Department of Health and Human Services 
OFFICE OF 
 
 
INSPECTOR GENERAL 
 
 
 
 
 
 
 
 
 
 
 
CMS E N A
  NSURED  EARLY  LL 
 
P   D D R
ART   RUG  ECORDS 
 
C V P
ON  TAINED  ALID  RESCRIBER 
 
I 2016 
DENTIFIERS IN 
 
 
 
 
 
 
 
   
 
Daniel R. Levinson  
Inspector General 
 
October 2017 
OEI-03-17-00040   
   
Report in Brief 
October 2017 
 
OEI-03-17-00040 
 
CMS Ensured Nearly All Part D Drug Records 
Why OIG Did This Review  
Contained Valid Prescriber Identifiers in 2016   
Prescriber identifiers are a valuable 
program integrity safeguard.  They enable  What OIG Found 
the Centers for Medicare & Medicaid 
Of the 1.5 billion PDE records that plan sponsors submitted to CMS for 
Services (CMS) and Part D plan sponsors to 
covered drugs in 2016, we found only 147 records that contained invalid 
determine if legitimate practitioners have 
prescriber identifiers.  These 
prescribed drugs for enrollees.  Plan 
Key Takeaways 
records represented $19,122 in 
sponsors are required to include prescriber 
  Nearly all PDE records for 
identifiers on the Part D prescription drug  Part D payments.  The 147 PDE 
Part D drug claims in 
event (PDE) records they submit to CMS.   records were associated with 
2016 contained valid 
The Medicare Access and CHIP  70 invalid prescriber identifiers, 
prescriber NPIs. 
Reauthorization Act of 2015 (MACRA)  which accounted for a small 
 
requires that, beginning in 2016, pharmacy    System edits that CMS 
percentage (0.005) of the 
claims for covered Part D drugs must  has in place are effective 
1.4 million unique prescriber 
contain valid prescriber National Provider  in ensuring the validity of 
identifiers on the PDE records in 
Identifiers (NPIs).  Additionally, the law  the vast majority of 
our review.  Specifically, 1 invalid 
requires the Secretary of the Department  Part D prescriber NPIs. 
NPI was not listed in the NPPES 
of Health and Human Services to establish 
procedures for determining the validity of  file, and the remaining 69 invalid NPIs had been deactivated more than 
these prescriber NPIs.  The law also  1 year prior to the dates of service on associated PDE records.   
requires the Office of Inspector General 
CMS has system edits in place to review PDE records to determine 
(OIG) to submit to Congress a report on 
whether prescriber identifiers are valid NPIs.  These edits reject PDE 
the effectiveness of these procedures no 
records (1) that do not contain a prescriber identifier that is an NPI in 
later than January 1, 2018.  This evaluation 
report fulfills OIGs MACRA mandate.  CMSs current NPPES file and (2) where the date of service is more than 
1 year after a prescriber NPI has been deactivated.  Regarding the one 
How OIG Did This Review 
NPI that was not listed in the NPPES file noted above, CMS stated that 
We compared the prescriber NPIs on 
this invalid identifier had bypassed its PDE system editing and that CMS 
calendar year 2016 PDE records submitted 
to CMS for covered drugs to the NPIs in  is in the process of determining if its edit logic can be modified.  For the 
CMSs National Plan and Provider  PDE records associated with the 69 deactivated prescriber NPIs noted 
Enumeration System (NPPES) file.  NPPES is  above, the dates of service occurred during a time when the date-of-
the system of record for health care  service edit was operating as an informational edit rather than a reject 
providers NPIs.  We considered prescriber 
edit.  This suggests that CMS accepted these PDE records because the 
NPIs to be invalid if (1) they did not appear 
edit flaggedrather than rejectedthese records.  This edit was 
in the NPPES file, or (2) they appeared in 
changed to a reject edit in May 2016.  Additionally, CMS has provided 
the NPPES file but had been deactivated 
plan sponsors with the procedures they should follow to ensure the 
before January 1, 2015, and remained 
validity of prescriber NPIs.   
deactivated through 2016.  We reviewed 
CMS documentation and its responses to a  What OIG Concludes  
questionnaire regarding its procedures to 
The system edits that CMS currently has in place to check PDE records 
determine the validity of Part D prescriber 
are effective in ensuring the validity of the vast majority of Part D 
NPIs.  
prescriber NPIs.   
 
