Atypical Provider Whitepaper Wedi CFM

WEDI Strategic National Implementation Process (SNIP)
SNIP Transactions Workgroup

National Provider Identifier Sub Workgroup
HIPAA
National Provider Identifier
White Papers
Atypical Service Providers

Final - Version 1.2
May 28, 2006
Workgroup for Electronic Data Interchange

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© 2006 Workgroup for Electronic Data Interchange, All Rights Reserved
The NPI and Atypical Service Providers
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© 2006 WEDI - SNIP - NPI Sub Workgroup Atypical Service Providers • 1

TABLE OF CONTENTS
DISCLAIMER .................................................................................................................. 1
I. PURPOSE ................................................................................................................ 1
II. SCOPE ................................................................................................................. 1
III. DEFINITIONS......................................................................................................... 1
IV. BACKGROUND ...................................................................................................... 4
V. BACKGROUND INFORMATION FROM THE TRANSACTION AND CODE SETS FINAL RULE .. 5
Atypical Services Discussion from the preamble. ..................................................... 5
VI. BACKGROUND INFORMATION FROM THE NPI FINAL RULE ......................................... 6
VII. BUSINESS AND IMPLEMENTATION ISSUES ................................................................ 7
How to evaluate whether a provider is eligible for an NPI or not?............................. 8
The entity that has an NPI and bills for atypical services.......................................... 9
The entity that has both an NPI AND an API. ........................................................... 9
The role of provider taxonomy codes........................................................................ 9
What we know about atypical service providers. .................................................... 10
How are atypical service providers enumerated and paid today?........................... 11
Atypical service providers and electronic transactions............................................ 12
Identifying atypical service providers in electronic transactions after the NPI
implementation date. .............................................................................................. 12
VIII. FUTURE ATYPICAL PROVIDER ENUMERATION CONSIDERATIONS .......................... 12
Desirable features for an API.................................................................................. 12
IX. ALTERNATIVE ENUMERATION APPROACHES AND RECOMMENDATION ....................... 13
A. Alternative Enumeration Approaches. ............................................................... 13
B. White Paper Recommendations........................................................................ 14
X. NPI ONLINE RESOURCES .................................................................................... 15
XI. ACKNOWLEDGEMENTS ........................................................................................ 15
XII. LIST OF APPENDICES .................................................................................... 16
APPENDIX A – 42 USC 1395(X) SECTION 1861(U) AND 1861(S) ......................... A - 1
APPENDIX B – ATYPICAL PROVIDER WORKSHEET........................................... B - 1

I. Purpose
The National Provider Identifier (NPI) Final Rule stipulates that only entities who meet
the definition of "health care providers" found at 45 CFR 160.103 are eligible for NPIs.
There are a number of entities who do not meet this definition who are therefore not
eligible for NPIs, but whose services are payable by some health plans. In many cases
these entities submit their claims to health plans in standard format (i.e., using the
electronic standard claim transaction formats), and identifying themselves by the
proprietary identifiers assigned to them by the health plans to which they submit claims.
The NPI final Rule refers to these entities as “atypical service providers” because the
services they render are not “health care” services.
This paper is an attempt to document many types of atypical service providers, describe
the type of services they deliver, identify and describe the way they are currently
enumerated, relate them to the current version of the Health Care Provider Taxonomy
code set, discuss their need to continue to use proprietary identifiers in standard claim
transactions for services, and review alternative approaches to enumeration of these
providers. We hope to gain industry consensus on the types of providers as listed in
Appendix B, Atypical Service Providers.
This paper is NOT intended to be a definitive resource; rather it should be used as

guidance.
II. Scope
This paper is NOT intended to provide a complete list of atypical service providers, but
to provide education and to reach industry consensus and agreement on definitions of
some of these providers and their need for an NPI. Business and implementation
issues related to the NPI and the enumeration of atypical service providers are
documented in this paper. A section that provides recommendations on how some of
the issues identified might be addressed is included.
III. Definitions
For purposes of this white paper the following definitions have been used:
Atypical Service Provider

Transaction Rule 65 FR 50315
An Atypical Service Provider is one that does not furnish health care services as defined in
section 1861 (u) of the SSA. Examples are taxi drivers, auto mechanics and carpenters.

API
Atypical service provider identifier.
Covered Entity
A health plan; a health care clearinghouse; or a health care provider who transmits any
health information in electronic form in connection with a transaction covered under
HIPAA.
Covered Health Care Provider

45 CFR § Subtitle A 160.103 Definitions
Covered health care provider means a health care provider that meets the definition at
paragraph (3) of the definition of “covered entity” at § 160.103 of this subchapter.
Health Care
Health care means care, services, or supplies related to the health of an individual.
Health care includes, but is not limited to, the following:
(1) Preventive, diagnostic, therapeutic, rehabilitative, maintenance, or palliative care,
and counseling, service, assessment, or procedure with respect to the physical or
mental condition, or functional status, of an individual or that affects the structure or
function of the body; and
(2) Sale or dispensing of a drug, device, equipment, or other item in accordance with a
prescription.
Health Care Provider

Health care provider means a provider of services (as defined in section 1861(u) of the
Social Security Act [SSA], 42 U.S.C. 1395x(u)), a provider of medical or health services
(as defined in section 1861(s) of the SSA, 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.
Appendix A is taken from the SSA and is provided as reference.
Health Care Provider Taxonomy Code

The following information was taken from the Health Care Provider Taxonomy code list
website maintained by the National Uniform Claim Committee (NUCC), and available at
http://www.nucc.org/content/view/14/40/.
The Provider Taxonomy is a unique alphanumeric code, 10 characters in length.

The code list is structured into three distinct “levels” including Provider Type
Type, Classification, and Area of Specialization.
The Health Care Provider Taxonomy code set allows a single provider
(individual, group, or non-individual) to identify a specialty category. Providers
may have one or more than one taxonomy associated to them. When
determining what code or codes to associate with a provider, the user needs to

review the requirements of the trading partner with which the code(s) are being
used.
Effective 2001, The National Uniform Claim Committee [NUCC] took over the
administration of the national Health Care Provider Taxonomy code set.
Ongoing duties, including processing taxonomy code requests and maintenance
of the external Health Care Provider Taxonomy code set, will fall under the
NUCC Code Subcommittee. NUCC has designated the Washington Publishing
Company (WPC - http://www.wpc-edi.com/taxonomy/more_information) as the
web host for distribution of the list.
Legacy Identifier
An identifier assigned by individual health plans to identify each provider enrolled in that
health plan. The legacy identifier is used to bill health care transactions to that specific
plan only. Other names used include: Proprietary identifier, Internal Registration
Number, or Health Plan Provider Number. Legacy identifiers include UPINs, BCBS
numbers, Medicaid IDs, PINs, etc. Taxpayer identifiers and social security numbers are
not considered legacy identifiers.
Standard
45 CFR Subtitle A §160.103 Definitions
Standard means a rule, condition, or requirement:
(1) Describing the following information for products, systems, services or practices:
(i) Classification of components.
(ii) Specification of materials, performance, or operations; or
(iii) Delineation of procedures; or
(2) With respect to the privacy of individually identifiable health information.
HIPAA Standard Transaction

Standard transaction means a transaction that complies with the applicable standard
adopted under 45 CFR Parts 160 and 162 Health Insurance Reform: Standards for
Electronic Transactions; Announcement of Designated Standard Maintenance
Organizations; Final Rule and Notice.
Standard Paper Transaction

Standard paper transaction means a paper health care form held out as the current
accepted paper claim in the industry that has been approved or adopted by the
responsible Standards Organization. The National Uniform Claim Committee (NUCC) is
responsible for the professional claim, the CMS 1500 form. The National Uniform Billing
Committee (NUBC) is responsible for the institutional claim, the UB-92 and soon to be
UB-04. The American Dental Association is responsible for the ADA Dental form.
Standard Electronic Transaction

For the purposes of this White Paper, the term Standard Electronic Transaction is a
HIPAA Standard Transaction as defined above.

Transaction
Transaction means the transmission of information between two parties to carry out
financial or administrative activities related to health care. It includes the following types
of information transmissions:
(1) Health care claims or equivalent encounter information.
(2) Health care payment and remittance advice.
(3) Coordination of benefits.
(4) Health care claim status.
(5) Enrollment and disenrollment in a health plan.
(6) Eligibility for a health plan.
(7) Health plan premium payments.
(8) Referral certification and authorization.
(9) First report of injury.
(10) Health claims attachments.
(11) Other transactions that the Secretary may prescribe by regulation.
Trading Partner
An entity that exchanges health care data or transactions with another.
IV. Background
In the health care world, entities that provide services to patients and receive
reimbursement from health plans are all referred to as “providers” With HIPAA the
definition of provider becomes very important as the law applies to “health care”
providers. Providers can be split into three major groups:
• Who is eligible to obtain a NPI

• Who is required to obtain a NPI
• Who is not eligible to obtain a NPI
All entities, both individuals and organizations, that meet the HIPAA definition of a
“health care provider” per 45 CFR § 160.103 are eligible to obtain a NPI. All covered
health care providers (entities that meet the definition of a “health care provider” AND
meet the definition of a “covered entity”, i.e., is a health care provider who submits
standard electronic transactions) are required to obtain a NPI. If the entity does not
meet the definition of a “health care provider” as defined under HIPAA, then the entity is
not eligible to obtain an NPI. Examples of health care providers include physicians,
hospitals, pharmacies, nurses, medical suppliers, psychologists, dentists, chiropractors,
clinics, etc. Examples of providers who are not health care providers and do not
provide health care include non emergency transportation providers such as taxis,
personal care attendants, building contractors, language interpreters, etc. These types
of providers are referred to as “atypical service providers.”

V. Background information from the

Transaction and Code Sets Final Rule
Atypical Services Discussion from the preamble.
50315 Federal Register / Vol. 65, No. 160 / Thursday, August 17, 2000 / Rules and
Regulations - Comments & responses to the proposed rule
3. Atypical Services
Proposal Summary: Transactions for certain services that are not normally considered health
care services, but which may be covered by some health plans, would not be subject to the
standards (63 FR 25276). These services would include, but not be limited to: nonemergency
transportation, physical alterations to living quarters for the purpose of accommodating
disabilities, and case management. Other services may be added to this list at the discretion of
the Secretary.
Comment: We received comments both for and against subjecting transactions for certain
services to the transaction standards. Some commenters recommended that any service that
could be billed to a health plan be required to comply with the standards in order to avoid the
need to maintain alternate systems. However, other commenters argued that certain Medicaid
services are not insured by any other program, thus, use of the standard is unnecessary.
Several commenters supported not subjecting these services to the standard, except for case
management, arguing that a more precise definition of case management needs to be
developed. Other commenters stated that case management is considered a health care
service by many health plans and health care providers, and reported using standard codes. We
received suggestions for additional services that should not be subject to the standards.
Suggestions included home and community based waiver services provided under the Medicaid
program and abbreviated transactions between State agencies, for example, claims between a
State health service and a State Medicaid agency.
Response: We agree with commenters that case management is a health care service since it
is directly related to the health of an individual and is furnished by health care providers. Case
management will, therefore, be subject to the standards. We recognize that the health care
claim and equivalent encounter information standard, with its supporting implementation
specification, is capable of supporting claims for atypical services. However, requiring all
services potentially paid for by health plans to be billed using the standards would lead to taxi
drivers, auto mechanics and carpenters to be regulated as health care providers. Instead, we
will use our definition of ‘‘health care’’ found at 160.103 to determine whether a particular
service is a ‘‘health care’’ service or not. Services that are not health care services or supplies
under this definition are not required to be claimed using the standard transactions. Thus,
claims for non-emergency transportation or carpentry services for housing modifications, if
submitted electronically, would not be required to be conducted as standard transactions. As
noted above, the standards do support such claims and a health plan may choose to require its
atypical service providers to use the standards for its own business purposes. Those atypical
services that meet the definition of health care, however, must be billed using the standard if
they are submitted electronically. If there are no specific codes for billing a particular service (for
example, there is not yet an approved code set for billing for alternative therapies), or if the
standard transactions do not readily support a particular method of presenting an atypical

service (for example, roster billing for providing immunizations for an entire school or nursing
facility), the health care service providers are urged to work with the appropriate Designated
Standard Maintenance Organizations (DSMOs) to develop modifications to the standard and
implementation specifications. (See ‘‘I. New and Revised Standards’’ in this section of the
preamble for a discussion of the DSMOs.)
We disagree with the proposal that home and community based waiver services should have a
blanket exemption from the administrative simplification standards. First, Congress explicitly
included the Medicaid programs as health plans that are subject to the administrative
simplification standards. Second, these waiver programs commonly pay for a mix of health care
and non-health care services. State Medicaid agencies with home and community based
waivers are not exempt from these standards for transactions relating to health care services or
supplies.
VI. Background Information from the NPI

Final Rule
Federal Register / Vol. 69, No. 15 / Friday, January 23, 2004 / Rules and Regulations 3437
It is important to note that not all health care providers who are eligible to receive NPIs will
necessarily be required to comply with the HIPAA regulations. This is because some health
care providers are not covered entities under HIPAA. The fact that a health care provider
obtains an NPI does not impose covered entity status on that health care provider. Only those
entities that (1) meet the definition of health care provider at § 160.103, and (2) transmit health
information in electronic form on their own behalf, or that use a business associate to transmit
health information in electronic form on their behalf, in connection with a transaction for which
the Secretary has adopted a standard (a covered transaction) are health care providers who are
required to comply with the HIPAA regulations. These health care providers are covered health
care providers and are considered ‘‘covered entities’’ under HIPAA. As noted above, we add a
definition of ‘‘covered health care provider’’ at § 162.402.
The following discussion clarifies the eligibility of health care providers to be assigned NPIs and
distinguishes between those that are covered entities under HIPAA and those that are not.
‘‘Health care provider’’ is defined in the regulations at § 160.103 as follows ‘‘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.’’ Examples of health care providers included in this
definition are: Physicians and other practitioners; hospitals and other institutional providers;
suppliers of durable medical equipment, supplies related to health care, prosthetics, and
orthotics; pharmacies (including on-line pharmacies) and pharmacists; and group practices.
Additional examples are health maintenance organizations that may be considered health care
providers as well as health plans if they also provide health care.
There are individuals and organizations that furnish atypical or nontraditional services that are
indirectly health care-related, such as taxi, home and vehicle modifications, insect control,
habilitation, and respite services. These types of services are discussed in the Transactions
Rule at 65 FR 50315. As stated in that Rule, many of these services do not qualify as health

care services because the services do not fall within our definition of ‘‘health care.’’ An
individual or organization must determine if it provides any services that fall within our definition
of ‘‘health care’’ at § 160.103. If it does provide those services, it is considered a health care
provider and would be eligible for an NPI. If it does not, and does not provide other services or
supplies that bring it within the definition of ‘‘health care provider,’’ it would not be a health care
provider under HIPAA, and would not be eligible to receive an NPI.
The nonhealth care services of some atypical or nontraditional service providers are reimbursed
by some health plans. Nevertheless, there is no requirement under HIPAA to use the standard
transactions when submitting electronic claims for these types of services, because claims for
these services are not claims for health care. (Health plans, however, are free to establish their
own requirements for submitting claims in these circumstances, which means that a health plan
could require atypical and nontraditional service providers to submit standard transactions. The
health plans could not require these entities to obtain NPIs to use in those transactions,
however, because those entities are not eligible to receive NPIs.)
There are other individuals and organizations that, in the normal course of business, bill or
receive payment for health care that is furnished by health care providers. These individuals
and organizations may include billing services, value-added networks, and repricers. While
these entities bill for health care, we do not read the statutory definition of ‘‘health care provider’’
as encompassing them. Rather, they would usually be acting as agents of health care providers
in performing the billing function, or as health care clearinghouses assuming that they perform
the data translation function described in the definition of ‘‘health care clearinghouse’’ at §
160.103. The definition of ‘‘health care clearinghouse’’ specifically lists these entities as
examples of health care clearinghouses. The health care industry does not consider these
types of entities to be health care providers. Further, we do not believe that the Congress
intended for them to be considered as such, as the statutory definition of ‘‘health care provider’’
refers only to ‘‘other person furnishing health care services or supplies’’ and thus would exclude
persons who only bill for, but do not furnish, health care services or supplies. Thus, this final
rule does not include billing services and similar entities as health care providers. Therefore,
because these kinds of entities are not health care providers, they will not be eligible for NPIs.
Important Notes from the above section of the rule:
- Because a provider has an NPI does not make them a covered health care provider.
- There is no requirement that atypical services be claimed/billed on standard paper or
electronic transactions. It is up to the trading partners to determine how these services will
be claimed/billed.
- Electronic claims for atypical services are not standard transactions because they are not
claims for health care. Whether the provider is a health care provider or an atypical
services provider, claims for atypical services are NOT ‘standard transactions’ and not
subject to the rule.
VII. Business and Implementation Issues

An Atypical Service Provider is one that does not provide health care services. These providers
are not eligible for an NPI, but may be required by some payers to conduct electronic
transactions using standards mandated by HIPAA. It’s important to note that in some instances
a health care provider can provide non-health care services. Once the NPI is mandated for use,

it is important to understand how to identify an atypical provider and how non health care
services provided by atypical providers can be billed in a standard transaction without a NPI.
How to evaluate whether a provider is eligible for an NPI or not?

