Do medical students, interns, and residents need National Provider Identifiers (NPIs)?

Question: Do medical students, interns, and residents need National Provider Identifiers (NPIs)?

Answer : All health care providers are eligible for NPIs and may apply for them. Because medical students, interns, residents, and fellows are health care providers, they are eligible for NPIs. If they do not transmit any health data in connection with a transaction for which the Secretary of Health and Human Services has adopted a standard, they are not “covered” health care providers under HIPAA and are not required by the NPI Final Rule to obtain NPIs.

If they do, however, they would be covered health care providers and they must get NPIs. If interns or residents prescribe medications for patients whose prescriptions are filled by pharmacies, refer patients to other health care providers, or order tests for patients from other health care providers, those pharmacies and other health care providers will need to identify them as prescribers or as providers who referred patients or who ordered tests for patients in the claims transactions that they submit to health plans.

Health plans may require that the NPI be used in those claims to identify the prescriber, the referring provider, and the ordering provider. Therefore, while the NPI Final Rule might not require these providers to obtain NPIs, it may be necessary for them to have NPIs in order for the pharmacies and providers described in the scenarios above to be reimbursed by health plans.

Which Healthcare Provider Taxonomy Code(s) should be selected by medical students, interns, residents and fellows when applying for National Provider

QuestionWhich Healthcare Provider Taxonomy Code(s) should be selected by medical students, interns, residents and fellows when applying for National Provider Identifiers (NPIs)?

Answer : The Healthcare Provider Taxonomy Code set is a code set which may be used in certain standard transactions to indicate health care provider type, classification, and/or specialization. A healthcare provider must select a Healthcare Provider Taxonomy Code from this code set when applying for a National Provider Identifier (NPI). The code set is maintained by the National Uniform Claim Committee (NUCC) and is made available to the public by the Washington Publishing Company (WPC). Information on requesting changes to the code set is available from the NUCC (www.nucc.org/). Frequently Asked Questions and information on printing or downloading the code set is available from the WPC (www.wpc-edi.com ).

All health care providers are eligible for NPIs and may apply for them. Because they are health care providers, medical students, interns, residents, and fellows are eligible for NPIs. If they do not transmit any health data in connection with a transaction for which the Secretary of Health and Human Services has adopted a standard, they are not “covered” health care providers under HIPAA and are not required by the NPI Final Rule to obtain NPIs. If they do, however, they would be covered health care providers and they must get NPIs.• A Healthcare Provider Taxonomy Code for classifying medical students, and interns and residents who are not yet licensed (based on state licensing requirements), is available for use: Student, Health Care (390200000X). The code is defined as follows: An individual who is enrolled in an organized health care education/training program leading to a degree, certification registration, and/or licensure to provide health care. Medical students, interns, and residents who are not licensed should select the Student, Health Care code when applying for NPIs.• Once licensed as an allopathic or osteopathic physician, the physician should update his/her data in the National Plan and Provider Enumeration System (NPPES) by submitting a change in the Healthcare Provider Taxonomy Code to reflect the change in status from medical student to physician. (If they are “covered” health care providers, they are required to do so, and any such change must be provided to the NPPES within thirty days of the change).• If physicians who have been assigned NPIs become board-certified in other specialties or subspecialties, the physicians should update his/her data in the NPPES with these changes or additions in their specializations (i.e., they would indicate the changes or additions by changing their Healthcare Provider Taxonomy Codes). (If they are “covered” health care providers, they are required to do so, and any such change must be provided to the NPPES within thirty days of the change.)

National Provider Identifier (NPI)?

Question: Should all institutional providers submit a taxonomy code on their claims after the implementation of the National Provider Identifier (NPI)?

Answer : Only institutional providers that currently bill Medicare using more than one legacy identifier in order to identify sub-parts of their facility are required to submit a taxonomy code on all of the claims they submit to Medicare. Medicare legacy identifiers are six digit Medicare provider numbers, also called OSCAR numbers.

A table of legacy identifiers that were used to identify sub-parts is included as an attachment to CMS Change Request 5243. Taxonomy codes shall be reported by these facilities whether or not the facility has applied for individual NPIs for each of their subparts. Institutional providers that do not currently bill Medicare for sub-parts are not required to use taxonomy codes on their claims to Medicare. The list of taxonomy codes is available at http://www.wpc-edi.com/content/view/793/1

Taxonomy Code for a non-individual provider

Question: May the Billing Provider Loop for the X12 837P be used to report a provider Taxonomy Code for a non-individual provider when the usage notes in the adopted Version of the Implementation Guide requires reporting only in certain situations?

