Provider Directory Task Force Karen Trudel, CMS September 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 – Monthly downloadable file – 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