Both the provider and the service they provide must be evaluated to determine if the
provider is eligible for a NPI.
Is the provider within the health care provider definition from 45 CFR 160.103?
o If yes, then the provider is eligible for a NPI on its own, regardless of the
services it provides.
o If not, then:
Does the provider deliver health care services as defined at 45 CFR 160.103?
o If yes, then the provider is also considered to be a health care provider
and is eligible for a NPI.
o If not, then the provider is considered an atypical service provider and is
not eligible for a NPI.
An entity that might not be generally considered a health care provider, as defined in 45
CFR would be eligible for a NPI if they provide health care services. An example is a
Local Education Agency or an Intermediate School District. These entities are not
considered to be health care providers, however they do provide health care in the
normal course of business when they provide school-based health services and bill the
Medicaid program. In short, they become health care providers when they provide
health care services.
It is important to emphasize that providers be evaluated in terms of both whether they

provide health care services or whether they are a health care provider under HIPAA. A
provider may be considered a health care provider in some states but not in others, e.g.,
depending on the states’ requirements for licensing and credentials. The test is not
whether the state considers an entity a health care provider but whether the entity
meets the requirements at the Federal level under HIPAA.
Atypical service providers in one state or enrolled in one health plan may not
necessarily be atypical service providers in another state or health plan. An example to
consider is that of an assisted living facility. As explained in the Appendix B, an
assisted living facility provides supportive services to individuals who can function
independently in some areas of activity, but need assistance and/or monitoring to
assure their safety and well being. Often, assistance is in the form of help with eating,
bathing, toileting, dressing, etc. and there are no health care services involved. The
people providing the care are often unskilled personal attendants. This type of assisted
living facility would not be eligible to obtain an NPI. However, there are other assisted
living facilities that include a medical component – health care services provided by a
health care professional such as a doctor, nurse, therapist, etc. This type of facility
would be eligible for an NPI and may be required to have one if they conduct electronic
transactions. The point being, the type of provider and the type of services provided
must be evaluated in order to determine if a NPI is assignable or not. A single facility

might provide a covered benefit to different health plans – one which includes a medical
component and one which does not. In that instance, the facility would have an NPI to
bill as a health care provider, but may still have to use a legacy ID to bill for the non-
health care services.
The entity that has an NPI and bills for atypical services.
There are times when a health care provider will deliver an atypical service. For
example a physician may provide interpreter services. While the physician is a health
care provider, the provision of language interpreter services is not health care, and thus
any claim generated would not be considered a health care claim. In this instance, the
provider could use the assigned NPI, or the health plan could require that a legacy ID
be used. Trading partner agreements should define the usage of a provider identifier in
these circumstances.
The entity that has both an NPI AND an API.

When conducting HIPAA standard electronic transactions, the NPI must be used.
When conducting non-standard transactions, WEDI recommends that the provider use
the NPI, whether the transaction is conducted electronically (i.e. using an X12 standard
or NCPDP standard) or via a paper form (i.e. CMS 1500, UB04). Based on trading
partner agreements the provider can submit a legacy ID, along with the NPI, during the
transition period.
The role of provider taxonomy codes.

Provider taxonomy codes are maintained by the National Uniform Claim Committee (NUCC).
This external non-medical list established as a standard code set for electronic transactions
under HIPAA is called “Health Care Provider Taxonomy” code set. The name of the code set
has created confusion in the industry as some believe that only health care providers are
assigned taxonomy codes. This is not true. Just because a taxonomy code exists does not
mean that the entity identified is a health care provider. For example, some of the
classifications with assigned taxonomy codes include:
• Adult foster care facility

• Adult companion
• Chore provider
• Driver
• Contractor
• Homemaker
• Home delivered meals
• Lodging
• Medical records provider
• Nonemergency transportation providers
• Veterinarian
• Personal care attendant
• Bus (transportation)

The above is just a sample of entities that are not health care providers, yet there is a taxonomy
code assigned. In the converse, if a taxonomy code does not exist, it does not mean that the
entity is not a health care provider. The NUCC is constantly updating the code set and adding
more specialties as they are identified. Again, the test of whether an entity is a health care
provider or not must be accomplished by looking at the definition of health care provider under
the HIPAA law.
What we know about atypical service providers.

An information request was sent to the WEDI NPI Subworkgroup and the NMEH (National
Medicaid EDI health care) workgroup asking for information about the enumeration of atypical
providers. The response was not large, however it does provide some good information for us
to consider. Predominantly, Medicaid plans responded and we know that many Medicaid plans
cover atypical service providers especially in the provision of home and community based
waiver services. The response from the commercial side was very low so we did not gain a
good understanding of the coverage of this type of provider in the commercial sector. We also
know that TRICARE, the Department of Defense military insurance program, covers a number
of atypical providers, however we were not able to get an accounting of the types or numbers.
From the responses, the number of atypical service providers appears to overwhelmingly be in
the Medicaid sector.
There were 18 responses - 14 from Medicaid plans and 4 from commercial plans. Two of the
commercial plans do not enroll atypical providers. Not all plans reported actual numbers of
atypical providers. Some reported totals of atypical service providers enrolled, but did not
breakout the type and number of each. These are the pertinent findings:
• Approximately 94,750 atypical service providers enrolled identified as enrolled in 13

plans with only 1200 identified as in the commercial sector
• Estimated that about 4950 are newly enrolled annually
• 6 plans indicated they would keep the current legacy ID for atypicals, however at the
same time indicated the number would be changed
• 2 plans are assigning a 10 digit numeric number
• 5 plans are assigning a 10 digit alpha numeric number
• 1 plan assigns 12 digit number (SSN plus 001)
• 1 plan uses 7 digit numeric
• 1 plan uses 6 digit alpha numeric
• 2 plans use 6 byte identifiers
• 6 plans indicated they would prefer a national enumeration solution for atypical service
providers
• 2 prefer a regional enumeration
• 6 prefer that the health plan be responsible for enumeration
We asked for a listing of the types of atypical service providers and the estimated number of
each enrolled in plans. We received many varied names, and some clearly appeared to be
health care providers – psychologists, HIV case managers, adult medical daycare, and a few
others. Predominantly, personal care workers lead the pack with about 55,700 identified. Next
was a grouping we called non medical living arrangements which totaled about 9550. The third
largest was non emergency transportation providers with about 8775. Non medical living
arrangements included assisted living, certified family homes, boarding homes, foster homes,
hotels, supervised independent living, and community residential facilities. Other types of

atypical service providers identified included chore providers, homemakers, habilitation service
providers, school attendants, school counselors, waiver providers (specific to Medicaid
programs), various mental health providers, home delivered meals, community service
agencies, state departments, and a multitude of case management and others.
How are atypical service providers enumerated and paid today?

The NPI Final Rule allows for the NPPES to assign a NPI only to entities that are health care
providers. Therefore, atypical service providers cannot be assigned a NPI. Unless an entity is
identified to assign APIs at a national level, then health plans must determine how these
atypical providers will be enumerated. Many in the industry have expressed a desire to make
the API look like the NPI. Some intend to assign a 10 digit alpha numeric identifier and some
have indicated they will assign a 10 digit numeric identifier. Health plans are advised not to
assign a 10 digit numeric identifier. All the space for 10 digit numeric identifiers is reserved.
There is the possibility that the health plan could assign an API which would duplicate a valid
NPI or other identifier that might be assigned in the future. This could create complications
when processing electronic transactions.
Current enumeration procedures for atypical service providers mirror the current enumeration
procedures for health care providers in the majority of plans. Most health plans view all entities
paid for services covered under the plan as “providers” and do not distinguish whether they are
health care providers or not. If the plan pays the entity, they are assigned a legacy identifier or
the SSN/EIN is used.
Many atypical service providers submit electronic and paper transactions and receive payment
just as health care providers do. Prior to HIPAA, each health plan often developed their own
homegrown or “local” procedure codes to identify non health care services. HCPCS Level II
codes were developed to identify some of these services, especially since the implementation of
the Transactions and Code Set Final Rule requiring standard procedure codes and the
elimination of “local” codes. Most health plans adopted the standard codes and prefer that
atypical services be billed electronically. Some plans have reported dropping all non health
care and atypical service provider claims to paper in order to continue with their local codes.
Services provided by atypical service providers are sometimes reimbursed to an organization

that is a health care provider. For example, personal care attendants can be employed by a
Home Health Agency. They also could be employed by an organization that is not a health care
provider such as a non certified home care agency or an employment agency. Some plans
enumerate atypical service providers, but make them noncovered providers in their system.
When a claim comes in, it is suspended, reviewed for coverage under the plan guidelines, and
when approved, payment is made to the policyholder or beneficiary, not the provider.
Other billing and payment methodologies include “invoicing” as in the retail arena with no
provider identifier assigned such as with environmental modifications made by carpenters or
others. Some atypical service providers are employed by the beneficiary. Services are often
preauthorized for a specified type and amount, documented as provided on logs, and automatic
biweekly or monthly payment is made. Payment can be generated through non standard
payment mechanisms and joint checks may go to the beneficiary and the provider. Often
nonemergency transportation providers are reimbursed through a “broker” under contract with
the health plan that covers the service. The broker or the health plan may use vouchers,
tokens, contracted rates, per mile rates and other types of reimbursement methods.

Atypical service providers and electronic transactions

An atypical provider may submit a claim that—except for not identifying the provider with NPI—
otherwise conforms to an 837 claim as specified in HIPAA implementation guides; however,
such a claim is not a HIPAA standard claim because the Transactions and Code Sets rule
defines a standard claim as a “request to obtain payment…from a health care provider to a
health plan, for health care”, but an atypical provider is not a health care provider; so the claim
is not standard.
The preamble to the NPI rule addresses this issue:

“The nonhealth care services of some atypical or nontraditional service providers are
reimbursed by some health plans. Nevertheless, there is no requirement under HIPAA to use
the standard transactions when submitting electronic claims for these types of services,
because claims for these services are not claims for health care. Health plans, however, are
free to establish their own requirements for submitting claims in these circumstances, which
means that a health plan could require atypical and nontraditional service providers to submit
standard transactions. The health plans could not require these entities to obtain NPIs to use in
those transactions, however, because those entities are not eligible to receive NPIs.”
Identifying atypical service providers in electronic transactions after

the NPI implementation date.
Some believe that atypical service providers cannot be identified in electronic transactions after
the NPI is mandated. This is not true. The HIPAA transactions allow the reporting of a legacy
identifier for atypical service providers – those that are not eligible to be assigned an NPI.
Transactions for atypical service providers will continue to be created in the same way they
have been, prior to the advent of the NPI. For example, in the 837 Health Care Claim:
Professional, the Tax Identifier will be located in loop 2010AA Billing Provider Name
NM109/Billing Provider Primary Identification Number and the Legacy Identifier as the
Secondary Identifier [REF Segment]. The servicing provider primary identifier is either an EIN
or SSN and the Legacy Identifier is contained in the Secondary Identifier [REF] segment.
Please refer to the applicable transaction Implementation Guide for additional details.
VIII. Future Atypical Provider Enumeration

Considerations
Desirable features for an API
The ideal features for Atypical Provider Identifiers include the following:
• An API should be unique, universal, and not payer-specific. An atypical provider should
be able to use the same identifier regardless of payer.
• It should support claim cross-over to secondary payers with the same identifier.
• There should be no duplicates.
• There should be a central database available to all payers. It should support inquiry by a
person such as through direct data entry, and it should permit computer-to-computer
inquiry.
• The status of an identifier should become “inactive” if the identifier is not used.

• There should be continuity with legacy identifiers.

• It should enable the same software logic to be used for API as for NPI.
• A payer needs ability to integrate data from NPI and API to avoid having two systems;
the payer’s system should only have to look at one internal directory.
• It would be technically desirable if it looks like NPI. It should avoid different
characteristics that require different editing requirements and different reporting.
IX. Alternative Enumeration Approaches

and Recommendation
A. Alternative Enumeration Approaches.
There are several alternative approaches to identify atypical service providers. These include:
Alternative 1: Maintain a Legacy Enumeration System
Option 1: Use current payer-assigned identifier

Under this approach, the payer continues to employ the same identifier for an atypical
service provider as it does now. Implications include:
• It means an atypical service provider must obtain a different ID from every payer.
• The atypical service provider must juggle using a different identifier for every payer.
• A claim submitter referring to an atypical service provider must juggle different IDs for
every payer.
• The identifier does not cross-over from payer to payer.
• Payers do not have an external database for the identifiers.
Option 2: Payer-assigned 10-digit ID

Some payers suggest that each payer assign a 10-digit identifier to be technically similar
to NPI. Implications include: This approach has all the same problems as Alternative 1,
including:
• An atypical service provider must obtain an ID from every payer and must juggle
different IDs for every payer.
• Claim submitters referring to an atypical service provider must juggle different IDs for
every payer.
• No ability for cross-over or COB using the same identifier.
• Payers have no external database for IDS.