 
Full report can be found at http://oig.hhs.gov/oei/reports/oei-03-17-00040.asp   
   
TABLE OF CONTENTS 
 
Objectives ....................................................................................................1 
Background ..................................................................................................1 
Methodology ................................................................................................4 
Findings........................................................................................................6 
  Nearly all PDE records for Part D drug claims in 2016 contained 
valid prescriber identifiers ...............................................................6 
  CMS has system edits to reject PDE records with invalid  
prescriber identifiers ........................................................................7 
  CMS has provided plan sponsors with the procedures they should 
follow to ensure the validity of prescriber NPIs ..............................8 
Conclusion .................................................................................................10 
Appendix .................................................................................................... 11 
A: Section 507 of MACRA............................................................ 11 
Acknowledgments......................................................................................12 
 
 
 
 
 
 
 
 
   
   
OBJECTIVES 
1.  To determine the extent to which invalid National Provider Identifiers 
(NPIs) were used as prescriber identifiers on Part D prescription drug 
event (PDE) records for calendar year 2016.   
2.  To identify how the Centers for Medicare & Medicaid Services (CMS) 
ensures the validity of prescribers NPIs on claims for covered Part D 
drugs. 
BACKGROUND  
Previous Office of Inspector General (OIG) work has emphasized that 
prescriber identifiers on PDE records submitted to CMS by Part D plan 
sponsors are a valuable program integrity safeguard.  These identifiers 
enable CMS and Part D plan sponsors to determine who prescribed 
covered drugs for Medicare enrollees.  Prescriber identifiers on PDE 
records can be used to determine if legitimate practitioners have 
prescribed drugs for enrollees, including during post-payment reviews and 
investigations.  Since OIGs prior work on prescriber identifiers was 
issued, CMS has made efforts to strengthen prescriber requirements to 
protect the integrity of the Part D program.   
This study fulfills the Medicare Access and CHIP Reauthorization Act of 
2015 (MACRA) mandate for OIG to evaluate the effectiveness of the 
procedures used to validate Part D prescriber NPIs and provide a report of 
the results of the evaluation to Congress no later than January 1, 2018.1   
Medicare Part D Program 
The Medicare Prescription Drug, Improvement, and Modernization Act of 
2003 established Part D to provide an optional prescription drug benefit 
for all Medicare beneficiaries.  Private companies, called plan sponsors,2 
administer the benefit through Part D drug plans.  Plan sponsors provide 
Part D benefits to enrollees and process claims for prescriptions submitted 
by network pharmacies at the point of sale.  Plan sponsors later submit 
PDE records based on these claims to CMS for payment calculations.  In 
2016, 43 million Medicare beneficiaries were enrolled in Medicare Part D 
 
1 P.L. 114-10 (April 16, 2015)  507.   
2 For the purpose of this report, we use the term plan sponsors to refer to stand-alone 
Medicare prescription drug plan sponsors and Medicare Advantage prescription drug plan 
sponsors.  We use the term Part D plans to refer to both of these sponsors plans. 
CMS Ensured Nearly All Part D Drug Records Contained Valid Prescriber Identifiers in 2016              1   
   
