National Provider Identifier (NPI)
The NPI is a 10-digit standard unique identifier for health care providers. It replaces any health care provider identifiers in use today, including the nine-digit Medi-Cal provider number. Health Insurance Portability and Accountability Act (HIPAA) of 1996 required a standard unique identifier for all health care providers for use in the nationwide health care system- the NPI. The National Plan and Provider Enumeration System (NPPES) was developed by the Centers for Medicare & Medicaid Services (CMS) in compliance with the HIPAA requirement. NPPES is the CMS-sponsored data repository for NPI-related information. It processes new applications, updates and generates NPIs. The NPPES website address is https://nppes.cms.hhs.gov. The NPI Enumerator is a CMS-contracted vendor that will perform provider registration and enumeration processing using the NPPES. The Enumerator enters data from paper applications, resolves problems and answers questions related to NPI and the registration process. Once the data processing is completed, the Enumerator will notify providers of their assigned NPI.
Medi-Cal Provider Enrollment
Health center sites enroll in the Medi-Cal program using the health center's NPI through the licensing process with the Centralized Applications Branch (CAB) of Licensing & Certification within the CA Department of Public Health. However, individuals attached to these health center sites must be individually enrolled into the Medi-Cal program as well: FQHC providers need to be individually enrolled because they order, refer or prescribe on behalf of the FQHC, as well as if they provide in-patient services billed by the FQHC. If FQHCs do not individually enroll their providers, when they refer their patients to someone like a specialist, the specialist will not get paid which could cause the specialist to stop accepting referrals from the health center. The same with pharmacy...if the health center does not individually enroll their providers the patient may not get their prescriptions filled, etc. Ultimately, Medi-Cal also plans to deny claims that do not list a validly enrolled provider, though as of May 2019, they have not set a date for that level of enforcement.
ORP Enrollment : For individuals who are simply ordering, referring, and/or prescribing on behalf of the FQHC, the ORP enrollment type is appropriate.
Clinic-Based Physician: Some FQHCs will choose to bill Fee-for-Service (outside of PPS) for inpatient services provided by an FQHC provider, (OB services in a hospital are one example of this). In this case, or in similar scenarios where claims will be billed under the individual provider's NPI rather than the FQHC's, the individual can opt for the clinic-based provider application rather than the ORP enrollment.
Both enrollment types are available through Medi-Cal's electronic Provider Application and Validation for Enrollment (PAVE) portal here.
Medicare Provider Enrollment
FQHCs are required to enroll as Medicare providers. On April 24, 2019, CMS held a webinar for health centers that described a new process for Medicare enrollment: once a new FQHC site is added into the HRSA Scope of Project, HRSA will send the site's information over to CMS and the Medicare electronic enrollment system, PECOS, will be pre-populated with the site's information. From there, the health center will work within PECOS to complete the enrollment. A copy of the webinar slides including notes are available for download here, in addition to the webinar recording: download webinar slides and access webinar recording.
CPCA Staff Contact
For questions regarding provider enrollment, please contact Emily Shipman, Associate Director of Health Center Operations, at firstname.lastname@example.org.