Alternative 2: Regional Coordination of Atypical Service Provider Enumeration

Under this approach, regions would set up cooperative enumeration of atypical service
providers. Implications include:
• That would solve some but not all of the problems
• It does not help at region boundaries.
• It would require the same infrastructure that a national program would require times the
number of regions.
• So why not national?
Alternative 3: National Enumeration of Atypical Service Providers

A National Atypical Service Provider Enumeration program would meet all the objectives:
• A National API would be a unique, universal, same number sent to any payer with
duplicates prevented.
• It would support cross-over and COB claims with the same identifier.
• It would have the look and feel of NPI; it would use the same logic.
• It would readily provide ability to integrate NPI and API databases.
• There would be a single API infrastructure to develop and operate.
Some basic considerations for a national API program include:

• Should atypical service providers be responsible for their own enumeration or should
payers apply on their behalf?
• How should the national program be funded?
• How soon must it be operative?
B. White Paper Recommendations.

WEDI recommends that the enumeration of atypical service providers be done using a
national enumeration approach for Atypical Service Providers (Alternative 3 above).
WEDI will work with the health care industry, NCVHS, HHS/CMS, and other appropriate bodies
to develop a proposal on how to achieve this recommended approach. A new white paper
focusing on how to achieve a national enumeration system for atypical service providers will be
developed by WEDI SNIP, in collaboration with these entities, and presented to the industry
over the next six months.

X. NPI Online Resources

CMS: http://www.cms.hhs.gov/NationalProvIdentStand/
• NPI final rule, overview
• Regulations
• NPI FAQs
• NPI Enumeration statistics
• How to apply for NPI (NPPES)
• Medicare NPI Implementation
• Medlearn Matters article on Medicare subparts
• Medicare Subpart guidance
• Electronic File Interchange
WEDI (Workgroup for Electronic Data Interchange) NPI Outreach Initiative:

http://www.wedi.org/npioi/
• White papers
• Press releases, fact sheets
• Power Point presentations
• Educational forums
• Other resources, links to NPI information
XI. Acknowledgements
NPI Sub Workgroup Leaders:
Peter Barry, Peter T. Barry Company
Walter Suarez, Institute for HIPAA/HIT Education and Research
WEDI/SNIP expresses its appreciation to the authors who prepared this White Paper:
Walter Suarez, Institute for HIPAA/HIT Education and Research, Co-leader

Linda McCardel, Michigan Public Health Institute; Co-leader
Mary Kay McDaniel, Consultant, Arizona Health Care Cost Containment System [AHCCCS],
Co-leader
Andrea Danes, Fox Systems, Inc.
Peter Barry, Peter T. Barry Company
Eric Guthrie, Cognode, Inc.
Suzanne Stewart, Aurora Health Care

XII. LIST OF APPENDICES

Appendix A
SSA definition of Health Care Provider.
Appendix B
Appendix B lists types of providers, definitions, and comments/recommendations regarding
whether the provider should be eligible for an NPI or not. Many of the entries were submitted to
the NMEH (National Medicaid EDI Health care) Workgroup by states who reimburse these
providers. In addition, the Health Care Provider Taxonomy code set on the Washington
Publishing Company website (http://www.wpc-edi.com/codes/taxonomy) was searched for
providers that appeared to be atypical service providers, i.e., not a health care provider. Some
providers recommended to be considered health care providers and thus eligible for an NPI, are
listed in order to provide education and basis for further comments.

APPENDIX A – 42 USC 1395(x)

SECTION 1861(u) and 1861(s)
© 2006 WEDI - SNIP - NPI Sub Workgroup Atypical Service Providers • A-1
APPENDIX A
1861(u) Provider of Services: The term “provider of services” means a hospital,

critical access hospital, skilled nursing facility, comprehensive outpatient rehabilitation
facility, home health agency, hospice program, or, for purposes of section 1814(g) and
section 1835(e), a fund.
1861(s) Medical and Other Health Services: The term “medical and other health
services” means any of the following items or services:
(1) physicians' services;
(2)
(A) services and supplies (including drugs and biologicals which are not usually
self-administered by the patient) furnished as an incident to a physician's
professional service, of kinds which are commonly furnished in physicians' offices
and are commonly either rendered without charge or included in the physicians'
bills (or would have been so included but for the application of section
1847B)[392];
(B) hospital services (including drugs and biologicals which are not usually self-
administered by the patient) incident to physicians' services rendered to
outpatients and partial hospitalization services incident to such services;
(C) diagnostic services which are—

(i) furnished to an individual as an outpatient by a hospital or by others
under arrangements with them made by a hospital, and
(ii) ordinarily furnished by such hospital (or by others under such
arrangements) to its outpatients for the purpose of diagnostic study;
(D) outpatient physical therapy services and outpatient occupational therapy

services;
(E) rural health clinic services and Federally qualified health center services;
(F) home dialysis supplies and equipment, self-care home dialysis support
services, and institutional dialysis services and supplies;
(G) antigens (subject to quantity limitations prescribed in regulations by the

Secretary) prepared by a physician, as defined in section 1861(r)(1), for a
particular patient, including antigens so prepared which are forwarded to another
qualified person (including a rural health clinic) for administration to such patient,
from time to time, by or under the supervision of another such physician;
(H)
APPENDIX A
(i) services furnished pursuant to a contract under section 1876 to a

member of an eligible organization by a physician assistant or by a nurse
practitioner (as defined in subsection (aa)(5)) and such services and
supplies furnished as an incident to his service to such a member as
would otherwise be covered under this part if furnished by a physician or
as an incident to a physician's service; and
(ii) services furnished pursuant to a risk-sharing contract under section

1876(g) to a member of an eligible organization by a clinical psychologist
(as defined by the Secretary) or by a clinical social worker (as defined in
subsection (hh)(2)), and such services and supplies furnished as an
incident to such clinical psychologist's services or clinical social worker's
services to such a member as would otherwise be covered under this part
if furnished by a physician or as an incident to a physician's service;
(I) blood clotting factors, for hemophilia patients competent to use such factors to
control bleeding without medical or other supervision, and items related to the
administration of such factors, subject to utilization controls deemed necessary
by the Secretary for the efficient use of such factors;
(J) prescription drugs used in immunosuppressive therapy furnished, to an

individual who receives an organ transplant for which payment is made under
this title;
(K)
(i) services which would be physicians' services if furnished by a physician
(as defined in subsection (r)(1)) and which are performed by a physician
assistant (as defined in subsection (aa)(5)) under the supervision of a
physician (as so defined) and which the physician assistant is legally
authorized to perform by the State in which the services are performed,
and such services and supplies furnished as incident to such services as
would be covered under subparagraph (A) if furnished incident to a
physician's professional service, but[393] only if no facility or other provider
charges or is paid any amounts with respect to the furnishing of such
services,
(ii) services which would be physicians' services if furnished by a

physician (as defined in subsection (r)(1)) and which are performed by a
nurse practitioner or clinical nurse specialist (as defined in subsection
(aa)(5)) working in collaboration (as defined in subsection (aa)(6)) with a
physician (as defined in subsection (r)(1)) which the nurse practitioner or
clinical nurse specialist is legally authorized to perform by the State in
which the services are performed, and such services and supplies
furnished as an incident to such services as would be covered under
subparagraph (A) if furnished incident to a physician's professional
APPENDIX A
service, but only if no facility or other provider charges or is paid any

amounts with respect to the furnishing of such services;
(L) certified nurse-midwife services;
(M) qualified psychologist services;
(N) clinical social worker services (as defined in subsection (hh)(2));
(O) erythropoietin for dialysis patients competent to use such drug without
medical or other supervision with respect to the administration of such drug,
subject to methods and standards established by the Secretary by regulation for
the safe and effective use of such drug, and items related to the administration of
such drug;
(P) prostate cancer screening tests (as defined in subsection (oo));
(Q) an oral drug (which is approved by the Federal Food and Drug
Administration) prescribed for use as an anticancer chemotherapeutic agent for a
given indication, and containing an active ingredient (or ingredients), which is the
same indication and active ingredient (or ingredients) as a drug which the carrier
determines would be covered pursuant to subparagraph (A) or (B) if the drug
could not be self-administered;
(R) colorectal cancer screening tests (as defined in subsection (pp));
(S) diabetes outpatient self-management training services (as defined in

subsection (qq));
(T) an oral drug (which is approved by the Federal Food and Drug
Administration) prescribed for use as an acute anti-emetic used as part of an
anticancer chemotherapeutic regimen if the drug is administered by a physician
(or as prescribed by a physician)—
(i) for use immediately before, at, or within 48 hours after the time of
the administration of the anticancer chemotherapeutic agent; and
(ii) as a full replacement for the anti-emetic therapy which would
otherwise be administered intravenously;
(U) screening for glaucoma (as defined in subsection (uu)) for individuals
determined to be at high risk for glaucoma, individuals with a family history of
glaucoma and individuals with diabetes;[394]
(V) medical nutrition therapy services (as defined in subsection (vv)(1)) in the
case of a beneficiary with diabetes or a renal disease who—
APPENDIX A
(i) has not received diabetes outpatient self-management training services

within a time period determined by the Secretary;
(ii) is not receiving maintenance dialysis for which payment is made

under section 1881; and
(iii) (iii) meets such other criteria determined by the Secretary after
consideration of protocols established by dietitian or nutrition
professional organizations; [395]
(W)[396] an initial preventive physical examination (as defined in subsection

(ww));[397]
(X)[398] cardiovascular screening blood tests (as defined in subsection (xx)(1));[399]
(Y)[400] diabetes screening tests (as defined in subsection (yy)); and[401]
(Z)[402] intravenous immune globulin for the treatment of primary immune

deficiency diseases in the home (as defined in subsection (zz));
(3) diagnostic X-ray tests (including tests under the supervision of a physician, furnished
in a place of residence used as the patient's home, if the performance of such tests
meets such conditions relating to health and safety as the Secretary may find necessary
and including diagnostic mammography if conducted by a facility that has a certificate
(or provisional certificate) issued under section 354 of the Public Health Service Act[403]),
diagnostic laboratory tests, and other diagnostic tests;
(4) X-ray, radium, and radioactive isotope therapy, including materials and services of
technicians;
(5) surgical dressings, and splints, casts, and other devices used for reduction of
fractures and dislocations;
(6) durable medical equipment;
(7)[404] ambulance service where the use of other methods of transportation is

contraindicated by the individual's condition, but[405] only to the extent provided in
regulations;
(8) prosthetic devices (other than dental) which replace all or part of an internal body
organ (including colostomy bags and supplies directly related to colostomy care),
including replacement of such devices, and including one pair of conventional
eyeglasses or contact lenses furnished subsequent to each cataract surgery with
insertion of an intraocular lens;
(9) leg, arm, back, and neck braces, and artificial legs, arms, and eyes, including
replacements if required because of a change in the patient's physical condition;
APPENDIX A
(10)
(A) pneumococcal vaccine and its administration and, subject to section 4071(b)
of the Omnibus Budget Reconciliation Act of 1987,[406] influenza vaccine and its
administration; and
(B) hepatitis B vaccine and its administration, furnished to an individual who is at

high or intermediate risk of contracting hepatitis B (as determined by the
Secretary under regulations);
(11) services of a certified registered nurse anesthetist (as defined in subsection (bb));
(12) subject to section 4072(e) of the Omnibus Budget Reconciliation Act of 1987[407],
extra-depth shoes with inserts or custom molded shoes with inserts for an individual
with diabetes, if—
(A) the physician who is managing the individual's diabetic condition (i)
documents that the individual has peripheral neuropathy with evidence of callus
formation, a history of pre-ulcerative calluses, a history of previous ulceration,
foot deformity, or previous amputation, or poor circulation, and (ii) certifies that
the individual needs such shoes under a comprehensive plan of care related to
the individual's diabetic condition;
(B) the particular type of shoes are prescribed by a podiatrist or other qualified
physician (as established by the Secretary); and
(C) the shoes are fitted and furnished by a podiatrist or other qualified individual
(such as a pedorthist or orthotist, as established by the Secretary) who is not the
physician described in subparagraph (A) (unless the Secretary finds that the
physician is the only such qualified individual in the area);
(13) screening mammography (as defined in subsection (jj));
(14) screening pap smear and screening pelvic exam; and
(15) bone mass measurement (as defined in subsection (rr)).

No diagnostic tests performed in any laboratory, including a laboratory that is part of a
rural health clinic, or a hospital (which, for purposes of this sentence, means an
institution considered a hospital for purposes of section 1814(d)) shall be included within
paragraph (3) unless such laboratory—
(16) if situated in any State in which State or applicable local law provides for licensing
of establishments of this nature, (A) is licensed pursuant to such law, or (B) is approved,
by the agency of such State or locality responsible for licensing establishments of this
nature, as meeting the standards established for such licensing; and
APPENDIX A
(17)
(A) meets the certification requirements under section 353 of the Public Health
Service Act;[408] and
(B) meets such other conditions relating to the health and safety of individuals
with respect to whom such tests are performed as the Secretary may find
necessary.
There shall be excluded from the diagnostic services specified in paragraph

(2)(C) any item or service (except services referred to in paragraph (1)) which
would not be included under subsection (b) if it were furnished to an inpatient of a
hospital. None of the items and services referred to in the preceding paragraphs
(other than paragraphs (1) and (2)(A)) of this subsection which are furnished to a
patient of an institution which meets the definition of a hospital for purposes of
section 1814(d) shall be included unless such other conditions are met as the
Secretary may find necessary relating to health and safety of individuals with
respect to whom such items and services are furnished.
APPENDIX A
APPENDIX B – Atypical Provider

