Adjudication The process of handling and making determinations about the payment of (or coverage for) them.

Ancillary Services Auxiliary or supplemental services, such as diagnostic services, home health services, physical therapy and occupational therapy, used to support diagnosis and treatment of a patient's condition. Room and board are not considered ancillary services.

Atypical Provider Individual or organization that provides non-traditional services that are indirectly health care related. (Not eligible for NPI.)

Check Digit A digit attached to the NPI number on the 10th position that is used for validation purposes.

Clearinghouse An entity including a billing service or repricing company that processes or facilitates the processing of health information received from another entity.

CMS 1500 The claim form for physicians and other health care professionals to use. This form is being revised to accommodate the NPI. The CMS 1500 was formerly known as the HCFA 1500.

Covered Health Care Provider A person who is trained and licensed to provide health care services or a facility that is licensed to provide health care services. Physicians, dentists, nurses, therapists and hospitals are examples of health care providers under the NPI system.

Emdeon A leading provider of business technology solutions that can simplify health care delivery and reimbursements. Horizon BCBSNJ recommends that physicians and health care professionals use Emdeon for electronic transactions. (Formerly known as WebMD.)

Electronic Data Interchange (EDI) A method for physicians, health care professionals and hospitals to submit claims electronically.

Electronic File Interchange (EFI) Submitter A group/organization who is certified to submit NPI applications in an electronic file. An EFI submitter might be a professional organization which, when authorized by a physician, health care professional or hospital, will submit an electronic application for its members. (Also known as a bulk enumerator.)

Entity Type Code The type of health care provider that is being assigned an NPI. Codes are: (Person): individual health care professionals who furnish health care. (Non person): entity other than an individual health care professional that furnishes health care (for example, hospital, skilled nursing facility, hospital sub-unit or pharmacy).

Entity Type Code 1 The type of NPI issued to health care professionals including physicians, dentists, nurses, chiropractors, pharmacists and physical therapists.

Entity Type Code 2 The type of NPI issued to health care organizations or institutions. This includes hospitals, home health agencies, clinics, nursing homes, residential treatment centers, clinical laboratories, ambulance companies, group practices, durable medical equipment suppliers, prosthetics and orthotics suppliers and pharmacies.

Enumerator An organization under contract with the Department of Health and Human Services to assign NPIs. Fox Systems is the NPI Enumerator and will: Receive and process NPI applications. Send notification of NPIs to each applicant. Use the National Plan and Provider Enumeration System (NPPES) to ensure the unique identification of each applicant. Answer questions about applying for and obtaining NPIs. Collect information, via the applications and updates, and maintain the NPPES database containing NPIs.

Health Insurance Portability and Accountability Act (HIPAA) A federal law that, among other things, set standards for the transmission of health care information as well as for the privacy and security of that information, the portability of health care coverage, and uniquely identifying critical players in the health coverage delivery system.

Individual Health Care Professional Health care professionals who are human beings. These individuals are considered Entity Type Code 1. Examples are physicians, dentists, nurses, chiropractors, pharmacists and physical therapists. May also be called Individual Health Care Providers.

J/K Code Horizon BCBSNJ only assigns J/K Codes to physicians who are credentialed as Primary Care Physicians (PCPs) with Horizon BCBSNJ. Specialists physicians do not have J/K Codes and can leave the J/K Code field blank on the NPI Collection Form. If you are a PCP and do not know your J/K Code, you can easily find your J/K Code by looking up your practice in our on-line provider directory. Please visit www.HorizonBlue.com and click the Provider Directory link at the top of the page. Perform a search using the PCP's last name and you will be shown the practice information and J/K Code.

Luhn Algorithm A method used to validate identification numbers, such as an NPI. It is a simple formula used to verify account numbers and check against accidental errors. Most credit card and government agencies use the Luhn Algorithm to ensure accuracy of identification numbers.

National Provider Identifier (NPI) A system for uniquely identifying all providers of health care services, supplies and equipment, in accordance with HIPAA. NPIs are assigned by CMS and are 10-position, all-numeric identification numbers that will identify a hospital, physician or other health care professional in standard transactions, such as electronic health care claims submissions.

Non-covered Entities Health care providers who do not conduct standard electronic transactions. (Not eligible for NPI.)

Organization Health Care Provider Providers of health care who are not human beings. These providers are classified as Entity Type Code 2. Examples are hospitals, home health agencies, clinics, nursing homes, residential treatment centers, clinical laboratories, ambulance companies, group practices, DME suppliers and pharmacies.

Subpart A entity/component or separate physical location of a covered organization health care provider. This entity may function independently of the covered organization and may have its own billing numbers, license and/or physical location, but is not, itself, a legal entity. Examples include: A subpart of a hospital could include outpatient departments, surgical centers, psychiatric units and laboratories; Provider chains that generally have a corporate headquarters and a number of separate physical locations. The separate physical locations are generally separately licensed or certified, i.e., DME supplier chain or pharmacy.

Suffix Some physician groups have a unique identifier assigned by Horizon BCBSNJ which must be appended to their group TIN number when submitting claims. This is referred to as a suffix. If you do not use a suffix when submitting claims to Horizon BCBSNJ, please leave the "suffix" field blank on the NPI Collection Form.

Taxonomy Code An administrative code set that classifies physicians and other health care professionals by type, classification and specialization.

Tax Identification Number The number assigned by the Internal Revenue Service (IRS) to uniquely identify that physician, dentist, hospital or other health care professional as a taxable entity. This number is used for payment and other HIPAA-related purposes in the conduct of standard transactions and health plan administration.

UB-04 A new claim form for institutional submitters (hospitals, home health agencies, etc.) that will replace the UB-92. The new UB-04 was designed by the National Uniform Billing Committee and includes improvements including better alignment with the electronic transactions and fields for NPIs.

Universal Provider Identifier Number A unique number used to identify physicians and other health care professionals.