Centers for Medicare & Medicaid Services, On the Job, Scope of Practice

Who Is Eligible for an NPI?

Determining who’s eligible for a National Provider Identifier (NPI) number may require some research, which is why, in part, I recently received the following request:

Mr. Balasa, I read with interest the following from your recent post to Legal Eye, “Medical Assistants and Incident-to Billing”:

Medical assistants do not have National Provider Identifier (NPI) numbers because they are not reimbursed directly by Medicare for their services. Rather, their services may only be billed and reimbursed incident to the services of the delegating provider.

Could you please provide documentation of which health professionals are and are not eligible for an NPI number?

Medical assistants whose employers request them to get an NPI number may use the following documentation to educate and provide clarity to employers and coworkers.

Note the following from a Centers for Medicare & Medicaid Services (CMS) fact sheet:

  • Who? All individuals and Organizations who meet the definition of health care provider as described at CFR 160.103 are eligible to obtain a National Provider Identifier, or NPI.

Note the following definition from 45 CFR 160.103:

Health care provider means a provider of services (as defined in section 1861(u) of the Act, 42 U.S.C. 1395x(u)), a provider of medical or health services (as defined in section 1861(s) of the Act, 42 U.S.C. 1395x(s)), and any other person or organization who furnishes, bills, or is paid for health care in the normal course of business.

Section 1861(s) of the Social Security Act does not contain a reference to medical assisting services. It references explicitly the services of the following health professionals:

  • Physicians
  • Nurse practitioners
  • Physician assistants
  • Certified nurse-midwives
  • Qualified psychologists
  • Clinical social workers
  • Certified registered nurse anesthetists

Therefore, according to federal statute and CMS rule, medical assistants are not considered health professionals who are eligible for NPI numbers.

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