CAQH, NPPES, PECOS
Updated: Apr 23, 2022
You may be asking, "why is she talking about CAQH, NPPES and PECOS?" Well, simple answer. Because I keep seeing providers get denied for credentialing and these are some of the reasons.
As we already know, medical credentialing is defined as 'the formal process that utilizes an established series of guideline to ensure that patients receive the highest level of care from healthcare professionals who have undergone the most stringent scrutiny regarding their ability to practice medicine." This is according to the National Center for Biotechnology Information, (https://www.ncbi.nlm.nih.gov/books/NBK519504/).
CAQH: Council for Affordable Quality Healthcare Inc.
CAQH is a non-profit alliance of health plans and related associations working together to streamline the business of healthcare (www.caqh.org)
Think of CAQH as your bank. This is the place where you can enter and save all of your important information and documents that others businesses can have access to. Per CAQH, "For more than 20 years, CAQH has delivered technology-enabled solutions, operating rules and research to help health plans, providers, government entities and vendors connect, exchange information and operate more efficiently."
The majority of major heath insurance companies, will request a CAQH number and will request for your (the provider) to add them to your CAQH list so they are able to access your professional information. This does save time, minimizes errors whole completing your credentialing process and it store all of your information in one safe, HIPAA compliant area.
How much will registering with CAQH cost me?
CAQH is FREE. Yes, FREE (this is also my favorite word, besides discount). There is absolutely no cost to healthcare providers to use CAQH. Healthcare organizations and plans pay an administrative fee to access any provider data.
There are 5 steps to complete the data collection process for CAQH
Here's the link for the CAQH Quick Reference Guide https://proview.caqh.org/content/Resources/upd_quick_reference_guide.pdf
Register with CAQH Proview (https://proview.caqh.org/Login) . Click on Register Now.
Complete the online application and review the data. You're required to enter your name, provider type, primary practice location address, date of birth, email address, and at least one personal identification number (SSN, UPIN, Medicare, Medicaid and NPI National Provider Identifier).
Authorize access to the information
Verify the data and / or attest to it
Upload and submit supporting documents. Make sure your documents are current and active. CV, Medical License, DEA Certificate (if applicable), CDS Certificate (if applicable), IRS Form W-9, Malpractice Insurance are also required.
NPPES: The National Plan and Provider Enumeration System
NPPES assigns the coveted NPI numbers (https://nppes.cms.hhs.gov/IAWeb/login.do)
What is an NPI? Seriously, you don't know?! Just kidding. Many people truly don't know and I'm here to explain. An NPI (Nation Provider Identifier) is a unique number for covered healthcare providers. Per CMS (www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/NationalProvIdentStand) "Covered health care providers and all health plans and health care clearinghouses must use the NPIs in the administrative and financial transactions adopted under HIPAA. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number). This means that the numbers do not carry other information about healthcare providers, such as the state in which they live or their medical specialty. The NPI must be used in lieu of legacy provider identifiers in the HIPAA standards transactions."
How to apply (https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/NationalProvIdentStand/apply):
Health care providers can apply for NPIs in one of three ways:
For the most efficient application processing and the fastest receipt of NPIs, use the web-based application process. Simply log onto the National Plan and Provider Enumeration System (NPPES) and apply on line (see ‘Apply Now’ link under the Related Links section below).
Health care providers can agree to have an Electronic File Interchange (EFI) organization (EFIO) submit application data on their behalf (i.e., through a bulk enumeration process) if an EFIO requests their permission to do so (See ‘EFI’ link on left hand column for more information regarding this process).
Health care providers may wish to obtain a copy of the paper NPI Application/Update Form (CMS-10114) and mail the completed, signed application to the NPI Enumerator located in Fargo, ND, whereby staff at the NPI Enumerator will enter the application data into NPPES. This form is now available for download from the CMS website (see link to the form under Downloads below). Health care providers who require assistance with this form from the NPI Enumerator may contact the enumerator in any of these ways:
Phone: 1-800-465-3203 or TTY 1-800-692-2326
Mail: NPI Enumerator 7125 Ambassador Road Suite 100 Windsor Mill, MD 21244-2751
Not only does NPPES assign the NPI numbers, they also maintain updated information about healthcare providers with NPI numbers. Providers are able to attest to the accuracy of their NPI data, as well as update any pertinent information. Here's a link for NPPES FAQs: https://www.cms.gov/files/document/nppes-frequently-asked-questions.pdf
If you're needing to verify an NPI number or need to locate an NPI number, go to: https://npiregistry.cms.hhs.gov
There are two different forms of NPI numbers, please make note of this.
