Provider Directory Task Force

Karen Trudel, CMSSeptember 30, 2010

CMS “Provider Directories”

• National Plan/Provider Enumeration System (NPPES)

• Provider Enrollment Chain Ownership System (PECOS)

NPPES

• Purpose: Assign NPIs under HIPAA• Covers: Any individual and organization that

meets the definition of provider under HIPAA • Covers: All providers, not just

Medicare/Medicaid• Currently: 2,440,000 active individuals (type

1) and 776,950 active organizations (type 2)

PECOS

• Purpose: Central provider repository for Medicare program operations

• Covers: Medicare provider types only– Professional and institutional– DME suppliers will be loaded in October

• Currently: 1.2 million providers total:– 236,685 institutions– 940,000 individuals

Responses to Questions: NPPES

• Validation– Real-time verification of SSN with SSA– Ad hoc verification of business name/EIN with IRS– Assures no duplicates (only one NPI per provider)

• Maintenance– Providers enter changes (within 30 days)

• Set of entities– Individual clinicians and organizations (but not

cross-referenced)

NPPES (cont’d)

• Data content– Name of individual or legal business name of

organization– One business location– Entity type and taxonomy code (specialty)– Other identifiers (UPIN, DEA, Medicaid, etc.)– State license info for individuals– Contact information

NPPES (cont’d)

• Public Availability– On-line query-only database• https://nppes.cms.gov/NPPES/NPIRegistryHome.do

– Monthly downloadable file• http://nppes.viva-it.com/NPI_Files.html

– EIN for organizations not included

Responses to Questions -- PECOS

• Validation – Same as NPPES plus:– Checks SSA death file, various exclusions

databases (e.g., OIG, GSA)– Verify license and registration data with States– Verify practice location address via phone check

or site visit– Verify legal business name and EIN

PECOS (cont’d)

• Maintenance – Providers required to update for “reportable

events”– Within 30 days (e.g., change in practice location)– Within 90 days (e.g., change in banking data)

• Set of entities– Individuals, organizations plus owners, managers– Group practices/practitioners are linked

PECOS (cont’d)

• Data Content – NPPES plus:– All practice locations– Banking information– Links members of chains to headquarters– Ownership/management information– Links practitioners to groups

• Public Availability– None at present

Other Responses

• Neither NPPES nor PECOS contains routing information for EDI – this information is maintained by MACs for FFS Medicare

• Provider motivation for timely updates– Regulatory – compliance issue– Direct relationship to accurate and timely

reimbursement

Considerations for Future

• Provider directories integral to health plan operations have stringent requirements for accuracy, trust, authentication– Payment accuracy– Program integrity/fraud prevention

• Centralized credentialing should be considered

• Federated structure would need to consider various uses/need for data