Worksheet
© 2006 WEDI - SNIP - NPI Sub Workgroup Atypical Service Providers • B-1
APPENDIX B
The NPI and Atypical Service Provider
Atypical Provider Worksheet
Provider Definition Comments Type* Taxonomy
Acupuncturist An acupuncturist is a person who performs Meets the definition of healthcare. Often H 171100000X
ancient therapy for alleviation of pain, anesthesia referred to as alternative healthcare provider.
and treatment of some diseases. Acupuncturists
use long, fine needles inserted into specific points
in order to treat painful conditions or produce
anesthesia. (NUCC)
Adult Companion An individual who provides supervision, Not a healthcare provider and does not provide A 372600000X
socialization, and non-medical care to a healthcare.
functionally impaired adult. Companions may
assist or supervise the individual with such tasks
as meal preparation, laundry and shopping, but
do not perform these activities as discrete
services. These services are provided in
accordance with a therapeutic goal in the plan of
care. (NUCC)
Adult Day (Health) Care Adult day care can be either a medical model or a If the program is a social model with no B 261QA0600X
social model. The services are sought primarily medical component, the facility would not be
for the three broad purposes of social and health eligible for an NPI.
maintenance, rehabilitation, and caregiver
respite. The social model provides planned care If the program has a medical component, then
supervision and activities, personal care, the facility would be a healthcare provider and
personal living skills training, meals and health eligible for an NPI.
monitoring in a group setting during a portion of a
continuous twenty-four hour period. The medical
model may also include health assessments,
nursing supervision, medication administration,
preventive, therapeutic and restorative health
related services such as physical, occupational
and speech therapy. Often transportation is
included in the services for both models. Adult
day care is designed to help keep individuals in
the community and out of an institution.
Services are usually furnished 4 or more hours

per day on a regularly scheduled basis, for one or
APPENDIX B
* Type (of provider): A = atypical provider H = health care provider B = could be either atypical or health care depending on provider and/or
service provided
NUCC – National Uniform Claim Committee – identifies that the definition came from the taxonomy code list
more days a week, in an outpatient setting other
than the individual's normal place of residence.
Adult Foster Care Facility A custodial care facility providing supportive and On taxonomy list as “adult care home”. A 311ZA0620X
personal care services to disabled and/or elderly There is no medical component. Medical
individuals who cannot function independently in services may be provided in this setting,
most areas of activity and need assistance and however they are normally provided by another
monitoring to enable them to remain in a home entity such as a home health agency or a
like environment. (NUCC) physician or visiting nurse, therapist, etc.
"Adult foster care services" means supervision,

assistance with eating, bathing, toileting,
dressing, self-medication and other routines of
daily living or services.
Provided in a residential setting that includes

room and board. The sponsor or manager
resides with the residents and provides a family
setting.
Alzheimer Center A freestanding facility or special care unit of a If the facility provides healthcare, it would be B 311500000X
/Dementia long term care facility focusing on patient care of eligible for an NPI.
Center/Dementia Special individuals diagnosed with dementia or
Care Unit Alzheimer’s Disease or their related diseases. Six If only custodial care is provided, then would
elements of the facility/unit set it apart from other not be eligible for an NPI.
(the rest of the) facilities(y): Admission of
residents with dementia (including those with
Alzheimer's disease); Staff who are specially
selected, trained, and supervised; Activities that
are specifically designed for the cognitively
impaired; A marketing of a special care unit in
brochures; A high level of family involvement; and
A physical environment designed to keep
residents safe and segregated from other
populations. (NUCC)
Art Therapist (1) An individual who uses art to achieve the Classified under Respiratory, Rehabilitative & B 221700000X
therapeutic goals of symptom relief, emotional Restorative Service Providers on Taxonomy
integration, and recovery from or adjustment to List.
illness or disability. (2) An art therapist uses a
APPENDIX B
service provided
form of treatment that enables patients with Could be providing healthcare and could be
mental or physical disabilities to use art as a way considered a healthcare provider.
of expressing and dealing with feelings and inner
conflicts. (3) An individual who uses arts
modalities and creative processes during
intentional intervention in therapeutic,
rehabilitative, community, or educational settings
to foster health, communication, and expression;
promote the integration of physical, emotional,
cognitive, and social functioning; enhance self-
awareness; and facilitate change. (NUCC)
Assisted Living Facility A facility providing supportive services to Assisted living facilities are for people needing B 310400000X
individuals who can function independently in assistance with ADLs but wishing to live as (assisted living)
most areas of activity, but need assistance and/or independently as possible for as long as
monitoring to assure safety and well being. possible. Assisted living exists to bridge the 3104A0630X
(NUCC). gap between independent living and nursing (assisted living,
homes. Residents in assisted living centers behavioral
The term used for assisted living facilities differs are not able to live by themselves but do not disturbances)
across the country. Other common terms for require constant care either. Assisted living
these facilities include:· facilities offer help with ADLs such as eating,
Residential care bathing, dressing, laundry, housekeeping, and 3104A0625X
· Personal care assistance with medications. Many facilities (assisted living,
· Adult congregate living care also have centers for medical care; however, mental illness)
· Board and care the care offered may not be as intensive or
· Domiciliary care available to residents as the care offered at a
· Adult living facilities nursing home. Assisted living is not an
· Supported care alternative to a nursing home, but an
· Enhanced care intermediate level of long-term care
· Community based retirement facilities appropriate for many seniors.
· Adult foster care
· Adult homes Assisted living facilities are often connected
· Sheltered housing with independent living residences and nursing
· Retirement residences homes. The combination is known as a
continuing care retirement community. The
Assisted Living, Behavioral Disturbances resident can take advantage of the full range of
A facility providing supportive services to services available and the ease of transfer to a
individuals who can function independently in different type of facility as his or her condition
APPENDIX B
service provided
most areas of activity, but exhibit abnormal and needs change without needing to look for
behavioral responses and habits and therefore a new facility, relocate, or adapt to a new
need special guidance, assistance and/or setting. For example, the resident may begin
monitoring to assure safety and well being. This in the independent living residences, move to
type of facility requires a staff with special training assisted living as he or she needs help with
in dealing with and redirecting negative, violent or activities of daily living, and eventually move to
destructive behaviors. (NUCC) the nursing home as ongoing care becomes
necessary.
Assisted Living, Mental Illness
A facility providing supportive services to
individuals who can function independently in
most areas of activity, but need special guidance,
assistance and/or monitoring as the result of a
psychiatric problem. This type of facility requires
a staff with special training in mental health
training and dealing with psychiatric emergencies.
(NUCC)
Assistive Technology No definition by NUCC. An Assistive Technology Practitioner (ATP) is a B 225CA2400X

Practitioner term used by RESNA to describe persons (rehab counselor)
(From RESNA): Individuals who evaluate, involved in analysis of a consumer's needs and
assess the need for, recommend, or provide in use of a particular device or assistive 231HA2400X
assistive technology. technology. These persons may be (audiologist)
occupational, physical or speech therapists,
(From PLUK): Assistive technology devices are educators or vocational rehabilitation
mechanical aids which substitute for or enhance counselors (Hammel & Luebben, 1996).
the function of some physical or mental ability
that is impaired. Assistive technology can be RESNA offers credentialing for ATPs.
anything homemade, purchased off the shelf, These individuals may be licensed healthcare
modified, or commercially available which is used professionals or may be persons trained or
to help an individual perform some task of daily with knowledge of assistive technology
living. The term assistive technology devices.
encompasses a broad range of devices from "low
tech" (e.g., pencil grips, splints, paper stabilizers) An ATP could be a teacher trained in
to "high tech" (e.g., computers, voice determining the school related assistive
synthesizers, Braille readers). These devices technology needs (software, equipment) of
include the entire range of supportive tools and students with special needs. This type of ATP
APPENDIX B
service provided
equipment from adapted spoons to wheelchairs would not be a healthcare provider and would
and computer systems for environmental control. not be providing healthcare, thus not eligible
for an NPI.
Assistive Technology No definition by NUCC The supplier could be a healthcare provider B 225CA2500X
Supplier (ATS) such as a medical supplier or could be a (rehab counselor)
(From ATIA): Assistive Technology, or AT, is any department store, grocery store, or other non
item, piece of equipment, product or system, healthcare related supplier. 231HA2500X
whether acquired commercially off the shelf, (audiologist)
modified, or customized, that is used to increase, Items supplied range from sophisticated
maintain, or improve the functional capabilities of computers to enable people to speak to simple
persons with disabilities. gadgets such as a long reach grabber to get
something off a high shelf
RESNA offers credentialing for ATSs.
Assistive (or adaptive) Technology Products
can enable people with disabilities to
accomplish daily living tasks, assist them in
communication, education, work or recreation
activities, in essence, help them achieve
greater independence and enhance their
quality of life.
The devices can help improve physical or

mental functioning, overcome a disorder or
impairment, help prevent the worsening of a
condition, strengthen a physical or mental
weakness, help improve a person's capacity to
learn, or even replace a missing limb.
Assistive Technology Services support people

with disabilities or their caregivers to help them
select, acquire, or use adaptive devices. Such
services include functional evaluations, training
on devices, product demonstration, and
equipment purchasing or leasing.
Athletic Trainer Athletic trainers are allied health care Provide healthcare as physician extenders. H 2255A2300X
professionals who work in consultation with or Athletic Trainer
under the direction of physicians, and specialize
APPENDIX B
service provided
in the prevention, assessment, treatment and
rehabilitation of injuries and illnesses. Currently,
the entry-level employment requirements are a
bachelor’s degree with a major in athletic training
from an accredited university or college. A
majority of athletic trainers hold advanced
degrees. National board certification is generally
required as a condition of state licensure and
employment. Most states regulate athletic
trainers, and they practice within the scope of that
license or regulation. Clinical practice includes
emergency care, rehabilitation, reconditioning,
therapeutic exercise, wellness programs,
exercise physiology, kinesiology, biomechanics,
nutrition, psychology and health care
administration.
Source: National Athletic Trainers’ Association
(www.NATA.org). (NUCC)
Attendant Care Provider An individual who provides hands-on care, of Most attendant care providers likely do not B 3747A0650X
both a supportive and health related nature, provide “healthcare” and thus would not be
specific to the needs of a medically stable, eligible for an NPI.
physically handicapped individual. Supportive
services are those that substitute for the absence, Those attendants that do provide healthcare
loss, diminution, or impairment of a physical or are eligible for an NPI.
cognitive function. This service may include
skilled or nursing care to the extent permitted by
state law. (NUCC)
Au Pairs (From Merriam Webster): A young foreigner who Does not provide healthcare A
does domestic work for a family in exchange for
room and board and a chance to learn the
family's language.
Behavior Services Behavioral Health and Social Service Most provide health care. Must evaluate each H See list for specific
Providers (psychiatrist, Providers provider as to whether a healthcare provider or taxonomy code
psychologist, behavior Broad classification aggregating providers who if they provide healthcare services.
analyst) are trained and educated to perform services
related to behavioral health, mental health, and
APPENDIX B
service provided
counseling and may be licensed or practice within
the scope or licensure or training. (NUCC)
Behavioral Respite From NUCC: Respite Care, Mental CMS has specified that respite care is not A 385HR2060X
Services Retardation and/or Developmental Disabilities, healthcare
Child
A facility or distinct part of a facility that provides
short term, residential care to children, diagnosed
with mental retardation and/or developmental
disabilities as respite for the regular caregivers.
Behavioral Specialist (From Hawaii DOE) Provide counseling, skill Some are healthcare professionals with B 103TB0200X
training and support services to individuals who master’s level requirements and provide (Behavioral
have, or are at risk for developing significant services considered to be healthcare, such as psychologist)
problem behavior(s) that impair their ability to clinical assessment and treatment. Others are
effectively participate and benefit from their not health care professionals and do not
education, work, and other daily functional provide services considered to be healthcare 101Y00000X
activities. The work involves conducting but rather behavior management services often (counselor)
behavioral assessments; developing and in a school setting. Could be eligible for an
implementing behavior intervention/management NPI depending on the services and type of
plans; and providing techniques, methods and provider.
strategies for teachers, employers, family
members, and others to use to facilitate
attainment of appropriate behavior(s). Individuals (Behavioral) Counselor: A provider who is
treated require specialized, individualized, trained and educated in the performance of
intensive, and multiple agency services in order behavior health services through interpersonal
to successfully overcome the problem communications and analysis. Training and
behavior(s). These are individuals with problems education at the specialty level usually requires
that are chronic and/or intense. Often times these a master’s degree and clinical experience and
individuals have mental and/or physical supervision for licensure or certification.
disabilities. Positions in this class work (NUCC)
independently under the professional technical
supervision of a Clinical Psychologist or other
qualified professional who may not be readily
available at the work-site.
(from Maine): A behavioral specialist provides

direct care behavioral health services. Two
levels. One requires no specific training but must
APPENDIX B
service provided
have relevant life experiences. Level 2 must be
certified by Dept of Behavioral & Developmental
Services.
(from Head Start Program): In the Early

Childhood BS model, they are the first to respond
to referrals. They are reachable during working
hours or after hours for behavioral emergencies.
They perform triage over the phone and
personally go to the classroom or send another
person. Specialists meet with staff and families
to develop behavior plans. They refer families
and children to mental health professionals in the
community who are able to work with them while
they are in our program and after they move on.
The specialists also maintain a database to
provide handouts to parents and staff about
specific behavior concerns. They are teachers
with additional training in child behavior and are
there to support teachers in the classroom with
children who exhibit severe temper tantrums,
rage, and children that bite others.
(From State of Oregon): The BEHAVIORAL

SPECIALIST provides psychological assessment
of clients or residents, develops treatment
strategy, and helps establish and implement
psychological and behavior modification
treatment programs.
Blood Bank An institution (organization or distinct part thereof) Per Privacy Rule preamble (82477) not A 331L00000X
that performs, or is responsible for the considered healthcare and the organizations
performance of, the collection, processing, performing the service are not considered
storage and/or issuance of human blood and healthcare providers.
blood components, intended for transfusion. The
institution may also collect, process, and/or
distribute human tissue, including bone marrow
APPENDIX B
service provided
and peripheral blood progenitor cells, intended for
transplantation. (NUCC)
Boarding Home A boarding home provides personal care, respite Requirements on licensure may vary between A Taxonomy code for
care and homemaker services. states. May also be referred to as a custodial assisted living could
care facility, adult foster care, assisted living, be used.
etc. (see under assisted living)
If no medical component is provided, then not