plans, and total Part D program expenditures (excluding administrative 
expenses) were $99.5 billion.3   
Part D Prescription Drug Events 
Pursuant to 1860D-15(c)(1)(C) and (d)(2) of the Social Security Act, all 
Part D plan sponsors must submit certain data and information to CMS as 
a condition of payment.  Part D plans submit an electronic record to CMS 
for each covered prescription filled by their enrollees.  This electronic 
record, the PDE record, contains drug cost and payment data fields as well 
as prescriber identifier fields that enable CMS to administer the Part D 
benefit.  Plan sponsors submitted 1.5 billion PDE records to CMS in 2016. 
Prescriber Identifier Requirements 
Part D plan sponsors are required to include prescriber identifiers on the 
PDE records they submit to CMS.4  Specifically, as of January 1, 2013, 
CMS required sponsors to submit an active and valid NPI to identify the 
prescriber on a PDE record (allowing for a group NPI in cases where the 
prescriber had not yet obtained an individual NPI).  Beginning May 6, 
2013, the Prescriber ID field on the PDE record must contain the 
individual NPI of the prescriber.5, 6 
MACRA Requirements.  Section 1860D-4(c) of the Social Security Act, as 
amended by section 507 of MACRA, requires that, beginning in plan year 
2016, i.e., calendar year, pharmacy claims for covered Part D drugs must 
contain a valid prescriber NPI.7  MACRA section 507 requires the 
Secretary of the Department of Health and Human Services to establish 
procedures for determining the validity of the prescriber NPIs included on 
Part D drug claims.  Appendix A provides the full text of section 507 of 
MACRA. 
National Provider Identifier.  The administrative simplification provisions 
of the Health Insurance Portability and Accountability Act of 1996 
mandated that the Secretary of the Department of Health and Human 
Services adopt a standard unique health identifier for health care 
 
3 2017 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and 
Federal Supplementary Medical Insurance Trust Funds.  Washington, D.C.  July 13, 
2017.  Accessed at http://www.cms.hhs.gov/reportstrustfunds/ on September 13, 2017. 
4 42 CFR  423.120(c)(5)(i).  Beginning January 1, 2016, see 42 CFR  423.120(c)(6)(i). 
5 CMS, Revised Reporting Requirements for Prescriber Identifiers and Other 
Prescription Drug Event Fields, October 1, 2012. 
6 According to CMS, a group NPI is permitted in the Prescriber ID field in limited 
circumstances to accommodate states of emergency. 
7 P.L. 114-10 (April 16, 2015)  507. 
CMS Ensured Nearly All Part D Drug Records Contained Valid Prescriber Identifiers in 2016            2   
   
providers.8, 9  Individuals and organizations apply for and acquire a unique 
10-digit NPI through CMSs National Plan and Provider Enumeration 
System (NPPES).  Since May 23, 2008, NPIs have been used in Medicare 
to identify health care providers on all covered electronic health care 
transactions.   
Related OIG Work 
In a June 2010 report, OIG found that Medicare drug plans and enrollees 
paid pharmacies $1.2 billion in 2007 for more than 18 million prescription 
drug claims that contained invalid prescriber identifiers.10  At the time of 
the study, the NPI was not required to be reported in the Prescriber ID 
field on Part D drug claims, and less than 4 percent of drug claims 
contained NPIs.  OIG recommended that CMS conduct periodic reviews 
to ensure the validity of Part D prescriber identifiers, and that CMS 
require Part D plan sponsors to identify invalid prescriber identifiers on 
Part D drug claims and flag those claims for review.  CMS concurred with 
and implemented OIGs recommendations.   
Additionally, a February 2011 OIG report found that in 2007 Schedule II 
gross drug costs for PDE records with invalid prescriber identifiers totaled 
approximately $20.6 million.11  This amount represented approximately 
228,000 PDE records for Schedule II drugs that contained invalid 
prescriber identifiers.  OIG recommended that CMS (1) require sponsors 
to include a valid DEA number on all PDE records involving Schedule II 
drugs and (2) implement an edit to reject PDE records for Schedule II 
drugs that contain an invalid prescriber identifier number.  CMS 
implemented the second but not the first recommendation.  CMS stated 
that it pursued requiring only valid prescriber NPIs on PDE records.  In 
addition, CMS stated that section 507 of MACRA reinforced this approach 
by also requiring only valid prescriber NPIs on Part D pharmacy claims. 
   
