Healthcare Provider Data Challenges and NPI Data Services

The purpose of the National Provider Identifier (NPI) is to uniquely identify a health

care provider in standard transactions, such as health care claims. It will replace other identifiers such as the UPIN, payer identifiers, CHAMPUS, Medicaid numbers, etc. Payer-assigned, Proprietary Identifiers need to be replaced with Provider-Defined, National Identifiers.

NPIs may also be used to identify Health care providers on prescriptions, internal files to link proprietary provider identification numbers and other information, coordination of benefits between health plans, patient medical record systems, program integrity files, and in other ways.

Provider ID Number (PIN) are issued by health plan. Single provider could have multiple PINs. PIN may contain embedded intelligence. PIN typically contains business rules. PIN is mapped to specific contracts and business edits. National Provider ID (NPI) is issued by Enumerator. NPI has no embedded intelligence. NPI doesn't need renewal and it is assigned for life of provider.

Payer's back end systems (Claims, Eligibility, Enrollment) rely on Provider ID Number (PIN) for proper routing of the transaction. It must associate the NPI to PIN in order to trigger back end system logic - One to one, One to many, Many to one, Many to many, to get business rules specific to the plan and to determine the proper contract terms. A sophisticated validation and matching process is required. Failure to make the correct match between NPI and PIN may result in various downstream issues. Those issues may include overpayment of a claim, underpayment of a claim, incorrect eligibility response and sponsor dissatisfaction.

To address the fundamental issues with healthcare provider data, NPI Data Services (NPIDS) provides variety of provider raw data and products such as Targeted Data Builder, Data Augmentation Tool, NPIDS eDirectory and Provider Data web services.

NPIDS is a health care data and information technology company. NPIDS designs, develops, and implements cost-effective products, services, and solutions for medical groups, hospitals, integrated health organizations, and health insurance companies. The innovative and easy-to-use provider data enrichment product and services improve financial outcomes for a wide range of stakeholders across the healthcare industry. In addition, NPIDS support providers and payer organizations of all sizes to address the challenges of provider data while reducing unnecessary costs. NPIDS is subsidiary of Arts Systems Inc., a privately held company. The leadership team includes developers and process management experts who have extensive experience working with various processes involving patient care; health insurance claims processes; and technology supporting health industry.

Healthcare Provider Data Challenges and NPI Data Services

By: White Scott

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