TO:Executive Directors, Community Developmental Disabilities Agencies, Individual Developmental Disabilities Providers

FROM: Reta Hoskin, Acting Director, Division of Developmental Disabilities

DATE: March 19, 2007

SUBJECT: National Provider Identification Number (NPI)

Beginning with bills submitted on or after May 23, 2007, Developmental Disabilities will require a National Provider Identifier (NPI) for certain health care providers that are required to have an NPI by the federal Health Insurance Portability and Accountability Act (HIPAA). This federal requirement affects only the service provider of record (the provider identified on the bill as the entity that actually provided the service). It does not affect the payee.

NOTE: Bills transmitted on or after May 23, 2007 by or on behalf of health care providers that lack required NPIs will be rejected.

See below for information to help you determine whether or not you are required to have an NPI, how to obtain an NPI and how to transmit the NPI to the Department if you haven't done so already. Steps to ensure compliance with this federal requirement are:

  1. Determine whether or not you or your agency is required to obtain an NPI.

    Each provider is responsible for making the determination whether or not it is required to obtain an NPI. The Department may offer guidance and suggestions, but is not responsible for this decision.

    For information on the NPI, please refer to the federal Centers for Medicare and Medicaid Services website: http://www.cms.hhs.gov/NationalProvidentStand/ Also, the Department of Healthcare and Family Services (HFS) has mailed notices. Please see copies of HFS Notices To Providers. These notices contains additional information.

    It is our understanding that professional developmental disabilities health care providers if they bill as individuals are required to have an NPI. Examples of professionals who bill for developmental disabilities services as individuals include:

    • Nurses
    • Occupational, physical and speech therapists
    • Behavioral service providers, such as clinical psychologists, professional counselors, social workers, behavior analysts, etc.

    It is our understanding that the following developmental disabilities providers are exempt from the NPI requirement, because the services provided are not considered to be health care or because the services are not billed for reimbursement (grants):

    • Providers of grant-in-aid funded services
    • Providers of community residential habilitation services, such as CILA, Community Living Facilities, Child Group Homes, etc.
    • Providers of community day habilitation or employment programs, such as Developmental Training, Supported Employment, Sheltered Employment, etc.
    • Providers of HBS Personal Support, HBS Transportation and other non-health care services.

    NOTE: If you determine you are not a HIPAA-covered health care provider, stop here. No further action is necessary. Continue to bill as usual.

  2. Apply for an NPI as soon as possible, if you are a HIPAA-covered health care provider.

    Information on How to Apply for NPI is found in the CMS web site. The web-based application process can also be found at this web site.  A third party organization may submit an electronic file application with the permission of the provider. For example, an agency may submit the application on behalf of therapists with whom the agency works.

    When applying for an NPI, providers are required to submit a taxonomy code, and may be required to submit state license information. The taxonomy code identifies the provider type such as physical therapy, clinical psychologist, etc. Please see Taxonomy Code Set.

    According to the federal Centers for Medicare and Medicaid Services, a health care provider submitting a properly completed electronic application should receive an NPI verification within ten days.

  3. Once you have obtained your NPI, transmit the NPI to the State in one of the following two ways:

    1. Transmit NPI to the Department of Healthcare and Family Services (HFS) if you are enrolled to provide services under the Medicaid waiver.

      Note: This is the preferred method and will work for Medicaid waiver enrolled providers. Almost all DDD health care services are part of the Medicaid waiver.

      DHS is working with the Department of Healthcare and Family Services to obtain the NPI you transmit to them so that providers do not have to transmit the NPI multiple times to the State by using The HFS Web-Based Application for Reporting an NPI. When you go to the web site, you need to:

      • Have your NPI verification handy for reference.
      • Enter your 12-digit HFS provider identification number.  Your 12-digit HFS provider number is either:
        • Enter your Social Security Number followed by 100 or
        • Enter your agency's Federal Employer Identification Number (FEIN) followed by 100
      • Enter your Provider Type and Category of Service. The adult DD waiver Provider Type is 91. Waiver health care Categories of Service are:
      • 10 - Nursing
      • 97 - All other professional services
    2. FAX to the Department of Human Services if you cannot use the HFS website.

      Note: Bogard Specialized Services and Mental Health HBS providers are probably in this group.

      DHS requires that you notify HFS or DHS of your NPI only once. If you sent your NPI to another Division within DHS or to HFS, you do not need to fax the NPI again to DDD.

      If you are unable to transmit the NPI to HFS as outlined above, please mail or fax the following information on the attached form no later than May 1, 2007 to:

      Division of Developmental Disabilities
      319 East Madison Street, Suite 3M
      Springfield, IL  62701
      FAX: (217) 558-2799.

      • Date
      • Contact name, phone number and e-mail address
      • Social Security Number or Federal Employer Identification Number (FEIN)
      • NPI verification containing legal name, NPI, taxonomy code and other information.
  4. Continue to transmit bills for developmental disabilities services as before.

Thank you for your prompt attention to this matter. 

Attachment: For health care providers that CANNOT submit to HFS web site