 
8 P.L. 104-191 (August 21, 1996)  262(a), amending  1173 of the Social Security Act. 
9 Beginning May 23, 2005, providers were able to start applying for an NPI.  CMS, MLN 
Matters, Number MM4320, January 1, 2006.  Accessed at 
http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM4320.pdf on June 20, 
2017. 
10 OIG, Invalid Prescriber Identifiers on Medicare Part D Drug Claims 
(OEI-03-09-00140), June 2010. 
11 The Controlled Substances Act (21 U.S.C.  812) established five drug schedules based 
on the medical use acceptance and the potential for abuse of a drug.  Schedule II drugs 
have a high potential for abuse, have an accepted medical use with severe restrictions, 
and may cause severe psychological or physical dependence if abused.  OIG, Oversight 
of the Prescriber Identifier Field in Prescription Drug Event Data for Schedule II Drugs 
(A-14-09-00302), February 2011. 
CMS Ensured Nearly All Part D Drug Records Contained Valid Prescriber Identifiers in 2016            3   
   
 
METHODOLOGY 
Data Collection and Analysis 
We focused this review on determining the extent to which invalid 
prescriber NPIs were used on Part D PDE records submitted to CMS for 
covered drugs for 2016.  We used data from three sources to conduct this 
review: (1) CMSs Part D PDE records, (2) CMSs NPPES data, and 
(3) CMSs responses to an information request. 
Prescriber Identifiers on PDE Records.  From CMSs Part D PDE data, 
we created a file of PDE records with dates of service from January 1, 
2016, to December 31, 2016.  We excluded PDE records for noncovered 
and over-the-counter drugs from our analysis.12  After these exclusions, the 
file contained 1.5 billion PDE records.  In addition, we obtained from 
CMS a copy of the NPPES file, which contains information for both active 
and deactive NPIs. 
To determine whether NPIs in the prescriber identifier field on PDE 
records were valid, we compared prescriber NPIs to the NPPES file.  We 
considered prescriber NPIs on PDE records to be valid if they were active 
in 2016, or if they were active at any point during 2015 to allow time for 
prescription refills in 2016.  We considered prescriber NPIs to be invalid if 
(1) they did not appear in the NPPES file or (2) they appeared in the 
NPPES file but had been deactivated before January 1, 2015, and 
remained deactivated through 2016. 
We calculated the number of PDE records for 2016 that contained invalid 
NPIs and calculated total Part D payments for these PDE records.  We 
summed four payment fields to calculate total Part D payments for PDE 
records with invalid prescriber identifiers: Ingredient Cost Paid, 
Dispensing Fee Paid, Total Amount Attributed to Sales Tax, and 
Vaccine Administration Fee. 
We examined the characteristics of the invalid prescriber NPIs such as an 
NPI having an inappropriate length or format.  In addition, we examined 
whether invalid prescriber NPIs were associated with certain Part D 
sponsors, drug codes, or pharmacies. 
CMSs Procedures to Ensure Validity of Prescriber Identifiers.  To 
determine the procedures that CMS has established to validate Part D 
prescriber NPIs, we developed and provided a self-administered 
questionnaire to CMS staff.  As part of the questionnaire, we requested 
 
12 The value C in the Drug Coverage Status Code field on the PDE record indicates a 
Part D-covered drug.  The value E in this field indicates an enhanced alternative drug, 
i.e., a non-Part D, noncovered drug; the value O indicates an over-the-counter drug. 
CMS Ensured Nearly All Part D Drug Records Contained Valid Prescriber Identifiers in 2016            4   
   
that CMS provide documentation of all policies and procedures it has in 
place to ensure that Part D prescriber NPIs are valid.  We reviewed CMSs 
responses and the associated documentation and summarized CMSs 
policies and procedures for determining the validity of Part D prescriber 
NPIs. 
Limitations 
We did not validate the accuracy of the NPPES data file that we used to 
verify prescriber identifiers on PDE records.   
Standards 
This study was conducted in accordance with the Quality Standards for 
Inspection and Evaluation issued by the Council of the Inspectors General 
on Integrity and Efficiency. 
CMS Ensured Nearly All Part D Drug Records Contained Valid Prescriber Identifiers in 2016            5   
   
