NPPES and your NPI: what payers read and when to update it. Every other file is checked against this one.

NPPES is the federal register behind every National Provider Identifier. Medicare's enrollment system checks each NPI against it, CAQH checks each clinician's name against it, and anyone can read the public part in the NPI Registry. Update it whenever a name, practice address, mailing address, specialty code or authorized official changes. The federal NPI rule sets the reporting window, and it starts on the day of the change.^B

Two kinds of NPI, one register.

A Type 1 NPI belongs to a person. A Type 2 NPI belongs to an organization, such as a group practice. Both live in NPPES, the National Plan and Provider Enumeration System, which CMS runs.

A clinician gets one NPI, however many specialties, licenses or locations they add. The CMS form says so plainly.^B Organizations are different. CMS guidance says a health plan, including a state Medicaid agency, may require a separate NPI for each location or each separately licensed part of a practice.^C Ask each payer before you assume one group NPI covers every address.

Who reads the record, and what they compare.

Medicare does not ask for a copy of your NPI letter. Its enrollment system, PECOS, verifies every NPI on the application directly against NPPES. The Medicare manual also requires the legal business name in NPPES and in PECOS to match exactly, in every case.^D

CAQH runs its own check. When a clinician enters an individual NPI in the CAQH profile, the name on the profile is compared with the name in the NPI Registry. A mismatch shows up as a required fix, and the profile cannot be attested until it is cleared.^E

The NPI Registry shows the public part of every active record, including name, specialty and practice address.^FH Plans use NPPES to check their own directories. CMS has said that name, specialty, address and phone, the fields NPPES holds, accounted for 91% of the errors it found when it reviewed Medicare Advantage plan directories.^G A stale address in NPPES tends to reappear in every directory that copies it.

The changes that should send you back to NPPES.

These are the changes we watch for in a growing practice.

1. A clinician joins or leaves

   A new hire's record often still shows a former employer's address. Fix it before any application goes out under your practice.

2. The practice moves or opens a location

   NPPES now holds more than one practice address. Name the primary location, then add the others.^G

3. A name changes

   A clinician's legal name, or the practice's legal business name. A trade name goes in NPPES as an "other name", marked as doing business as, and never in the legal name field.^D

4. A specialty is added

   Each record carries a primary taxonomy code for provider type and specialty. Add codes as the work changes, and keep the primary one true.^B

5. The signing official changes

   An organization's record names an authorized official who can change it. When that person leaves, replace them before the next update is needed.^B

How to update the record, step by step.

1. Read the public record first

   Search the NPI Registry for each clinician and for the practice. Compare every line with the license, the IRS letter that assigned your tax ID, CAQH and Medicare.

2. Sign in to NPPES

   Updates are made online at nppes.cms.hhs.gov, or on the paper form. A clinician signs in for their own record. An organization's changes run through its authorized official.^A

3. Change it and attest

   When you save a change, NPPES lets you attest that the record is accurate and stamps a certification date. That date is published in the NPI Registry, so payers can see how recently the record was confirmed.^G

4. Carry the change everywhere else

   Updating NPPES does not update Medicare. Medicare has its own reporting windows, shorter for a new practice location or an ownership change than for most other changes.^F Then update CAQH and re-attest, and tell each commercial plan and your state Medicaid program in the way each one asks.

What trips practices up.

A common one is a trade name typed into the legal name field years ago. It looked harmless until Medicare compared it with the IRS letter. The manual's fix is to put the legal name in the legal name field and move the trade name to "other name".^D

Another is the login. The authorized official who set up the practice's record has left, and nobody else can sign in. That is a short fix on a quiet week and a long one in the middle of an application. We also see group NPIs typed into the individual field in CAQH, which CAQH flags as a required fix.^E

Before we file anything, we pull the NPPES record for the practice and for each clinician and set it beside the license, the tax letter and the CAQH profile. Every difference gets fixed at the source first. It is the dullest part of enrollment, and where much of the avoidable waiting starts.

Questions practices ask about NPPES.