NPI 1: This is the number given to individual providers: including physicians, psychiatrists and all sole proprietors.
NPI 2: This is the number given group practices / organizations from large to small: including physician groups, hospitals, nursing homes and corporation formed when an individual provider incorporates themselves into a group practice (a sole LLC).
PECOS: Provider, Enrollment, Chain, and Ownership System
aka the holy grail to Medicare
Don't think too hard asking "What is PECOS"? PECOS is the online Medicare enrollment management system. You're able to apply and enroll as a Medicare provider or supplier.
I will honestly tell you, this can be a pain in the neck if you don't have all of your requested documents correct and up to date. Literally, everything needs to match 100%!
What do I need to enroll? You sure about this, lol..just kidding. Here's a link for PECOS FAQs https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/downloads/OrganizationGettingStarted.pdf
PECOS Pre-Enrollment Checklist (also I provide these checklists to all of my providers ahead of time):
PECOS Identification and Authentication (I&A) user ID and password (this is the NPPES I just spoke about)
Personal Identifying Information:
*Type of Provider/Supplier (Part A and DMEPOS applicants only)
*Legal Business Name on file with the Internal Revenue Service(IRS)
*Tax Identification Number or Employer Identification Number
*Business Structure, Incorporation Date and State Where Incorporated (if applicable)
State Business License Information:
*State license number
*Original effective date
*State where issued
*Original effective date
*State where issued
Recognition Status (Medicare Diabetes Prevention Program (MDPP) supplier applicants only)
*Recognition Status Effective Date
*Recognition Status Expiration/Renewal Date
*Date of Accreditation
*Name of Accrediting Body
*Type of Accreditation or Accreditation Program
If applicable, information regarding any final adverse actions.
Practice location information:
*Organization's medical practice location
*Base of Operations location (Part A applicants only)
*Special Payment Information
*Medical Record Storage Information
*Rendering Services in Patient's Homes (Part B applicants only)
*Mobile or Portable Providers Only - Location of Business Office or Dispatcher/Scheduler (Part A applicants only)
*Vehicle Information (Part A applicants only, if applicable)
*Geographic Location for mobile or portable providers where the base of operations and/or vehicle renders services (Part A applicants only, if applicable)
*Medicare Diabetes Prevention Program (MDPP) Location information, including any Community Settings
Ownership Interest and/or Managing Control Information for Organizations
Ownership Interest and/or Managing Control Information for Individuals
Medicare Diabetes Prevention Program (MDPP) Coach Information (MDPP supplier applicants only)
Billing Agency Information (if applicable)
Any Federal, State, and/or local (city/county) business licenses, certifications and/or registrations specifically required to operate as a health care facility.
Electronic Funds Transfer documentation - mechanism by which providers and suppliers receive Medicare Part A and Part B payments directly into a designated bank account
*If providing EFT, make sure you have a voided check or a signed letter from your bank showing routing and account number
*If you have an LLC, make sure your voided check lists your LLC first (primary), do not use a PO Box
*Make sure you check matches what your IRS form lists
Per CMS: "Please Note: Before any enrollment action can be taken by an individual using Internet-based PECOS on behalf of a provider or supplier organization, a number of processes must be completed. These processes will register and authenticate the Authorized Official (AO) of the provider or supplier organization and the individual(s) who will be using Internet-based PECOS on behalf of the provider or supplier organization. In addition, these processes will establish the relationship between the provider or supplier organization and the organization whose employee(s) will use Internet-based PECOS on behalf of the provider or supplier organization. These processes begin with the AO of the provider or supplier organization, and they may take several weeks to be completed. For complete instructions, please visit:
Below are a few websites that I would recommend if you have further unanswered questions:
Until We Meet Again....