FINDINGS 
Nearly all PDE records for Part D drug claims in 2016 
contained valid prescriber identifiers 
MACRA required that, beginning in 2016, pharmacy claims for covered 
Part D drugs contain valid prescriber NPIs.  Of the 1.5 billion PDE records 
that plans submitted to CMS for covered drugs in 2016, we found only 
147 PDE records that contained invalid prescriber identifiers.  These 
147 PDE records with invalid prescriber identifiers represented $19,122 in 
Part D payments.  Individually, the PDE payments ranged from a 
minimum of $1.48 for a 4 days supply of Prednisone tablets to a 
maximum of $7,947.88 for a 90 days supply of Fosrenol. 
These 147 PDE records were associated with 70 invalid prescriber 
identifiers, which accounted for a small percentage (0.005) of the 
1.4 million unique prescriber identifiers on the PDE records in our review.  
The number of PDE records associated with each of these invalid 
prescriber identifiers ranged from 1 to 17 records. 
One invalid prescriber NPI was not listed in the NPPES 
database 
One of the 70 invalid prescriber identifiers on 2016 PDE records did not 
match to any NPI contained in the NPPES database.  This invalid 
identifier appeared in the expected length and format of an NPI,13 but it 
contained an incremental sequence of numbers in the first nine positions 
of the identifier.  This invalid NPI was used on three PDE records to 
identify the prescriber as well as the pharmacy that filled the enrollee 
prescription.   
In response to our inquiry about this invalid identifier, CMS reported that 
the invalid identifier had bypassed CMSs PDE system editing.  Prescriber 
identifier editing was bypassed because the same identifier was used in the 
prescriber identifier and service provider identifier fields on the PDE 
records.  An exception to prescriber identifier editing exists to 
accommodate states of emergency in which a pharmacy may serve as both 
prescriber and service provider on a PDE record.  At this point, the PDE 
records would have undergone further editing to check the validity of the 
service provider identifier.  In this case, however, the service provider 
editing was bypassed because the PDE records were for vaccines, which 
are typically administered by an individual practitioner rather than 
dispensed as a prescription by a pharmacy.  CMS stated that it is in the 
process of determining if its edit logic can be modified.  If not, CMS 
 
13 NPIs are 10-digit numbers beginning with a 1, 2, 3 or 4. 
CMS Ensured Nearly All Part D Drug Records Contained Valid Prescriber Identifiers in 2016            6   
   
stated that it will perform data analysis and exclude PDEs with invalid 
NPIs during the Part D payment reconciliation process.  
Sixty-nine invalid prescriber NPIs were deactivated more than 
1 year prior to dates of service on PDE records 
Sixty-nine of the seventy invalid NPIs had been deactivated in NPPES 
prior to January 1, 2015.  These NPIs were used as prescriber identifiers 
on 144 PDE records from 2016, but they had been deactivated between 
March 2009 and December 2014.  For the purpose of this review, we 
considered prescriber NPIs to be valid if they were active in 2016 or if 
they were active at any point during 2015, to allow for prescription refills 
in 2016.   
On average, the 69 NPIs had been deactivated 3 years prior to the dates of 
service on the PDE records.  Assigned NPIs may be deactivated when, for 
example, a health care provider dies or when a provider goes out of 
business.  The earliest deactivation date among these NPIs was 
March 3, 20097 years prior to the May 4, 2016, date of service on the 
PDE record that contained this invalid prescriber NPI.   
Three plan sponsors accounted for half of the PDE records 
that contained invalid prescriber NPIs 
Forty Part D plan sponsors each submitted at least one PDE record for 
2016 that contained an invalid prescriber NPI.  Of these plan sponsors, 
3 submitted half (74 of 147) of the PDE records that contained invalid 
prescriber identifiers.  One plan sponsor submitted 46 PDE records that 
were associated with 16 different invalid prescriber NPIs. 
Additionally, while some prescription drug codes and pharmacies 
appeared in the PDE data more frequently than others, no individual drug 
code or pharmacy represented a considerable portion of the PDE records 
that contained invalid prescriber NPIs. 
CMS has system edits to reject PDE records with 
invalid prescriber identifiers 
CMS has system edits in place to review Part D prescriber information on 
PDE records submitted by Part D plan sponsors.  Two edits are used 
specifically to determine whether prescriber identifiers on PDE records are 
valid NPIs.  Edit 833 is a reject edit used to determine whether the 
prescriber identifier on a PDE record is an individual NPI in CMSs 
CMS Ensured Nearly All Part D Drug Records Contained Valid Prescriber Identifiers in 2016            7   
   
