In guidance provided on April 2, 2007, the Centers for Medicare and Medicaid Services (CMS) announced that, through May 23, 2008, it would not impose penalties on covered entities that deploy contingency plans to facilitate National Provider Identifier (NPI) compliance. However, as of May 24, 2008, CMS will lift that leniency policy. Complaints will be investigated as they are today, but CMS will impose penalties if the entity does not demonstrate compliance or corrective action.
CMS will continue to employ a complaint-driven approach to enforcement. For example, if a complaint is received alleging a failure to comply with the NPI requirements, CMS will contact the entity for evidence of compliance and the contingency plan that had been in place. If violations are identified, enforcement actions will take place.
In conversations and correspondence with health care providers, health plans, and others within the healthcare industry, it is clear that there are misconceptions concerning the National Plan and Provider Enumeration System (NPPES) and the NPI enumerator. Following are some common misconceptions and the facts correcting them.
Misconception: NPPES sends data directly to the Medicare provider enrollment system.
Fact: NPPES does not send data to the Medicare provider enrollment system or to the provider enrollment system of any health plan. As explained in the NPI final rule, applying for enrollment in a health plan is a completely separate process from that of applying for an NPI.
Misconception: NPPES sends data directly to the Medicare claims system.
Fact: NPPES does not send data to the Medicare claims system or to the claims system of any health plan. Medicare extracts certain NPPES data and uses those data in its Medicare NPI crosswalk. That crosswalk is used in processing Medicare Part A and Part B claims. Other health plans are also free to use NPPES data to help process their claims.
Misconception: NPPES is part of the Medicare provider enrollment system.
Fact: Obtaining an NPI is required in order for a healthcare provider to enroll in Medicare; however, the NPPES does not function as a part of the Medicare provider enrollment system. Medicare requires a healthcare provider to have an NPI and to furnish it on the Medicare provider enrollment application form (CMS-855). In addition, once a provider submits a CMS-855 to Medicare, Medicare compares the NPI and certain other information on the CMS-855 with certain information in that provider’s record in NPPES. If the information being compared does not match, the provider must correct whichever information (NPPES or CMS-855) is incorrect in order for the enrollment process to continue.
Misconception: Obtaining an NPI guarantees payment to the healthcare provider by a health plan.
Fact: As explained in the NPI final rule, obtaining an NPI does not guarantee payment to the healthcare provider by Medicare or by any other health plan. NPI assignment simply establishes the uniqueness of an enumerated healthcare provider among all other enumerated healthcare providers. Most health plans will not pay a healthcare provider that is not enrolled in that health plan.
Misconception: NPPES verifies licenses and credentials that are reported by healthcare providers when applying for NPIs.
Fact: NPPES does not verify licenses or credentials. NPPES verifies only two things: (1) a healthcare provider’s Social Security number if the provider is an individual who furnished his/her SSN when applying for the NPI; and (2) whether the provider’s business mailing and practice location addresses are legitimate postal service addresses, but not that the provider is actually associated with or located at either of those addresses. Licensure and credentials must be verified by health plans as part of their enrollment processes. It is possible, under certain circumstances, that the NPI enumerator may contact providers who have submitted applications, updates, or deactivations to verify information that was furnished in order to properly process those actions. Healthcare providers are reminded that the information they send to NPPES must be true, correct, and complete, in accordance with the certification statement of the NPI application/update form (paper form and web-based form).
Misconception: NPPES is a Medicare system.
Fact: NPPES is not a Medicare system; it belongs to no health plan. It is maintained by CMS for the healthcare industry in general, in accordance with the NPI final rule and as part of CMS’ delegated HIPAA authority. Healthcare providers who apply for NPIs are not required to furnish any information about their enrollment in any health plan. In an optional field, providers may report legacy identifiers that health plans have assigned to them in the past. This field, “Other Provider Identification Numbers,” can capture the legacy identifiers and the issuers of those identifiers (i.e., the names of the health plans that assigned them). The information in this field is used by health plans to help them locate their enrolled providers in NPPES in order to know of their NPI assignments. For this reason, Medicare providers are urged to report their Medicare legacy identifiers in this field.
Misconception: The NPI enumerator can update the Medicare claims and enrollment systems.
Fact: The NPI enumerator cannot view, update, or interact with Medicare claims or the Medicare enrollment systems, nor can it do so with any health plan’s claims or enrollment systems.
Misconception: The NPI enumerator can view and update/change the Medicare NPI crosswalk.
Fact: The NPI enumerator cannot view or update/change the Medicare NPI crosswalk. The NPI enumerator can assist providers with certain aspects of updating their NPPES records, and some of that information in those NPPES records could be used by Medicare in the Medicare NPI crosswalk.
Misconception: The NPI enumerator serves Medicare providers and supports Medicare operations, not other providers or health plans.
Fact: The NPI enumerator operates under contract to CMS in accordance with the NPI final rule and as part of CMS’s delegated HIPAA authority. The NPI enumerator serves the entire healthcare provider community for NPI purposes, not just Medicare providers. The functions of the NPI enumerator are not specific to any health plan.
CMS has posted information that lists the specific duties and responsibilities of the NPI enumerator in a recent MLN Matters article. An article that further clarifies the functions of NPPES and the NPI enumerator is in development; this article will be announced once available.