eligible for NPI.
Care Coordinator (From Alaska Medicaid): 1. Education and CMS has specified that Case Management is a B 163WC0400X
Experience: healthcare service and that persons who (case
A. AA degree in psychology, social work, provide case management are eligible for an management)RN
rehabilitation, nursing or a closely related human NPI (preamble of TCS final rule pg 50315).
services field from an accredited college or However, some case managers are not health 251B00000X
university, and one year full time of paid work care providers and the services are not (agency)
experience with human service recipients and healthcare related such as case management
providers OR to keep people in their own homes, or to assist
B. Two years of college in psychology, social with employment services.
work, rehabilitation, nursing or a closely related
human services field from an accredited college Case management, RN has a taxonomy code
or university, and one year full time of paid work however NUCC has not yet defined the term.
experience with human service recipients and
providers OR The State Medicaid Manual Section 4442.3
C. Three years of paid full time work experience definition: “13. Case management is
with at least one year full time of paid work commonly understood to be an activity which
experience with human service recipients and assists individuals in gaining access to needed
providers OR waiver and other State plan services, as well
D. Hold certification as a rural community health as needed medical, social, educational, and
aide or practitioner and have a minimum of one other appropriate services, regardless of the
full time year experience related to providing funding source for the services to which access
home care or similar service. is gained. The responsibility for these activities
2. Distinguishing Characteristics: rests with a specific person or organization.
A. Knowledge of the medical, behavioral, Case management services may be used to
habilitative and rehabilitative considerations of locate, coordinate, and monitor necessary and
people appropriate services and may be used to
B. Knowledge of laws, rules, regulations, encourage the use of cost effective medical
policies, procedures, precedents and terminology care by referrals to appropriate providers and
APPENDIX B
service provided
used in the work, requirements for HCB Waiver to discourage over utilization of costly services
care coordination services, family centered such as emergency room care for routine
services the HCB Waiver care coordination procedures. Case management services may
process, knowledge of resources available, also serve to provide necessary coordination
applicable state regulations, the Individual with with providers of nonmedical services, such as
Disabilities Act (IDEA) and Americans with local education agencies or department of
Disabilities Act (ADA). vocational rehabilitation, when the services
C. Ability to assess treatment of individuals who provided by these entities are needed to
experience physical and/or mental disabilities. enable the individual to function at the highest
D. Ability to organize, evaluate and present attainable level or to benefit from programs for
information effectively, both orally and in writing, which he or she might be eligible.
within a prescribed time frame. Within the context of home and community-
E. Ability to work with professional and support based waiver services, case management may
staff include (but is not limited to) the following
F. Within the last 24 months, have successfully functions:
completed and passed Division of Senior and • Evaluation and/or reevaluation of level of
Disability Services (DSDS) care coordinator care,
training as established by DSDS. • Assessment and/or reassessment of the
3. Service Provision need for waiver services,
A. Intake/Screening: an informal evaluation to • Development and/or review of the plan of
determine the waiver applicant’s financial care,
eligibility and whether a full assessment is • Coordination of multiple services and/or
warranted. If the applicant is not a current Alaska providers,
Medical Assistance recipient, the care coordinator • Monitoring of quality of care,
will refer the applicant to the Alaska Division of • Review of medical necessity of waiver
Public Assistance for Medical Assistance services, and
eligibility determination.
• Determination of cost effectiveness or
B. Assessment: a written comprehensive
waiver services for an individual.”
assessment of the applicant’s physical,
emotional, social, and cognitive functioning to
Care coordination appears to be very similar to
determine the need for services and the level of
many people’s interpretation of case
care required. The assessment includes
management.
personal contact with the applicant in his/her
residence. The care coordinator will personally
A care coordinator who is a psychologist, a
conduct the assessment or arrange for any of the
rehab specialist or a nurse would be eligible for
following persons to participate: health care
an NPI as a healthcare provider.
professional, social service professional, family
APPENDIX B
service provided
caregiver or designated representative,
appropriate hospital or nursing facility personnel, Alaska has indicated they plan to request a
any other provider relevant to the applicant’s taxonomy for this provider type.
needs. The care coordinator has full
responsibility for completing the assessment,
using the standard assessment form to record the
applicant’s needs. Based on assessment
information, the care coordinator and the health
professional will record their recommended level
of care for the applicant.
C. Plan of Care Development: based on the
needs identified in the assessment, the plan of
care specifies (1) the applicant’s location, (2) all
services to be provided, (3) the frequency,
amount, projected duration and cost of each
service, (4) who will provide the services, and (5)
the expected outcome goals. The plan of care,
along with the screening and assessment is
forwarded to the HCB Waiver administrative unit
for review and approval (DSDS).
D. Reassessment: the review and update of an
assessment and plan of care; both should be
reviewed at least annually or when a change to
the recipient’s condition warrants it.
E. Ongoing Care Coordination: includes the
following:
• Coordinating formal and informal supports
• Gaining access to other plan services and
entitlements
• Providing assistance with housing
• Monitoring services to ensure quality of care
and utilization
• Conducting case reviews to assess
participant’s progress and satisfaction in
meeting goals and objectives established in
the plan of care
APPENDIX B
service provided
• Recommending modifications, transfers or
termination when appropriate
• Providing for crisis intervention, client
advocacy or assistance, consultation,
networking, and family support
• Contacting the recipient twice a month. At
least one contact must be face-to-face unless
this requirement is waived by the managing
agency (DSDS)
Chore Provider Chore Provider Not a healthcare provider and does not provide A 372500000X
An individual who provides home maintenance healthcare
services required to sustain a safe, sanitary living
environment for individuals who because of age
or disabilities are unable to perform the activities.
These services include heavy household chores
such as washing floors, windows, and walls;
tacking down loose rugs and tiles; and moving
heavy items of furniture in order to provide safe
access and egress. (NUCC)
Christian Science A practitioner listed and certified by The First From CMS State Operations manual: Section H 374T00000X
Practitioner/Nurse; Church of Christ, Scientist, Boston, 1861(e) of the Act includes in the definition of
Massachusetts. (NUCC) "hospital" a religious nonmedical health care
Christian Science Nursing includes twenty-four institution that is operated or listed and certified
hour nursing care under the supervision of a by the First Church of Christ, Scientist, in
"Journal"-listed nurse. It may include, but is not Boston, Massachusetts, with respect to certain
limited to, food modification, cleansing and items and hospital services furnished to
bandaging wounds, assistance with baths, inpatients. Section 1861(y) includes sanatoria
incontinence care, mobility assistance or full bed with respect to items and services furnished to
care as well as nail care, a whirlpool bath or other inpatients in a long-term care setting. All
nursing care support, including sudden needs. approvals are handled by the Boston RO. No
(from CS Churches of Oregon) SA certifications are necessary. The State may
also include these services under the State
(From AOCSN) Christian Science nursing care plan for Medicaid.
includes:
• Expectancy of complete and immediate
APPENDIX B
service provided
healing Based on the above, both the facility and a CS
• Spiritual reassurance: acknowledging God's nurse would be eligible for an NPI
all-presence and absolute power; faithfully
and consistently affirming the patient's
spirituality
• Encouragement: gently offering Christian
assistance to support the individual's
expression of vitality and normal activity
• Reading aloud: reading from the Bible,
Science and Health with Key to the Scriptures
and other writings by Mary Baker Eddy; also,
additional literature published by The
Christian Science Publishing Society
• Communication: contacting the Christian
Science practitioner on the case or family
members if patient is unable to do so;
maintaining an ethical, moral, and loving
manner in all communications with the
patient, family, friends, practitioner, and
others
• Personal care: assistance with bathing, using
the commode, oral care
• Mobility assistance: lifting, turning; positioning
in a chair or bed; help with the use of
wheelchairs, crutches, walkers, canes or
other aids
• Nourishment: preparation and/or modification
of food; assistance with feeding; also gentle
encouragement to eat when appropriate
• Dressing/bandaging: proper cleansing and
bandaging of wounds to provide for comfort
and protection
• Instruction: instructing the patient and/or
other care givers in providing proper care for
meeting individual needs
• Being obedient to the laws of the land
APPENDIX B
service provided
Christian Science A Christian Science sanitarium operated, or From CMS State Operations manual: Section H 287300000X
Sanitarium (now called listed and certified, by The First Church of Christ, 1861(e) of the Act includes in the definition of (CS Sanitarium)
RNHCI – religious non Scientist, Boston, Massachusetts, furnishing "hospital" a religious nonmedical health care
healthcare institution) inpatient hospital care services. (NUCC) institution that is operated or listed and certified 317400000X
by the First Church of Christ, Scientist, in (CS Facility)
Christian Science Facility (skilled nursing Boston, Massachusetts, with respect to certain
services) items and hospital services furnished to
A Christian Science sanitarium operated, or listed inpatients. Section 1861(y) includes sanatoria
and certified, by The First Church of Christ, with respect to items and services furnished to
Scientist, Boston, Massachusetts, furnishing inpatients in a long-term care setting. All
extended care services. (NUCC) approvals are handled by the Boston RO. No
SA certifications are necessary. The State may
also include these services under the State
plan for Medicaid.
Based on the above, both the facility and a CS

nurse would be eligible for an NPI
Coding Specialist, No definition by NUCC yet. Not a healthcare provider and does not provide A 246YC3301X
Hospital or Physician healthcare (hospital based)
Office Based A Coding Specialist analyzes health information
and assigns codes to index diagnoses and 246YC3302X
procedures to support clinical care, to assist (physician office
medical research and to provide information for based)
reimbursement purposes.
Community Health Aides (From Alaska Medicaid): A Community Health These are healthcare providers. H
for Dental, Medical, Aide/Practitioner (CHA/P) goes in the bush
Behavioral Health communities where there are no health Current practice in AK is to bill the services of a
professionals and provides varying levels of CHA/P under the supervising physician’s ID#
healthcare under the supervision of a physician. and using modifiers to designate that a CHA/P
They are trained and certified at varying levels. rendered the service. Likely they will not seek
Are part of the Indian Tribal Organizations and NPIs.
established per 25 USC §1616 (l) under HHS,
Indian Health Service, Public Health Service. This is the same as the Community Health
Representative.
APPENDIX B
service provided
Community Health P.L. 100-713 establishes the CHR Program as a This is on the HIS website. The Alaska CHA/P H
Representative (CHR) component of health care services of American is part of this program, and the state has done
Indian people. It is an IHS funded, tribally some special legislative things to recognize
contracted/granted and directed program of well- this category of health care provider in AK.
trained, community-based, health care providers,
designed to integrate the unique helping of tribal
life with the practices of health promotion and
disease prevention.
Custodial Care Facility Custodial Care Facility Does not provide healthcare A 311Z00000X
A facility providing care that serves to assist an
individual in the activities of daily living, such as
assistance in walking, getting in and out of bed,
bathing, dressing, feeding, and using the toilet,
preparation of special diets, and supervision of
medication that usually can be self-administered.
Custodial care essentially is personal care that
does not require the continuing attention of
trained medical or paramedical personnel.
(NUCC)
Dance Therapist The dance therapist, sometimes called a Classified under Respiratory, Rehabilitative & B 225600000X
movement therapist, focuses on rhythmic body Restorative Service Providers.
movements as a medium of physical and
psychological change. Dance therapy is practiced Could be providing healthcare and could be
more often with mental health patients than with considered a healthcare provider.
physically disabled patients. A master’s degree is
required by the American Dance Therapy
Association to award the credentials Dance
Therapist Registered (DTR). (NUCC)
Day Care Providers Day Training, Developmentally Disabled "Developmentally disabled day care" means a A 251C00000X
(Developmentally Services service that provides planned care supervision (day training,
Disabled Daycare) These agencies are authorized to provide day and activities, personal care, activities of daily developmentally
habilitation services to developmentally disabled living skills training and habilitation services in disabled)
individuals who live in their homes. The function a group setting during a portion of a continuous
of day habilitation is to assist an individual to twenty-four hour period.
acquire and maintain those life skills that enable 261QA0600X
APPENDIX B
service provided
the individual to cope more effectively with the "Activities of daily living" means ambulating, (adult day care)
demands of independent living. Also to raise the communicating, bathing, toileting, grooming,
level of the individual's physical, mental, social, feeding and homemaking.
and vocational functioning. (NUCC)
See also adult daycare provider
Day Training, These agencies are authorized to provide day CMS specifies that habilitation is not a A 251C00000X
Developmentally habilitation services to developmentally disabled healthcare service
Disabled Services individuals who live in their homes. The function
of day habilitation is to assist an individual to
acquire and maintain those life skills that enable
the individual to cope more effectively with the
demands of independent living. Also to raise the
level of the individual's physical, mental, social,
and vocational functioning. (NUCC)
Driver A person employed to operate a motor vehicle as Not a healthcare provider and not providing A 172A00000X
a carrier of persons or property. (NUCC) healthcare.
Emergency Response Response system triggered by patient or machine A company that makes or installs the system is A
System Companies indication of an emergency which may require not providing healthcare so is not eligible for an
(Alarm Companies) medical attention. NPI.
Environmental Contractor: A person who contracts to supply Environmental providers remodel homes A 171W00000X
Modifications Provider certain materials or do certain work for a [widen doorways for wheelchairs, install grab (contractor)
[Environmental stipulated sum; esp., one whose business is bars in bathroom, etc.] when it is a cost 171WH0202X
Accessibility Providers, contracting work in any of the building trades. For effective alternative to nursing facility (home modifications)
Building Contractors, purposes of the taxonomy, a person who placement.
Home Modifications] contracts to complete home repairs or
modifications to accommodate a health condition CMS has specified that building contractors,
(e.g. wheelchair ramp, kitchen counter lowering). carpenters, etc. are not providing healthcare
(NUCC) and are not eligible for an NPI.
Exclusive Provider (1) An EPO is a form of PPO, in which patients This would be considered a health plan, but it H 302F00000X
Organization must visit a caregiver that is specified on its panel also could be considered an organization
of providers (is a participating provider). If a visit health care provider.
to an outside(not participating) provider is made
the EPO offers very limited or no coverage for the
APPENDIX B
service provided
medical service; (2) While similar to a PPO in that
an EPO allows patients to go outside the network
for care, if they do so in an EPO, they are
required to pay the entire cost of care. An EPO
differs from an HMO in that EPO physicians do
not receive capitation but instead are reimbursed
only for actual services provided; (3) An
organization identical to a preferred provider
organization except that persons enrolled in the
plan are eligible to receive benefits only when
they use the services of the contracting providers.
No benefits are available when non-contracting
providers are used, except in certain emergency
situations. (NUCC)
Family Model Residential (From Tennessee): A type of residential service (From AZ statute): MRDD Waiver services. B
Support providers having individualized services and supports that "Family support" means services, supports and
enable an enrollee to acquire, retain, or improve other assistance that are provided to families
skills necessary to reside successfully in a family with members who have a developmental
environment in the home of trained caregivers disability and that are designed to:
other than the family of origin. The service (a) Strengthen the family's role as a primary
includes direct assistance as needed with care giver.
activities of daily living (e.g., bathing, dressing, (b) Prevent inappropriate out of home
personal hygiene, eating, meal preparation placement.
excluding cost of food), household chores (c) Maintain family unity.
essential to the health and safety of the enrollee, (d) Reunite families with members who have
budget management, attending appointments, been placed out of the home.
and interpersonal and social skills building to (e) Include respite care, assistive technology,
enable the enrollee to live in a home in the appropriate personal assistance services,
community. It also may include medication parent training and counseling, vehicular and
administration as permitted under Tennessee’s home modifications and assistance with
Nurse Practice Act. The caregivers shall be extraordinary expenses associated with the
recruited, screened, trained prior to providing needs of the person with a developmental
services, and supervised by the Family Model disability.
Residential Support provider agency.
The Family Model Residential Support provider
shall oversee the enrollee’s health care needs. The TN model requires that the provider
The Family Model Residential Support provider oversee the enrollee’s healthcare needs and
APPENDIX B
service provided
shall be responsible for providing an appropriate can include medication administration as
level of services and supports 24 hours per day permitted under the TN Nurse Practice Act.
during the hours the enrollee is not receiving Day This could be construed as a healthcare
Services or is not at school or work. Therapeutic service and thus the provider would be eligible
goals and objectives shall be required for for an NPI.
enrollees receiving Family Model Residential
Support. The AZ family supports model is not healthcare
and a provider of these supports would not be
Provider Qualifications for Family Model eligible for an NPI.
Residential Support:
Provider Type: Waiver service agency
Licensure: Must be licensed by the Department
of Mental Health and Developmental Disabilities
(TCA Title 33 Chapter 2) as Mental Retardation
Placement Service provider.
Financial Administration Waiver service. Facilitates the employment of Not providing healthcare – acting as a fiscal A
Entity service workers by the waiver participant and the agent or contract employment agency
management of the self-determination budget.
FA is available only to participants who self-direct
services. The use of FA is mandatory whenever
the participant is the employer of record for one
or more service workers. The FA acts in the
place of a home health agency in respect to the
employment of the service workers.
Fitness Providers A personal trainer teaches people how to Generally not considered healthcare providers. B 2255A2300X
Personal Fitness Trainer exercise, lose weight, and adopt a healthier Today more physicians are writing (athletic trainer)
lifestyle. A trainer takes people through workouts prescriptions for patients to see personal
(aerobic, weights, flexibility training), monitors the trainers to leverage fitness for the benefit of
client’s progress, and provides advice on their addressing medical conditions such as
lifestyle and general information about health and hypertension, depression, obesity, etc.
nutrition.
Some could be eligible for an NPI if considered
a healthcare provider such as a medical
exercise therapist or athletic trainer.
Foster Homes for Residential setting in a family home in which the Not providing healthcare (see Adult Foster A
Children care, physical custody and supervision of the Care)
APPENDIX B
service provided
child are the responsibility, under a twenty-four
hour care model, of the licensee who serves as
the foster parent of the child in the home setting
and who, in that capacity, is not an employee of
the division or of a service provider and the home
provides the following services for a group of
siblings or up to three children:
(a) Room and board.
(b) Appropriate personal care.
(c) Appropriate supervision.
Funeral Director A person, usually an embalmer, whose business Not a healthcare provider – not eligible for an A 176P00000X
is to arrange for the burial or cremation of the NPI.
dead and to assist at the funeral rites (NUCC)
Graphics Designer The practice or profession of designing print or Not a healthcare provider – not eligible for an A 1744G0900X
electronic forms of visual information, as for an NPI.
advertisement, publication, or website. (from
American Heritage Dictionary)
Habilitation Provider Day Training/Habilitation Specialist CMS specifies that habilitation is not A 373H00000X
(Daily living skills)/ Individuals experienced or trained in working with healthcare.
Residential Habilitation developmentally disabled individuals who need
providers assistance in acquiring and maintaining life skills In Medicaid waiver services, habilitation
that enable them to cope more effectively with the services include prevocational, educational and
demands of independent living. (NUCC) supported employment services. The services
are not healthcare services so a habilitation
provider would not be eligible for an NPI.
Habilitation services are provided to people

