Provider : Npi

Since May 23, 2008,  and in accordance with the Health Insurance Portability and Accountability Act (HIPAA), claims submitted to WellCare, and/or its designees, must comply with the requirement to use only the National Provider Identifier (NPI) on standard transactions.  This excludes atypical providers who are not eligible to receive NPIs. 

NPI Claim / Encounter Submission Requirements

• Electronic, direct data entry (DDE), paper health care claims and encounters submissions must include an NPI in the primary and secondary provider fields
• Claims / encounters are considered non-compliant and will be rejected
  if either of the following conditions exist for the primary and/or secondary provider fields:
  • Lack of NPI when required per Implementation Guides and CMS requirements
  • Contain an invalid NPI

For more information on how to comply with HIPAA's NPI requirement, please click the links below for instructions on the various methods of claim submission:

Electronic Data Exchange (EDI)CMS 1500 UB-04

If You Have Not Submitted Your NPI to WellCare

To submit your NPI:

1. Complete the appropriate NPI Submission form, Type 1 and Type 2 or spreadsheet listing.

   Type 1 form: To record the NPI of the individual member who renders health care either independently or as part of a group

   Type 2 form: To record the NPI assigned to the entity receiving payment as well as an organization that renders health care or its subpart

   Spreadsheet : To record NPIs on multiple providers within a medical group on a spreadsheet, include the respective names of the rendering and pay-to providers, NPI, address, WellCare ID, Tax ID, taxonomy, social security number and date of birth for each provider listed

2. Submit the completed form or spreadsheet to your local Provider Relations representative to be entered into our system.

If you have yet to obtain an NPI, or to get more information, please visit the National Plan and Provider Enumeration System at https://nppes.cms.hhs.gov/NPPES/Welcome.do(opens in new window)

For questions regarding NPI, please contact your Provider Relations representative or call the Provider Hotline, which can be found on the Quick Reference Guide.

Providers Should Always Remember:

• The NPI is yours. It doesn't belong to a health plan or the employer you work for. And it is assigned to you for life.
• The NPI is unique. It identifies you uniquely across the country and with one single ID, regardless of where you practice or the type of practice you have.
• The NPI will be your only identifier. It will be the only permitted identifier used in HIPAA transactions to identify providers.
• You must share your NPI. Other entities will need to know your NPI in order to conduct business with you.
• You must use your NPI. It is required in all HIPAA transactions, including claims, claim payment, coordination of benefits, eligibility, referrals and claim status.
• You must use your NPI with all health plans. Medicare, Medicaid and all private health plans are required by HIPAA to receive/submit the NPI as the only provider identifier in electronic transactions.
• You must protect your NPI. Only in rare circumstances like fraudulent use will the NPI be able to be replaced.
• You must take care of your NPI. Changes to any of the required information furnished during the NPI application need to be reported to the NPI Enumerator within 30 days of the change.
• You must still report your Tax ID to health plans. This will allow them to properly report payment information to the IRS on form 1099-MISC.

Information Resources

• CMS Main NPI Web site - http://www.cms.hhs.gov/NationalProvIdentStand/ (opens in new window)Contains NPI Final Rule, FAQs, Fact Sheets, Tip Sheets, NPI Viewlet, Medicare MedLearn Articles, Enumeration Statistics.
• NPI Enumerator Web site - https://nppes.cms.hhs.gov/NPPES/Welcome.do (opens in new window)Main site to enter an NPI application.
• WEDI NPI White Papers - http://www.wedi.org/snip/ (opens in new window)Industry NPI papers, including "NPI Impact on Providers"; "NPI Dual Use Strategy"; "NPI and Subparts"; and others.
• WEDI NPI Outreach Initiative - http://www.wedi.org/npioi/index.shtml (opens in new window)sNPI Resource Center with information resources, web links, Industry readiness assessment survey, other.