Examples of NPI Compliant Transactions |
NPI Exemption Notification Form
Medical - HIPAA Regulations for National Provider Identifier in Transaction Submission
HIPAA regulations require providers to transmit electronic transactions that conform to HIPAA standard format and content. The National Provider Identifier (NPI) is a required element in HIPAA standard transactions.
We have identified below examples of requirements for compliant transactions. We may reject transactions sent to us by health care providers when these requirements are not met. If you are sending transactions on behalf of providers to whom the regulations do not apply, you must send us an NPI Exemption Notification Form.
The grid below is not a complete list of HIPAA NPI requirements. Additional information on compliance requirements is available at www.cms.hhs.gov/home/regsguidance.asp.
| Eligibility |
Requesting Provider |
NPI is required. Other IDs must not be included. If an NPI is not included, we may reject your transaction. Your vendor/software supplier may populate this information for you. |
| Referral |
Referring/ Requesting Provider |
NPI is required. Other IDs must not be included. If an NPI is not included, we may reject your transaction Your vendor/software supplier may populate this information for you. |
| Referred To Provider/ Service Provider |
If you know the NPI for the referred to and /or service provider, use it as the only identifier. Other IDs must not be included when NPI is used.
Note: when referring to a specialty family using a Taxonomy code, no NPI is required. |
| Precertification |
Requesting Provider |
NPI is required. Other IDs must not be included. If an NPI is not included, we may reject your transaction. Your vendor/software supplier may populate this information for you. |
Attending Provider
Admitting Provider
Facility and/or Vendor |
If you know the NPI, use it as the only identifier. Other IDs must not be included when NPI is used. |
| Claim Status Inquiry |
Requesting Provider |
If you know the NPI, you may use it, but it is not required in this location. Your vendor/software supplier may populate this information for you. |
| Servicing Provider |
NPI is required. Other IDs must not be included. If NPI is not included, we may reject your transaction. Your vendor/software supplier may populate this information for you. |
| Claim – Professional and Dental |
Billing Provider/ Pay To Provider (if different from Billing Provider) |
NPI and Tax ID are required. Other IDs must not be included. Your vendor/software supplier may populate this information for you. |
| Rendering Provider (if different from Billing Provider) |
If you know the NPI for rendering provider, use it as the only identifier. Other IDs must not be included when NPI is used. |
| Claim – Institutional |
Billing Provider/ Pay To Provider (if different from Billing Provider) |
NPI and Tax ID are required. Other IDs must not be included. Your vendor/software supplier may populate this information for you. |
| Servicing Facility (if different from Billing Facility) |
If you know the NPI for the servicing facility, use it as the only identifier. Other IDs must not be included when NPI is used. |