with disabilities to develop the skills necessary
to live and work in the community at their
highest level of independence.
Health Maintenance A form of health insurance in which its members This would be considered a health plan, but B 302R00000X
Organization prepay a premium for the HMO’s health services could also be considered an organization
which generally include inpatient and ambulatory health care provider if providing health care
care. For the patient, an HMO means reduced directly.
out-of-pocket costs (i.e. no deductible), no
APPENDIX B
service provided
paperwork (i.e. insurance forms), and only a
small co-payment for each office visit to cover the
paperwork handled by the HMO; (2) A
organization of health care personnel and
facilities that provides a comprehensive range of
health services to an enrolled population for a
fixed sum of money paid in advance for a
specified period of time. These health services
include a wide variety of medical treatments and
consults, inpatient and outpatient hospitalization,
home health service, ambulance service, and
sometimes dental and pharmacy services. The
HMO may be organized as a group model, an
individual practice association (IPA), a network
model or a staff model. (NUCC)
Holistic healthcare Holistic Medicine is the art and science that addresses Holistic providers are also called alternative H 364SH1100X
providers the whole person, body, mind and spirit. The practice providers. Many are trained health (holistic clinical nurse
of holistic medicine integrates conventional and professionals. specialist)
complementary therapies to prevent and treat disease,
but most importantly to promote optimal health. Request Taxonomy
code for “holistic
medicine
professional”
Home Delivered meals Home-delivered meals are those services or Home delivered meals, which means a service A 332U00000X
activities designed to prepare and deliver one or that provides for a nutritious meal containing at
more meals a day to an individual's residence in least one-third of the recommended dietary
order to prevent institutionalization, malnutrition, allowance for an individual and which is
and feelings of isolation. Component services or delivered to the member's residence.
activities may include the cost of personnel,
equipment, and food; assessment of nutritional
and dietary needs; nutritional education and
counseling; socialization services; and
information and referral. (NUCC)
Home Health Aide A person trained to assist public health nurses, H 374U00000X
home health nurses, and other health
professionals in the bedside care of patients in
APPENDIX B
service provided
their homes. (NUCC)
Homemaker An individual who provides general household Not a healthcare provider – not eligible for an A 376J00000X
activities such as meal preparation, laundry, and NPI.
light housekeeping, when the individual regularly
responsible for these activities is temporarily
absent or unable to provide for himself.
Homemakers must meet the state defined
training standards. (NUCC)
Homeopath A provider who is educated and trained in a Often considered an alternative healthcare B 175L00000X
system of therapeutics in which diseases are provider.
treated by drugs which are capable of producing
in healthy persons symptoms like those of the (From Nat’l Center for Homeopathy):
disease to be treated. Treatment requires Homeopathy is practiced by a wide variety of
administering a drug in minute doses. (NUCC) health-care practitioners, including medical
doctors, osteopaths, naturopathic physicians,
nurse practitioners, physician assistants,
dentists, veterinarians, chiropractors,
acupuncturists, nurse midwives, and
podiatrists, as well as by professional
homeopaths, who practice only homeopathy
and are unlicensed in any other discipline.
(Language) Interpreters A person who translates oral communication CMS has said that language interpreters are A
between two or more people. This includes not health care providers and thus are not
translating from one language to another or eligible for an NPI
interpreting sign language
.
Lodging (hotel) A public or privately owned facility providing Not a healthcare provider and not providing A 177F00000X
overnight lodging to individuals traveling long healthcare
distances or receiving prolonged outpatient
medical services away from home. (NUCC)
Marriage & Family A marriage and family therapist is a person with a Provides counseling, thus fits the definition of H 106H00000X
Therapist master's degree in marriage and family therapy, healthcare
or a master's or doctoral degree in a related
mental health field with substantially equivalent
coursework in marriage and family therapy, who
APPENDIX B
service provided
receives supervised clinical experience, or a
person who meets the state requirements to
practice as a marriage and family therapist. A
marriage and family therapist treats mental and
emotional disorders within the context of marriage
and family systems. A marriage and family
therapist provides mental health and counseling
services to individuals, couples, families, and
groups. (NUCC)
Massage Therapist An individual trained in the manipulation of Classified under Respiratory, Rehabilitative & B 225700000X
tissues (as by rubbing, stroking, kneading, or Restorative Service Providers. In this context
tapping) with the hand or an instrument for is a healthcare provider.
remedial or hygienic purposes. (NUCC)
However, could be providing massage for
general relaxation, comfort, not related to
healthcare needs. In this context, would not be
eligible for an NPI
Medical Food Provider (From the FDA) A medical food is prescribed by Parenteral and enteral nutrition has no H 332BP3500X
a physician when a patient has special nutrient definition yet (under suppliers) (PEN)
needs in order to manage a disease or health
condition, and the patient is under the physician's
ongoing care. The label must clearly state that
the product is intended to be used to manage a
specific medical disorder or condition. An
example of a medical food is a food for use by
persons with phenylketonuria, i.e., foods
formulated to be free of the amino acid
phenylalanine.
Medical foods are not meant to be used by the

general public and may not be available in stores
or supermarkets. Medical foods are not those
foods included within a healthy diet intended to
decrease the risk of disease, such as reduced-fat
foods or low-sodium foods, nor are they weight
loss products.
APPENDIX B
service provided
(From ASPEN): PEN stands for parenteral and
enteral nutrition. All people need food to live.
Sometimes a person cannot eat any or enough
food because of an illness. The stomach or bowel
may not be working quite right, or a person may
have had surgery to remove part or all of these
organs. Under those conditions, nutrition must be
supplied in a different way.
Parenteral Nutrition is one of the ways people

receive food when they cannot eat. It is a special
liquid food mixture given into the blood with a
needle through a vein. The mixture contains all
the protein, sugars, fat, vitamins, minerals, and
other nutrients needed. It is sometimes called
"total parenteral nutrition," "TPN," or
"hyperalimentation."
Enteral Nutrition is another way people can

receive the food they need. Also called "tube
feeding," enteral nutrition is a mixture of all the
needed nutrients. It is thicker than parenteral
nutrition and sometimes it looks like a milk shake.
It is given through a tube in the stomach or small
intestine.
Medical Genetics, Ph.D. A medical geneticist works in association with a Provides healthcare H 170100000X
Medical Genetics medical specialist, is affiliated with a clinical
genetics program, and serves as a consultant to
medical and dental specialists. (NUCC)
Medical Records Technician, Health Information This is an administrative service, not A 247000000X
Providers Preferred term for an Accredited Record healthcare that is provided, so not eligible for
Technician who is an individual with an an NPI
associate’s degree from an accredited college or
independent study program who is skilled in
analyzing health information and in examination
APPENDIX B
service provided
of medical records for accuracy, reporting of
patient data for reimbursement, and creation of
disease registries for researchers. (NUCC)
Medical Residential Alaska is considering coverage of this type of B
Services providers provider to serve medically fragile children who
no longer need acute care in a hospital, but
need to remain in an urban setting near the
source of medical care and cannot yet return to
their rural home setting due to ongoing medical
needs.
(From NUCC): Community Based

Residential Treatment Facility, Mental 320900000X
Retardation and/or Developmental
Disabilities
A home-like residential facility providing
habilitation, support and monitoring services to
individuals diagnosed with mental retardation
and/or developmental disabilities.
If the services provided are habilitation and

personal care, then not healthcare. If medical
services are provided by the facility, then would
be eligible for an NPI.
Medical Schools, Students in medical schools and health training These schools provide healthcare usually H 261Q00000X
Healthcare Training schools such as dental and optometry schools, through clinics or hospitals that they own or are (clinic/center –
Schools provide health services and the school is associated with. It is reasonable to assume multiple taxonomy
reimbursed. that the clinic or hospital will obtain an NPI that codes identify various
pertains to that agency or facility because they types of clinics)
would be the billing entity. Therefore, the
taxonomy code would pertain to the billing
entity. Multiple taxonomy
codes identify types
Clinic/Center of hospitals and units
A facility or distinct part of one used for the within hospitals.
APPENDIX B
service provided
diagnosis and treatment of outpatients.
"Clinic/Center" is irregularly defined,
sometimes being limited to organizations
serving specialized treatment requirements or
distinct patient/client groups (e.g., radiology,
poor, and public health). (NUCC)
Hospitals
A health care organization that has a governing
body, an organized medical staff and
professional staff and inpatient facilities and
provides medical nursing and related services
for ill and injured patients 24 hrs per day,
seven days per week. For licensing purposes,
each state has its own definition of hospital.
(NUCC)
Mental Health Clinical (from Alaska): Mental Health Clinical Associate Each state may have different definitions for H
Associate (renders rehabilitation services such as individual this type of professional but it appears to be a
skill development, support services, etc)a person healthcare provider.
who may have less than a master's degree in
psychology, social work, counseling, or a related
field with specialization or experience in working
with chronically mentally ill adults or severely
emotionally disturbed children or adults.
Responsibilities may include psychosocial
evaluation, individual skill development services,
family skill development services, group skill
development services, recipient support services
or day treatment rehabilitation services AND is
working within the scope of his or her training and
experience, and under the direction of a mental
health professional clinician, physician, or
psychiatrist in a community mental health clinic
Music Therapist The music therapist works with patients with a Classified under Respiratory, Rehabilitative & B 225A00000X
broad variety of diagnoses and therapeutic goals. Restorative Service Providers.
The interventions may involve musical
APPENDIX B
service provided
performance with instruments, voice or body Could be a healthcare provider and could be
movements; listening to music; or attending considered providing healthcare.
musical events. (NUCC)
Naturopathic medicine If a healthcare provider, eligible for an NPI. B 175F00000X
Naturopath
providers
An individual who practices naturopathy, a
system of therapeutics in which neither surgical
nor medicinal agents are used, dependence
being placed only on natural (nonmedicinal)
forces. (NUCC)
Doctors of naturopathic medicine (NDs) are

trained as primary care providers and, as such,
their scope of practice may include...
Nutritional Science
Natural Hygiene
Botanical Medicine
Naturopathic Physical Medicine
Homeopathy
Ayurvedic Medicine
Counseling
Spirituality and Health
Minor Surgery
Methods of Laboratory and Clinical Diagnosis
Naturopathic medicine is a system of health care
first developed in the late 1890’s which
emphasizes the natural self-healing processes of
the human body. Central principles include using
healing approaches which derive from nature,
encouraging self responsibility for health, and
treatment which takes into account the whole
person. A naturopathic physician typically
combines several modalities, including herbal
medicine, to prevent illness, treat disease, and
promote well-being.
A licensed naturopathic physician (ND) attends a
APPENDIX B
service provided
four-year graduate level naturopathic medical
school and is educated in all of the same basic
sciences as an MD but also studies holistic and
nontoxic approaches to therapy with a strong
emphasis on disease prevention and optimizing
wellness. In addition to a standard medical
curriculum, the ND is required to complete four
years of training in clinical nutrition, acupuncture,
homeopathic medicine, botanical medicine,
psychology and counseling (to encourage people
to make lifestyle changes in support of their
personal health). A naturopathic physician takes
rigorous professional board exams so that he or
she may be licensed by a state or jurisdiction as a
primary care general practice physician.
Non-Emergency Taxi Transportation to and from medically A 344600000X
Transportation Providers A land commercial vehicle used for the necessary services. Could be taxi companies. (taxi)
transporting of persons in non-emergency Individual providers must have proof of
situations. The vehicle meets local, county or insurance. Companies must ensure that
state regulations set forth by the jurisdictions employees are licensed to drive, have current 347B00000X
where it is located. (NUCC) insurance. (bus)
Bus
A public or private organization or business Other types of transportation include boats,
licensed to provide bus services. hovercraft, ferries, airlines, charter planes, 343900000X
helicopters, etc. (NMT –Van)
Non-emergency Medical Transport (VAN)
A land vehicle with a capacity to meet special
height, clearance, access, and seating, for the
conveyance of persons in non-emergency 347C00000X
situations. The vehicle may or may not be (private vehicle)
required to meet local county or state regulations.
Private Vehicle
An individual paid to provide non-emergency
transportation using their privately owned/leased
vehicle. 347D00000X
APPENDIX B
service provided
(train)
Train
An organization or business licensed to provide
passenger train service, including light rail,
subway, and traditional services. 347E00000X
(transportation
Transportation Broker broker)
A public or private organization or business
contracted to arrange non-emergency medical
transportation services, including appropriate
ancillary services, e.g., lodging. (NUCC)
APPENDIX B
service provided
Nutritionists/Dietitians Dietary and Nutritional Service Providers These are healthcare providers H 133N00000X
Broad category defining practitioners who help (nutritionist)
prevent and treat illness by promoting healthy
eating habits, scientifically evaluating diets and
suggesting modifications. They may also assess
the nutritional needs of patients, develop and 133V00000X
implement nutritional care plans. (reg dietician)
Nutritionist
A specialist in adapting and applying food and
nutrient knowledge to the solution of food and
nutritional problems, the control of disease, and
the promotion of health. Nutritionists perform
research, instruct groups and individuals about
nutritional requirements, and assist people in
developing meal patterns that meet their
nutritional needs; (2) A nutritionist is someone
who has completed undergraduate and/or
graduate training in the discipline of nutrition
without necessarily meeting the academic and
experience requirements to qualify for the
Registered Dietitian designation.
Dietitian, Registered
A registered dietician (RD) is a food and nutrition
expert who has successfully completed a
minimum of a bachelor’s degree at a US
regionally accredited university or college and
course work approved by The American Dietetic
Association (ADA); an ADA-accredited or
approved, supervised practice program, typically
6 to 12 months in length; a national examination
administered by the Commission on Dietetic
Registration; and continuing professional
educational requirements to maintain registration.
(NUCC)
Organ Procurement A federally designated organization that works Does not meet the definition of health care A 335U00000X
Organization with hospital personnel in retrieval of organs for provider found at 45 CFR 160.103.
transplantation. The federal government
APPENDIX B
service provided
designates an OPO’s service area and the
hospitals with which an OPO is to establish
working relationships. (NUCC)
Orientation and Mobility Orientation and Mobility (O&M) specialists teach Some may be medical care providers others B
Training providers children and adults who have visual impairments may not.
the specific orientation skills used to find one's
way in the environment and the mobility skills This is a specialty within the field of
needed to travel safely and efficiently at home, rehabilitation. Certification often required.
school, work, and in the community. Preferred education is a bachelor’s or master’s
degree from an accredited O & M program.
Instruction is usually provided one-on-one and
can include skills such as how to use a long cane,
the operation of low vision devices and electronic
travel aids when appropriate, how to orient
oneself to new environments, navigate public
transportation systems, how to cross streets
safely, and traveling by using hearing, remaining
vision, and other senses.
In addition, O&M Specialists help children to

