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HIPAA National Provider Identifier
HIPAA Employer Identifier
TRICARE Provider Types

HIPAA National Provider Identifier

The HIPAA National Provider Identifier (NPI) Final Rule, published in the Federal Register January 23, 2004, adopts the NPI as the standard unique identifier for health care providers. The rule becomes effective May 23, 2005, and TRICARE must be compliant by May 23, 2008. All entities who meet the definition of “health care provider” are eligible for NPIs.  However, providers who are “covered entities” are required to obtain and use NPIs.

The NPI is a 10-digit, all-numeric identifier that must be used in all HIPAA standard electronic transactions upon the compliance date of May 23, 2008. NPIs do not contain intelligence about the provider. For enumeration purposes, there are two categories of health care providers. Entity Type 1 is for individuals, such as physicians, nurses, dentists, chiropractors, pharmacists, and physical therapists. Entity Type 2 is for organizations, such as hospitals, home health agencies, clinics, nursing homes, laboratories, and MTFs. The NPI is meant to be a lasting identifier and will not be replaced as a result of changes in a health care provider’s name, address, ownership, membership in health plans, or Healthcare Provider Taxonomy classification.

NPI enumeration of health care providers (i.e., assignment of NPIs to providers) and maintenance of NPI-associated data is being conducted through the National Plan and Provider Enumeration System (NPPES). The NPPES is the central system for identifying and uniquely enumerating health care providers at the national level. TRICARE providers should begin to obtain their NPIs and can apply through a Web-based application at the National Plan & Provider Enumeration System Web site, or by submitting a paper application that can be found at the Centers for Medicare & Medicaid Services Web site.  A copy of the paper application can also be obtained by calling the NPI Enumerator at 1-800-465-3203 or TTY at 1-800-692-2326.

A Web site with the latest NPI information can be accessed at the Centers for Medicare & Medicaid Services Web site. As more information becomes available, TRICARE-specific NPI information may be accessed at the TRICARE Web site. Processes are being developed for providers to submit their NPIs to TRICARE. Humana Military will provide more information regarding these processes.


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HIPAA Employer Identifier
The National Employer Identifier Final Rule was published on May 31, 2002. Compliance with this rule was effective July 30, 2004.  For HIPAA purposes, employers are defined as the sponsors of health insurance for their employees. The standard selected for the national employer identifier is the Employer Identification Number (EIN) as issued by the Internal Revenue Service (IRS). This number is the EIN that appears on an employee’s IRS Form W-2, Wage and Tax Statement, and is the number that will be used to identify that employer in standard electronic health care transactions.  Covered health care providers, health plans, and health care clearinghouses must accept and transmit the EIN where required in electronic health transactions.


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TRICARE Provider Types

TRICARE defines a provider as a person, business, or institution that provides or gives health care. For example, a doctor is a provider.  A hospital is a provider. An ambulance company is a provider. There are many other provider types. A provider must be authorized under the TRICARE Regulation and must have their authorized status verified (certified) by Humana Military. 

Note: Active duty service members and civilian employees of the Federal Government who are health care providers are generally not authorized to be TRICARE providers in civilian facilities. Only TRICARE-authorized civilian providers may receive reimbursement from TRICARE.

Figure 2.2 provides an overview of various TRICARE provider types.

 
TRICARE Provider Types

Fig. 2.2
TRICARE-authorized Providers
  • TRICARE-authorized providers are those who meet TRICARE's licensing and certification requirements and have been certified by TRICARE to provide care to TRICARE beneficiaries.  These include doctors, hospitals, ancillary providers (such as laboratory and radiology providers), and pharmacies.
  • There are two types of TRICARE-authorized providers:  Network and Non-network.
Network Providers (1)
Non-network Providers(2)
  • Have a signed agreement with Humana Military to provide care.
  • Agree to file claims and handle other paperwork for TRICARE beneficiaries.
  • Do not have a contractual relationship with Humana Military.
  • There are two types of non-network providers:  Participating and Nonparticipating.
Participating
NonParticipating
  • Have agreed to file claims for TRICARE beneficiaries, to accept payment directly from TRICARE, and to accept the TRICARE allowable charge as payment in full for their services.
  • May participate on a claim-by-claim basis.
  • Have not agreed to accept the TRICARE allowable charge or file claims for TRICARE beneficiaries.
  • Have the legal right to charge beneficiaries up too 15% above the TRICARE allowable charge for services.

1 All network providers are required to have malpractice insurance.
2 To become a network provider, visit the Provider Resources section and select “Becoming a TRICARE Network Provider” or contact Humana Military at 1-800-444-5445.


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Last Update: July, 2007