of potential users that have been working with HCFA in designing the database prior to the passage of HIPAA. All of these data elements represent only a fraction of the information that would comprise a provider enrollment file. The data elements in the table, plus cease/effective/termination dates, switches (yes/no), indicators, and history, are being considered as those that would form the NPF. We have included comments, as appropriate. The table does not display systems maintenance or similar fields, or health care provider cease/effective/termination dates.

National Provider File Data Elements

KEY: I - Used for the unique identification of a provider.

A - Used for administrative purposes.

U - Included at the request of potential users (optional).

Data Elements

Comments

Purpose

National Provider Identifier (NPI)

8-position alpha-numeric NPI assigned by the NPS.

I

Provider’s current name

For Individuals only. Includes first, middle, and last names.

I

Provider’s other name

For Individuals only. Includes first, middle, and last names. Other names might include maiden and professional names.

I

Provider’s legal business name

For Groups and Organizations only.

I

Provider’s name suffix

For Individuals only. Includes Jr., Sr., II, III, IV, and V.

I

Provider’s credential designation

For Individuals only. Examples are MD, DDS, CSW, CNA, AA, NP, RNA, PSY.

I

Provider’s Social Security Number (SSN)

For Individuals only.

I

Provider’s Employer Identification Number (EIN)

Employer Identification Number.

I

Provider’s birth date

For Individuals only.

I

Provider’s birth State code

For Individuals only.

I

Provider’s birth county name

For Individuals only.

I

Provider’s birth country name

For Individuals only.

I

Provider’s sex

For Individuals only.

I

Provider’s race

For Individuals only.

U

Provider’s date of death

For Individuals only.

I

Provider’s mailing address

Includes 2 lines of street address, plus city, State, county, country, 5- or 9-position ZIP code.

A

Provider’s mailing address telephone number

 

A

Provider’s mailing address fax number

 

A

Provider’s mailing address e-mail address

 

A

Resident/Intern code

For certain Individuals only.

U

Provider enumerate date

Date provider was enumerated (assigned an NPI). Assigned by the NPS.

A

Provider update date

Last date provider data was updated. Assigned by the NPS.

A

Establishing enumerator/agent number

Identification number of the establishing enumerator.

A

Provider practice location identifier (location code)

2-position alpha-numeric code (location code) assigned by the NPS.

I

Provider practice location name

Title (e.g., “doing business as” name) of practice location.

I

Provider practice location address

Includes 2 lines of street address, plus city, State, county, country, 5- or 9-position ZIP code.

I

Provider’s practice location telephone number

 

A

Provider’s practice location fax number

 

A

Provider’s practice location e-mail address

 

A

Provider classification

From Accredited Standards Committee X12N taxonomy. Includes type(s), classification(s), area(s) of specialization.

I

Provider certification code

For certain Individuals only.

U

Provider certification (certificate) number

For certain Individuals only.

U

Provider license number

For certain Individuals only.

I

Provider license State

For certain Individuals only.

I

School code

For certain Individuals only.

I

School name

For certain Individuals only.

I

School city, State, country

For certain Individuals only.

U

School graduation year

For certain Individuals only.

I

Other provider number type

Type of provider identification number also/formerly used by provider: UPIN, NSC, OSCAR, DEA, Medicaid State, PIN, Payer ID.

I

Other provider number

Other provider identification number also/formerly used by provider.

I

Group member name

For Groups only. Name of Individual member of group. Includes first, middle, and last names.

I

Group member name suffix

For Groups only. This is the Individual member’s name suffix. Includes Jr., Sr., II, III, IV, and V.

I

Organization type control code

For certain Organizations only. Includes Government - Federal (Military), Government - Federal (Veterans), Government - Federal (Other), Government - State/County, Government - Local, Government - Combined Control, Non-Government - Non-profit, Non-Government - For Profit, and Non-Government - Not for Profit.

U

We need to consider the benefits of retaining all of the data elements shown in the table versus lowering the cost of maintaining the database by keeping only the minimum number of data elements needed for unique provider identification. We solicit input on the composition of the minimum set of data elements needed to uniquely identify each type of provider. In order to consider the inclusion or exclusion of data elements, we need to assess their purpose and use.

The data elements with a purpose of “I” are needed to identify a health care provider, either in the search process (which is electronic) or in the investigation of health care providers designated as possible matches by the search process. These data elements are critical because unique identification is the keystone of the NPS.

The data elements with a purpose of “A” are not essential to the identification processes mentioned above, but nonetheless are valuable. Certain “A” data elements can be used to contact a health care provider for clarification of information or resolution of issues encountered in the enumeration process and for sending written communications; other “A” data elements (e.g., Provider Enumerate Date, Provider Update Date, Establishing Enumerator/Agent Number) are used to organize and manage the data.

Data elements with a purpose of “U” are collected at the request of potential users of the information in the system. While not used by the system’s search process to uniquely identify a health care provider, Race is nevertheless valuable in the investigation of health care providers designated as possible matches as a result of that process. In addition, Race is important to the utility of the NPS as a statistical sampling frame. We solicit comments on the statistical validity of race data. Race is collected “as reported”; that is, it is not validated. It is not maintained, only stored. The cost of keeping this data element is virtually nil. Other data elements (Resident/Intern Code, Provider Certification Code and Number, and Organization Type Control Code) with a purpose of “U”, while not used for enumeration of a health care provider, have been requested to be included by some members of the health care industry for reports and statistics. These data elements are optional and do not require validation; many remain constant by their nature; and the cost to store them is negligible.

The data elements that we judge will be expensive to either validate or maintain (or both) are the license information, provider practice location addresses, and membership in groups. We solicit comments on whether these data elements are necessary for the unique enumeration of health care providers and whether validation or maintenance is required for that purpose.

Licenses may be critical in determining uniqueness of a health care provider (particularly in resolving identities involving compound surnames) and are, therefore, considered to be essential by some. License information is expensive to validate initially, but not expensive to maintain because it does not change frequently.

The practice location addresses can be used to aid in investigating possible provider matches, in converting existing provider numbers to NPIs, and in research involving fraud or epidemiology. Location codes, which are discussed in detail in section B. Practice Addresses and Group/Organization Options below, could be assigned by the NPS to point to and identify practice locations of individuals and groups. Some potential users felt that practice addresses changed too frequently to be maintained efficiently at the national level. The average Medicare physician has two to three addresses at which he/she practices. Group providers may have many more practice locations. We estimate that 5 percent of health care providers require updates annually, and that addresses are one of the most frequently changing attributes. As a result, maintaining more than one practice address for an individual provider on a national scale could be burdensome and time consuming. Many potential users believe that practice addresses could more adequately be maintained at local, health-plan specific levels.

Some potential users felt that membership in groups was useful in identifying health care providers. Many others, however, felt that these data are highly volatile and costly to maintain. These users felt it was unlikely that membership in groups could be satisfactorily maintained at the national level.

We welcome your comments on the data elements proposed for the NPF and input as to the potential usefulness and tradeoffs for these elements such as those discussed above.

We specifically invite comments and suggestions on how the enumeration process process might be improved to prevent issuance of multiple NPIs to a health care provider.