develop fundamental skills such as fine and gross
motor skills, concept development and problem
solving skills. Adult clients can also benefit from
an O&M specialist evaluating their current use of
travel-related skills, discussing their future goals,
and helping them select a program of instruction
that will allow them to reach their greatest travel
potential. (SFSU website)
PACE (Program of All- (from CMS) The Program of All-Inclusive Care This is a managed care organization. It is a H Needs taxonomy
Inclusive Care for the for the Elderly (PACE) is a capitated benefit health plan, but also could be a health care code
Elderly) authorized by the Balanced Budget Act of 1997 provider and as such would need a NPI.
(BBA) that features a comprehensive service
delivery system and integrated Medicare and
Medicaid financing. The program is modeled on
the system of acute and long term care services
developed by On Lok Senior Health Services in
APPENDIX B
service provided
San Francisco, California. The model was tested
through CMS (then HCFA) demonstration
projects that began in the mid-1980s. The PACE
model was developed to address the needs of
long-term care clients, providers, and payers. For
most participants, the comprehensive service
package permits them to continue living at home
while receiving services rather than be
institutionalized. Capitated financing allows
providers to deliver all services participants need
rather than be limited to those reimbursable
under the Medicare and Medicaid fee-for-service
systems.
The BBA established the PACE model of care as

a permanent entity within the Medicare program
and enables States to provide PACE services to
Medicaid beneficiaries as a State option. The
State plan must include PACE as an optional
Medicaid benefit before the State and the
Secretary of the Department of Health and
Human Services (DHHS) can enter into program
agreements with PACE providers.
Participants must be at least 55 years old, live in

the PACE service area, and be certified as
eligible for nursing home care by the appropriate
State agency. The PACE program becomes the
sole source of services for Medicare and
Medicaid eligible enrollees.
An interdisciplinary team, consisting of

professional and paraprofessional staff, assesses
participants' needs, develops care plans, and
delivers all services (including acute care
services and when necessary, nursing facility
services) which are integrated for a seamless
APPENDIX B
service provided
provision of total care. PACE programs provide
social and medical services primarily in an adult
day health center, supplemented by in-home and
referral services in accordance with the
participant's needs. The PACE service package
must include all Medicare and Medicaid covered
services, and other services determined
necessary by the interdisciplinary team for the
care of the PACE participant.
Spiritual Counselor or (various web info) Spiritual counseling is to A spiritual counselor does not appear to be a A
Care Provider assist you in finding God in the midst of life healthcare provider or an entity providing
events and prayerfully support you during life's healthcare – would be atypical.
changes. Spiritual counseling is designed to
inspire and awaken you to the possibilities of
spiritual growth in the midst of life events.
Spiritual counselors joyously give you
unconditional love and empower you to connect
with your own divine guidance. You may speak
with us about relationships, prosperity, health,
substance abuse, family or career issues,
spiritual growth or anything of concern to you. It
is our aim to help you focus on the solution, not
the problem, and to see the solution with the eyes
of Christ as you build your conscious awareness
of God's presence, power, and activity in your life.
Some identify themselves as psychics, faith
healers, Christian counselors, life coaches,
channels, ministers, soul advisors, and more.
Pastoral Counselor/ NUCC lists under Behavioral Health and Social No definition yet of pastoral counselor. This B 101YP1600X
Provider Service Providers – Counselor: A provider who type of counseling appears to be healthcare. (pastoral)
is trained and educated in the performance of
behavior health services through interpersonal Could be either atypical or healthcare 101Y00000X
communications and analysis. Training and (counselor)
education at the specialty level usually requires a
APPENDIX B
service provided
master’s degree and clinical experience and
supervision for licensure or certification.
(from AAPC): Pastoral Counseling is a unique

form of psychotherapy which uses spiritual
resources as well as psychological understanding
for healing and growth. Pastoral Counselors are
certified mental health professionals who have
had in-depth religious and/or theological training.
Under the auspices of AAPC, pastoral counseling
adheres to rigorous standards of excellence,
including education and clinical training,
professional certification and licensure. Typical
education for the AAPC-certified pastoral
counselor consists of study that leads to:
a bachelor’s degree from an accredited
college or university
a three-year professional degree from a
seminary
a specialized masters or doctoral degree in
the mental health field
A significant portion of this education is spent in
clinical training. Post-graduate training involves
completion of at least 1,375 hours of supervised
clinical experience (that is, the counselor provides
individual, group, marital and family therapy) and
250 hours of direct approved supervision of the
therapist’s work in both crisis and long-term
situations.
Peer Support Specialist (From Peer-to-Peer Resource Center): A Peer Not a healthcare provider and not providing a A
Specialist is a person with a mental illness who health care service
has been trained to help her/his peers - other
people with mental illnesses - to identify and
achieve specific life goals. The Peer Specialist
cultivates the ability of those they assist to make
APPENDIX B
service provided
informed, independent choices and set goals, and
to gain information and support from the
community to achieve those goals.
A Peer Specialist promotes self-determination,

personal responsibility and empowerment
inherent in self-directed recovery, and assists
people with mental illnesses in regaining control
over their own lives and over their own recovery
process. As someone who experiences a mental
illness themselves, the Peer Specialist models
competency in recovery and maintaining ongoing
wellness.
Peer Specialists work for pay in either the public
or private sectors of health care and in outpatient,
inpatient, and agency settings.
Personal Care An individual who provides assistance with CMS has identified personal care as a non A 3747P1801X
Attendants/ Personal eating, bathing, dressing, personal hygiene, healthcare service
Care Providers activities of daily living as specified in the plan of
care. Services which are incidental to the care
furnished or essential to the health and welfare of
the individual may also be provided. Personal
care providers must meet state defined training
and certification standards. (NUCC)
Personal Care Provider (From MN): These are agencies that provide No healthcare is provided. A
Organizations personal care services (activities of daily living
like bathing, assistance with eating, toileting,
dressing etc.) They do not have Medicare
certification like a Home Health Agency.
Personal Emergency Individuals that are specially trained to assist A PERS attendant would be eligible for an NPI H 146D00000X
Response Attendant patients living at home with urgent/emergent as providing healthcare.
situations. These individuals must be able to
perform CPR and basic first aid and have
sufficient counseling skills to allay fears and
assist in working through processes necessary to
resolve the crisis. Functions may include
APPENDIX B
service provided
transportation to various facilities and businesses,
contacting agencies to initiate remediation service
or providing reassurance. (NUCC)
Point of Service This product may also be called an open-ended This would be considered a product – not a A 305S00000X
HMO and offers a transition product incorporating healthcare provider and not a healthcare
features of both HMOs and PPOs. Beneficiaries service.
are enrolled in an HMO but have the option to go
outside the networks for an additional cost.
Polygraph examiner Polygraph examiners detect deception, verify A polygraph exam may be required by courts A
(licensed) truthfulness or provide a diagnostic opinion of and child welfare agencies related to sex
either, through the use of an instrument or offenders.
mechanical device.
A polygrapher is not providing healthcare so is
not eligible for an NPI
Preferred Provider A group of physicians and/or hospitals who A PPO is an arrangement whereby a third- A 305R00000X
Organization contract with an employer to provide services to party payer contracts with a group of medical
their employees. In a PPO, the patient may go to care providers who furnish services at lower
the physician of his/her choice, even if that than usual fees in return for prompt payment
physician does not participate in the PPO, but the and a certain volume of patients.
patient receives care at a lower benefit level.
(NUCC) This would be considered a product, insurance
plan or financial arrangement, not a healthcare
provider.
Pre-maternal Homes Pregnant women who live in the rural villages will The homes do not provide healthcare so are A
be brought to urban areas 30 days before their not eligible for an NPI.
due date. They stay in what is similar to a hostel
or residential facility. Congregate meals, have Lodging
room mates, may share a bathroom. They A public or privately owned facility providing 177F00000X
receive education on taking care of their baby. overnight lodging to individuals traveling long
The purpose of these homes is to ensure that the distances or receiving prolonged outpatient
mom-to-be is not without medical care when it is medical services away from home. (NUCC)
time to deliver.
Registered Records No definition by NUCC yet Not providing healthcare. A 246YR1600X

Administrator
(from Univ of CA Irvine): Medical Record
APPENDIX B
service provided
Administrators plan, direct and/or supervise the
acquisition, analysis, storage and retrieval of
medical and related information in a campus
medical facility; and perform other related duties
as required.
Incumbents typically design, initiate, and
coordinate methods for collecting, analyzing,
storing, retrieving and reporting patient medical
information and statistics in accordance with the
requirements of federal, state and local laws, the
standards of accrediting and regulatory agencies,
the data needs of physicians, researchers,
students and administrators, and information
requirements of patients, attorneys, insurance
firms, and governmental agencies; plan and
coordinate the development of medical
information systems to insure effective
maintenance and retrieval medical records;
inspect records to insure completeness and
internal consistency in quality control and data
substantiating diagnosis and treatment; assist
clinical staff in establishing criteria for the
evaluation of patient care; maintain confidentiality
of patient records in accordance with established
legal requirements; maintain liaison with clinical
and other users of medical records; assist clinical
staff in research utilizing medical records; assist
in defining and maintaining standards for medical
record keeping; and may supervise other
professional, technical and/or clerical personnel.
Must have certification as a Registered Record
Administrator by the American Medical Record
Association or eligibility for examination for
accreditation.
Respite Providers [Adult, "Respite" refers to short term, temporary care CMS has specified that respite care is not B
Developmentally provided to people with disabilities in order that healthcare.
APPENDIX B
service provided
Disabled, Behavioral their families can take a break from the daily
Respite] Individual routine of care giving. Unlike child care, respite Often the individual is a volunteer lay person.
services may sometimes involve overnight care Would not be eligible for an NPI.
for an extended period of time.
One of the important purposes of respite is to If a person providing respite care is a nurse or
give family members time and temporarily relieve other healthcare professional, they are eligible
the stress they may experience while providing for an NPI.
extra care for a son or daughter with mental
retardation or other disability. This, in turn, can
help prevent abuse and neglect, and support
family unity (US/GAO, September 1990). Respite
care enables families to take vacations, or just a
few hours of time off. Respite is often referred to
as a gift of time.
Respite Providers [Adult, Respite Care Facility CMS has specified that respite care is not B 385H00000X
Developmentally A facility with dorm rooms where individuals who healthcare. (respite care)
Disabled, Behavioral are unable to care for themselves may stay on a
Respite] Institution Non short term basis overnight to allow relief to If the facility provides healthcare (skilled 385HR2050X
Medical persons normally providing care to them. nursing care) as part of the respite service, (respite camp)
(NUCC) then it would be eligible for an NPI.
Respite Care Camp 385HR2055X
A camping facility that provides specialized From AZ Statute (respite mental
respite care to individuals requiring enhanced Respite care, which means a service that illness, child)
services to enable them to remain in the provides short-term care and supervision
community, (e.g., those with developmental available on a twenty-four hour basis. 385HR2060X
delays, mental retardation, mental/behavioral (disabilities)
disorders). The staff must have training in
working with the target populations and dealing 385HR2065X
with emergency situations which might be related (respite physical
to or exacerbate the individual's condition. disabilities, child)
(NUCC)
Respite Care, Mental Illness, Child
with mental illness, as respite for the regular
caregivers. (NUCC)
APPENDIX B
service provided
Respite Care, Mental Retardation and/or
Developmental Disabilities, Child
with mental retardation and/or developmental
disabilities as respite for the regular caregivers.
(NUCC)
Respite Care, Physical Disabilities, Child
A facility or distinct part of a facility that providers
with complex or profound disabilities as respite
for the regular caregivers. (NUCC)
School Based Attendant Attendant Care Provider If the service provided is healthcare, the B 3747A0650X
Care An individual who provides hands-on care, of provider is eligible for an NPI. If not (attendant care)
both a supportive and health related nature, healthcare, not eligible for an NPI.
specific to the needs of a medically stable,
physically handicapped individual. Supportive Atypical if providing only supportive services or
services are those that substitute for the absence, personal care.
loss, diminution, or impairment of a physical or
cognitive function. This service may include
skilled or nursing care to the extent permitted by
state law. (NUCC)
School Based Services Physical Therapist: (1) Physical therapists are These are providers that render Medicaid H 225100000X
Providers health care professionals who evaluate and treat covered services in the school setting as (physical therapist)
people with health problems resulting from injury opposed to obtaining the services from another
or disease. PT’s assess joint motion, muscle source such as an outpatient hospital or a
strength and endurance, function of heart and therapy facility.
lungs, and performance of activities required in 103T00000X
daily living, among other responsibilities. Each individual provider must be assessed as (psychologist)
Treatment includes therapeutic exercises, to whether they are a healthcare provider or if 103TS0200X
cardiovascular endurance training, and training in they provide healthcare. The majority of (School psychologist)
activities of daily living. (2) A physical therapist is providers rendering services in the schools
a person qualified by an accredited program in whose services would be covered by Medicaid 225X00000X
physical therapy, licensed by the state, and are healthcare providers and eligible for an (occupational
practicing within the scope of that license. NPI. therapist)
Physical therapists treat disease, injury, or loss of
APPENDIX B
service provided
a bodily part by physical means, such as the Various taxonomies
application of light, heat, cold, water, electricity, for speech/language
massage and exercise. They develop treatment
plans based upon each patient’s strengths,
weaknesses, range of motion and ability to Various taxonomies
function. (3) A health professional who for physician, nurse
specializes in physical therapy- the health care
field concerned primarily with the treatment of
disorders with physical agents and methods, such
as massage, manipulation, therapeutic exercises,
cold, heat (including short-wave, microwave, and
ultrasonic diathermy), hydrotherapy, electric
stimulation and light to assist in rehabilitating
patients and in restoring normal function after an
illness or injury.
Psychologist: An individual who specializes in

psychological research, testing, and/or therapy.
Psychology is the branch of science that deals
with mental processes and behavior, composed
of the following major fields: abnormal, clinical,
comparative, counseling, developmental,
educational, engineering, experimental, industrial,
learning, motivation, perception, personality,
physiological, psychometrics, school, and social
psychology.
Occupational Therapist
An occupational therapist is a person qualified by
completion of an approved program in
occupational therapy, licensed by the state and
practicing within the scope of that license, or
where licensure does not exist, certified by the
American Occupational Therapy Certification
Board. An occupational therapist evaluates the
self-care, work and leisure performance skills of
well and disabled clients and plans and
APPENDIX B
service provided
implements programs to restore, develop or
maintain the task performance skills necessary
for daily living and for the client’s particular
occupational role.
Speech, Language and Hearing Providers

