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NPPES Background
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires that a unique identifier be assigned to each health plan and healthcare provider. Accordingly, the Centers for Medicare & Medicaid Services (CMS) uses enrollment systems, including the Medicare Provider Enrollment, Chain, and Ownership System (PECOS) and the National Plan and Provider Enumeration System (NPPES), to manage provider information and identifiers.
There are two types of providers within the NPPES, and an individual is eligible for only one NPI. Type 1 providers are individual healthcare providers including physicians, dentists, and all sole proprietors. Type 2 providers are organizational healthcare providers including physician groups, hospitals, nursing homes, and the corporation formed when an individual incorporates him/herself.
Finally, the CMS NPI Final Rule (45 CFR 162.410(a)(4)) requires all healthcare providers to update information included in the NPPES within 30 days of a change.
Who Uses NPPES?
Primarily, CMS uses the NPPES database to feed data to regulatory programs, claims processing, etc. However, many others use this database for data validation purposes. They include insurance payers, NCVOs, EHR developers, HISPs / Direct Trust, health information exchanges, and other HIT developers. NPPES updates the full database weekly and provides the file publicly to anyone and everyone who needs it.
How Do I Update My NPPES Data?
First, view this CMS video to learn about recent updates to the system. Then, you can update your information on the NNPES website by following these steps.
If you’re a provider, begin by either logging in directly to the NPPES or logging in via the PECOS.
If you’re working on behalf of a provider or organization, then you’ll first need to set up Surrogacy Access via I&A. Surrogacy allows administrative users to update records in the NPPES and PECOS on behalf of a provider. This video is a great place to start!
Sign in using your I&A login credentials.
Scroll down to “Manage Provider Information.”
Under the “Action” column, click the pencil.
Make changes to the individual categories.
Click “Error Check.”
Click “Save and Return to Main Page” to activate a dialogue window.
Choose “Complete NPI Application” to submit all entered changes to the NPPES.
Click “Main Page” at the top of the menu bar on the left to return to the NPPES main page. From there, you can make further changes or sign out from the upper right corner.
Processing of new or edited information may take several weeks.
Why Is CMS Looking at the NPPES from A Regulatory Perspective?
1. NPPES ties Medicare claims to regulatory participation.
CMS draws information from the PECOS and NPPES and supplies it to the Quality Payment Program (QPP) to decide not only eligibility, but also data for cost category scoring. Based on information obtained from these systems, providers are tied to one or more tax identification numbers (TINs) for QPP eligibility and reporting. Additionally, historical records of participation that determine adjustments are tied to this data (remember PQRS and meaningful use?). It’s a big, interwoven web and, therefore, accurate PECOS and NPPES data are critical to QPP accuracy and your incentives (or penalties).
2. Are you information blocking?
In 2020, a new requirement to enter Health Information Exchange (HIE) Endpoints into the NPPES landed on our desks. Under the 21st Century Cures Act Final Rule, the ONC and CMS now mandate a central repository of provider “direct” addresses for data exchange, which lives within the NPPES and supports health information exchange and interoperability. The NPPES website is searchable and allows providers to look up the “direct” address of any other provider. Failure to enter this information could constitute information blocking, which carries a penalty of up to $1 million per violation.
How Do I Update My HIE Endpoint Information?
Log in to the NPPES.
Go to the provider you want to update, then go to the “Health Information Exchange” tab.
Update the following fields: • Endpoint Type: Select “Direct Messaging Address.” • Endpoint: Enter your provider’s direct address. Don’t enter an email address! Direct addresses usually include the word “direct” (e.g., michelle.bowes@cerner.direct.com). • Endpoint Location: Select the practice/hospital to which the direct address is affiliated. • Is the Endpoint affiliated to another organization?:Enter “No” unless your provider uses a direct address from another practice or the hospital instead of from your organization.
Review and agree to the Terms and Conditions, then save and submit. Repeat for all providers at your practice.
MAVIN Credentialing
At MAVIN, we’re surrogates for our credentialing clients. We’ll gladly manage and maintain both NPPES and PECOS records on your behalf. There are several other benefits of credentialing with us, too! For more information, please feel free to check out our step-by-step process and our worry-free Annual Credentialing Maintenance Plan. If you have any questions or concerns about NPPES records, then we encourage you to contact us today to see how we can help!
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