Answer : The Healthcare Provider Taxonomy Code (HPTC) that is permitted for certain situations in the 4010/4010A1 837P Implementation Guide is a 10-character alphanumeric administrative code that identifies the health care provider type, classification, and, for some classifications, the area of specialization of health care providers. The code set is maintained and updated by the National Uniform Claim Committee (NUCC). Health care providers may have more than one HPTC depending on their classifications and specializations, and select their own HPTCs from a list of available codes that is published by the Washington Publishing Company (available at www.wpc-edi.com/taxonomy.) While HPTCs are not health care provider identifiers, they do identify provider type, classification, and/or specialization, which is information that is often needed by health plans to determine claim reimbursement and subscriber benefits.

The Version 4010/4010A1 of the 837P Implementation Guide (for professional claims) states that it is not compliant to send the HPTC in both the Billing/Pay-to Provider Specialty Loop (PRV 2000A) and in the Rendering Provider Identifier loop (2310B), except in certain situations. Only when the Billing and Rendering Provider are the same is it permissible to report the HPTC in the Billing Provider Loop (2000A). The inability to report a Billing Provider’s type, classification, or specialization, except when the Billing/Pay-to Provider is the same as the Rendering Provider, can burden health plans with the need to suspend claims, telephone providers for the additional information, and, in some cases, incorrectly adjudicate claims because needed information is not permitted by the IG to be submitted on the original claim.

This problem with the 4010/4010A1 837P Implementation Guide arose with the implementation of the NPI because the NPI does not contain intelligence about the type, classification, or specialization of the health care provider it identifies; whereas the previously used legacy identifier numbers often did. In order to obtain health care provider type, classification, or specialization information, some health plans are requesting submission of the HPTC in the Provider Specialty Loop (PRV 2000A) when the Billing Provider and Rendering Provider are not the same, even though this is inconsistent with the instructions in the Implementation Guide. For example, an Acute Care Testing medical group may have a number of different specialty providers within the group. In order to adjudicate a claim, a health plan may need to identify the specialty of the billing provider with a taxonomy code in the Loop 2000A PRV segment, even though, according to the 837 P 4010/4010A1 Implementation Guide, this segment is not used when the Billing or Pay-To Provider is a group and the individual Rendering Provider is identified in Loop 2310B.


There is an incompatibility between the 4010/4010A1 Implementation Guide requirements and the business need of the Billing Provider’s type, classification, specialization. Therefore, until the adoption of a new Version of the professional health care claims transaction standard that corrects this problem, CMS will exercise enforcement discretion if HPTCs are reported for Billing Providers in the 837P claims transactions where the Billing Provider and the Rendering Provider are different. Each complaint will be evaluated on a case-by-case basis.

What are the Healthcare Provider Taxonomy codes? Where may I obtain a copy of the codes?

What are the Healthcare Provider Taxonomy codes? Where may I obtain a copy of the codes?

Answer : The Healthcare Provider Taxonomy codes are a HIPAA standard code set named in the implementation specifications for some of the ASC X12 standard HIPAA transactions. The “Healthcare Provider Taxonomy Code” is a situational data element in the X12 Implementation Guides for the 837 4010A1 Institutional and Professional claims/encounter information transactions. If the Taxonomy code is required in order to properly pay or process a claim/encounter information transaction, it is required to be reported. Thus, reporting of the Healthcare Provider Taxonomy Code varies from one health plan to another. The Healthcare Provider Taxonomy code set divides health care providers into hierarchical groupings by type, classification, and specialization, and assigns a code to each grouping. The Taxonomy consists of two parts: individuals (e.g., physicians) and non-individuals (e.g., ambulatory health care facilities). All codes are alphanumeric and are 10 positions in length. These codes are not “assigned” to health care providers; rather, health care providers select the taxonomy code(s) that most closely represents their education, license, or certification. If a health care provider has more than one taxonomy code associated with it, a health plan may prefer that the health care provider use one over another when submitting claims for certain services. The Healthcare Provider Taxonomy code set is available at no charge from the Washington Publishing Company’s website: http://www.wpc-edi.com/codes/taxonomy The Healthcare Provider Taxonomy code set is maintained by the National Uniform Claim Committee (NUCC). The NUCC accepts requests for new codes and requests for changes to existing codes or descriptions. The criteria for review of a request for a new code or a change are available on the NUCC web site at: www.nucc.org The code set is updated twice a year.