A provider who renders services to improve
communicative skills of people with language,
speech and hearing impairments.
Allopathic & Osteopathic Physicians

A broad category grouping state licensed
providers in allopathic or osteopathic medicine
whose scope of practice is determined by
education
Nursing Service Providers

Providers who are trained and educated to
perform services in health promotion, disease
prevention, acute and chronic care, and
restoration of health, and health maintenance
across the life span. (NUCC)
School Based From Michigan Medicaid School Based policy: Bus A 347B00000X
Transportation Special education transportation services include A public or private organization or business
transport to and from the student's pick-up and licensed to provide bus services. (NUCC)
drop-off site where school based services are
provided. It includes no more than one round-trip
on a date of service.
The need for special education transportation
must be specified in the student’s IEP/IFSP
treatment plan. Medicaid may reimburse for
special education transportation when a student
receives a Medicaid-covered service on the same
day.
Medicaid does not reimburse for transportation
provided in a regular or general education school
bus. Also, there is no additional payment for an
APPENDIX B
service provided
attendant.
School Counselor Not healthcare providers and do not provide A 101YS0200X

(From ASCA): The professional school
healthcare
counselor is a certified/licensed educator trained
in school counseling with unique qualifications
and skills to address all students’ academic,
personal/social and career development needs.
Professional school counselors implement a
comprehensive school counseling program that
promotes and enhances student achievement.
Professional school counselors are employed in
elementary, middle/junior high and high schools
and in district supervisory, counselor education
and post-secondary settings. Their work is
differentiated by attention to developmental
stages of student growth, including the needs,
tasks and student interests related to those
stages. Professional school counselors have a
master’s degree or higher in school counseling or
the substantial equivalent, meet the state
certification/licensure standards and abide by the
laws of the states in which they are employed.
School Systems The term local education agency means a public When providing health care services, the LEA H 251300000X
Intermediate School board of education or other public authority or ISD would be a Type 2 health care provider (local education
District legally constituted within a State to either provide and the individual health care providers would agency)
Local Education Agency administrative control or direction of, or perform a be enrolled as type 1 providers.
service function for public schools serving
individuals ages 0 – 21 in a state, city, county,
township, school district, or other political
subdivision including a combination of school
districts or counties recognized in a State as an
administrative agency for its public schools. An
LEA may provide, or employ professional who
provide, services to children included in the
Individuals with Disabilities Education Act (IDEA),
such services may include, but are not limited to,
APPENDIX B
service provided
such medical services as physical, occupational,
and speech therapy. (NUCC)
Specialist/Technologist An individual with a high school diploma, on-the- Not a healthcare provider and does not provide A 246Y00000X
, Health Information job experience and coding education from healthcare
seminars or college classes who passes a
national certification examination in either
inpatient and outpatient facility services coding, or
physician services coding.
Specialist/Technologist, General classification identifying individuals Lists various categories: B 246Z00000
Other trained on specific equipment and technical Art, Medical - 246ZA2600X –type A (other)
procedures in one of a collection of Biochemist - 246ZB0500X – type A
miscellaneous healthcare disciplines. (NUCC) Biomedical Engineering - 246ZB0301X – type
A
Biomedical Photographer - 246ZB0302X -
type A
Biostatistician - 246ZB0600X – type A
EEG - 246ZE0500X type H
Electroneurodiagnostic - 246ZE0600X – type H
Geneticist, Medical (PhD) - 246ZG1000X -
type H
Graphics Methods - 246ZG0701X – type A
Illustration, Medical - 246ZI1000X – type A
Nephrology - 246ZN0300X - type H
Surgical - 246ZS0400X – type H
No definitions by NUCC. Some would be

healthcare providers, others are not and do not
appear to be providing healthcare.
Specialized Medical Durable Medical Equipment & Medical NUCC does not yet have definitions for the H 332B00000X
Equipment, Supplies, Supplies subcategories of supplies but all appear to be (DME & med
A supplier of medical equipment such as included in the definition of healthcare provider supplies)
respirators, wheelchairs, home dialysis systems, under 1861(s) of the SSA.
or monitoring systems, that are prescribed by a 332BC3200X
physician for a patient’s use in the home and that See Assistive Technology Devices for (customized
are usable for an extended period of time. additional information. equipment)
APPENDIX B
service provided
(NUCC)
332BD1200X
(dialysis equip &
supplies)
332BN1400X
(nursing facility
supplies)
332BX2000X
(oxygen equipment &
supplies)
332BP3500X
(parenteral/enteral
nutrition)
State School for Deaf Schools for the Deaf and Blind is a statewide If the school provides school-based health A
and Blind agency providing educational services to visually services and bills Medicaid for the services,
impaired students and youth. usually the LEA (Local Education Agency) or
Technical Assistance to Schools (TAS) works Intermediate school district is the designated
with IEP teams in school districts throughout the biller and pay-to provider. See discussion
state to provide comprehensive assessments to under School Systems.
support effective educational programming for
students who have sensory impairments, Educational services are not healthcare in this
including those with multiple disabilities. Support context so the school for the Deaf & Blind
is also offered through consultation and training would not be eligible for an NPI.
for teachers, school personnel and families to
address the specialized needs of these students.
Supervisory Care Home Provide room, board, and general supervision to Sounds like a custodial care facility – see A
multiple people. definition.
Supported Employment Supported employment is paid employment Not a healthcare service. The provider of this A
Services which: service likely is not a healthcare provider and
• Is for persons for whom competitive would not be eligible for an NPI.
employment at or above the minimum wage
is unlikely and who, because of their
APPENDIX B
service provided
disabilities, need intensive ongoing support to
perform in a work setting;
• Is conducted in a variety of settings,
particularly worksites in which persons
without disabilities are employed; and
• Is supported by any activity needed to sustain
paid work by persons with disabilities,
including supervision, training and
transportation. (State Medicaid Manual
4442.3)
Supported Living Supported living services assist people with These services are covered under Medicaid A
Providers Individual disabilities to live in their own home or apartment Waiver programs. These are not healthcare
with the support of trained staff assistance. services.
Supported Living Services include: assistance
with securing and maintaining housing,
housekeeping and meal preparation, personal
care, money management, hiring, training,
scheduling and supervising direct support staff
and 24 hour emergency response services.
Supported Living See services provided above. The institutional This is not healthcare provider. A
Providers Institution setting would be for people who cannot live totally
by themselves, or are aged or disabled, and need
support in meals, laundry, chore service, personal
care.
Supports Brokerage From CMS Independence Plus Waiver template: Similar to non medical case management A
Providers Case Management/Supports Brokerage: activities. Not providing health care so not
Service/function that assists participating families eligible for NPI.
and individuals to make informed decisions about
what will work best for them, are consistent with
their needs and reflect their individual
circumstances. Serving as the agent of the family
or participant, the service is available to assist in
identifying immediate and long-term needs,
APPENDIX B
service provided
developing options to meet those needs and
accessing identified supports and services. A
family or person-centered planning approach is
used. Supports Brokerage offers practical skills
training to enable families and individuals to
remain independent. Examples of skills training
include providing information on recruiting and
hiring personal care workers, managing personal
care workers and providing information on
effective communication and problem solving.
The service/function provides sufficient
information to assure that participants and their
families understand the responsibilities involved
with self-direction and assist in the development
of an effective back-up and emergency plan.
States may elect to fulfill the requirement of this
service/function using a self-directed case
manager or creating a distinct service. States
may elect to fulfill this required service/function
either as a service cost or an administration cost,
but must clearly identify which method will be
used. The services/functions included in Supports
Brokerage are mandatory requirements of the
template.
From Louisiana Waiver: Supports Brokerage is

provided by targeted case managers and
includes the following:
• Educates the family about the service planning
process
• Elicits information from the individual or family
regarding their preferences, goals and service
needs 1
• Assists with the identification of direct supports,
community, public and private resources
• Monitors consumer satisfaction and service
delivery
APPENDIX B
service provided
• Initiates and facilitates planning meetings
From Kansas Waiver application: Supports

Brokerage: Services include assistance in
enrolling, accessing other systems, developing
the Plan for Independence and the Individualized
Budget, managing personal attendants,
documenting the need for assistive services,
planning for and documenting the use of excess
funds and locating and maintaining services.
From New Hampshire Independence Plus

Waiver: Supports Brokerage is called Family
Support/Service Coordination. It is a waiver
services, and includes the following:
• Coordinating, facilitating and monitoring
services provided under the waiver;
• Assessing and reassessing service needs;
• Assistance with recruiting, screening, hiring, and
training in-home support providers;
• Identifying, providing information regarding and
assisting families to access community resources
and supports;
• Development, review, and modification of
service agreements;
• Providing counseling and support;
• Skills and advocacy training for the
child/individual or representative;
• Monitoring consumer satisfaction;
• Initiating, collaborating and facilitating the
development of a transition plan at the age of 16,
to access adult supports, services, and
community resources when the child/individual
turns age 21; and
• Creating and maintaining work registries.
APPENDIX B
service provided
Technician, Health Preferred term for an Accredited Record Appears to be administrative and not a A 247000000X
Information Technician who is an individual with an provider of healthcare
associate’s degree from an accredited college or
independent study program who is skilled in 2470A2800X
analyzing health information and in examination No definition for Assistant Record Technician Assistant Record
of medical records for accuracy, reporting of yet. Technician
patient data for reimbursement, and creation of
disease registries for researchers. (NUCC)
Technician, Other A collective term for persons with specialized Lists various categories: B 247200000X
training in various narrow fields of expertise Biomedical Engineering - 2472B0301X – type (other)
whose occupations require training and skills in A
specific technical processes and procedures; and Darkroom - 2472D0500X - type A
where further classification is deemed EEG - 2472E0500X – type H
unnecessary by the user. (NUCC) Renal Dialysis - 2472R0900X – type H
Veterinary - 2472V0600X – type A
No definitions by NUCC yet. Some would be

healthcare providers, others are not be and are
not providing healthcare.
Vehicle Accessibility (Contractor) Vehicle Modifications Not a healthcare provider – not eligible for an A 171WV0202X
Modifications provider A contractor who makes modifications to private NPI.
vehicles to accommodate a health condition.
(NUCC)
Veterinarian A doctor of veterinary medicine, trained and Not a healthcare provider and does not provide A 174M00000X
authorized to practice veterinarian medicine and healthcare to individuals – not eligible for an
surgery. (NUCC) NPI.
Weight loss centers Promote healthier lifestyles through proper weight Could be both a healthcare provider and an B May need taxonomy
management. atypical provider depending on staff and code
services provided.
Some centers provide advice and monitoring
using non healthcare providers. Others are for
medical weight management and may be
associated with large health systems. Some
provide gastric bypass surgery.
APPENDIX B
service provided
APPENDIX B
service provided

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WEDI Strategic National Implementation Process (SNIP)

SNIP Transactions Workgroup

Atypical Service Providers

Workgroup for Electronic Data Interchange

The existence of a link or organizational reference in any of the following materials

Document is for Education and Awareness Use Only.

© 2006 WEDI - SNIP - NPI Sub Workgroup Atypical Service Providers • 1

APPENDIX A – 42 USC 1395(X) SECTION 1861(U) AND 1861(S) ......................... A - 1

APPENDIX B – ATYPICAL PROVIDER WORKSHEET........................................... B - 1

© 2006 WEDI - SNIP - NPI Sub Workgroup Atypical Service Providers • 1

This paper is NOT intended to be a definitive resource; rather it should be used as

Atypical Service Provider

© 2006 WEDI - SNIP - NPI Sub Workgroup Atypical Service Providers • 1

Covered Health Care Provider

Health Care Provider

Health Care Provider Taxonomy Code

The Provider Taxonomy is a unique alphanumeric code, 10 characters in length.

© 2006 WEDI - SNIP - NPI Sub Workgroup Atypical Service Providers • 2

HIPAA Standard Transaction

Standard Paper Transaction

Standard Electronic Transaction

© 2006 WEDI - SNIP - NPI Sub Workgroup Atypical Service Providers • 3

• Who is eligible to obtain a NPI

© 2006 WEDI - SNIP - NPI Sub Workgroup Atypical Service Providers • 4

V. Background information from the

© 2006 WEDI - SNIP - NPI Sub Workgroup Atypical Service Providers • 5

VI. Background Information from the NPI

© 2006 WEDI - SNIP - NPI Sub Workgroup Atypical Service Providers • 6

Important Notes from the above section of the rule:

VII. Business and Implementation Issues

© 2006 WEDI - SNIP - NPI Sub Workgroup Atypical Service Providers • 7

How to evaluate whether a provider is eligible for an NPI or not?

It is important to emphasize that providers be evaluated in terms of both whether they

© 2006 WEDI - SNIP - NPI Sub Workgroup Atypical Service Providers • 8

The entity that has both an NPI AND an API.

The role of provider taxonomy codes.

• Adult foster care facility

© 2006 WEDI - SNIP - NPI Sub Workgroup Atypical Service Providers • 9

What we know about atypical service providers.

• Approximately 94,750 atypical service providers enrolled identified as enrolled in 13

© 2006 WEDI - SNIP - NPI Sub Workgroup Atypical Service Providers • 10

How are atypical service providers enumerated and paid today?

Services provided by atypical service providers are sometimes reimbursed to an organization

© 2006 WEDI - SNIP - NPI Sub Workgroup Atypical Service Providers • 11

Atypical service providers and electronic transactions

The preamble to the NPI rule addresses this issue:

Identifying atypical service providers in electronic transactions after

VIII. Future Atypical Provider Enumeration

© 2006 WEDI - SNIP - NPI Sub Workgroup Atypical Service Providers • 12

• There should be continuity with legacy identifiers.

IX. Alternative Enumeration Approaches

Alternative 1: Maintain a Legacy Enumeration System

Option 1: Use current payer-assigned identifier

Option 2: Payer-assigned 10-digit ID

© 2006 WEDI - SNIP - NPI Sub Workgroup Atypical Service Providers • 13

Alternative 2: Regional Coordination of Atypical Service Provider Enumeration

Alternative 3: National Enumeration of Atypical Service Providers

Some basic considerations for a national API program include:

B. White Paper Recommendations.

© 2006 WEDI - SNIP - NPI Sub Workgroup Atypical Service Providers • 14

X. NPI Online Resources

WEDI (Workgroup for Electronic Data Interchange) NPI Outreach Initiative:

Walter Suarez, Institute for HIPAA/HIT Education and Research, Co-leader