current NPPES file.14  Our analysis of 2016 PDE records for covered drugs 
identified one invalid prescriber identifier that did not match to any NPI 
contained in CMSs NPPES file.  As noted above, in response to our 
inquiry about this invalid identifier, CMS reported that this identifier had 
bypassed CMS system editing and that it is in the process of determining 
if its edit logic can be modified. 
CMSs Edit 834 rejects PDE records in which the date of service is more 
than 1 year after the prescriber NPI has been deactivated.15  CMS allows 
the date of service on a PDE record to be within 1 year of the NPI 
deactivation date to accommodate State prescribing laws that permit refills 
up to 1 year after a prescriber has died.  However, from February 9, 2014, 
through May 7, 2016, CMS had modified Edit 834 to function as an 
informational edit rather than a reject edit, due to State laws that allow for 
prescriptions beyond the 1-year time period.  As noted above, we found 
69 prescriber NPIs on the PDE records reviewed that had been deactivated 
in NPPES prior to January 1, 2015.  The dates of service on the 144 PDE 
records associated with these 69 prescriber NPIs were between January 4, 
2016, and May 7, 2016.  This suggests that CMS accepted these PDE 
records because Edit 834 was operating as an informational edit during 
this time.   
CMS has provided plan sponsors with the procedures 
they should follow to ensure the validity of prescriber 
NPIs 
CMS issued a memorandum16 on June 1, 2015, to all plan sponsors in 
which it described its existing Part D claims procedures with respect to 
prescriber NPIs and the changes to prescriber NPI requirements under 
section 507 of MACRA.    
In the memorandum, CMS outlined the current Part D claims procedures 
of the National Council for Prescription Drug Programs.  These 
procedures support the following actions regarding prescriber NPIs: 
  A Part D sponsor communicates at point of sale to the pharmacy 
whether or not a submitted prescriber NPI is active and valid.  
 
14 If Edit 833 triggers, the PDE record is rejected, and the message reported to the plan 
sponsor is, The submitted Prescriber ID is not found on the CMS NPPES NPI table.  
CMS, Updates to Prescriber ID Editing on the Prescription Drug Event (PDE) Record, 
April 7, 2016. 
15 If Edit 834 triggers, the PDE record is rejected, and the message reported to the plan 
sponsor is, The submitted Prescriber ID is not active on the CMS NPPES NPI table for 
the given DOS [Date of Service].  CMS, Updates to Prescriber ID Editing on the 
Prescription Drug Event (PDE) Record, April 7, 2016. 
16 CMS, Medicare Part D Prescriber Enrollment Requirement Update, June 1, 2015. 
CMS Ensured Nearly All Part D Drug Records Contained Valid Prescriber Identifiers in 2016            8   
   
 
  A sponsor pays a claim if the sponsor determines that the 
prescriber NPI is active and valid.  
 
  If the sponsor communicates that the prescriber NPI is not active 
and valid, but the pharmacy corrects the NPI or confirms that the 
NPI is active and valid because the pharmacy has so determined 
through more up-to-date information, the sponsor pays the claim.   
In the memorandum, CMS stated that, in addition to these existing 
procedures, it interpreted section 507 of MACRA to mean that beginning 
January 1, 2016, a Part D sponsor cannot pay a claim that the sponsor 
determines does not have an active and valid prescriber NPI unless the 
pharmacy corrects the NPI or confirms that it is active and valid. 
Also, CMS has issued additional memoranda to Part D plan sponsors 
describing the system edits that CMS has in place to ensure the validity of 
prescriber NPIs on PDE records.  
 
   
CMS Ensured Nearly All Part D Drug Records Contained Valid Prescriber Identifiers in 2016            9   
   
CONCLUSION 
Section 507 of MACRA requires that, beginning in 2016, pharmacy claims 
for covered Part D drugs must contain valid prescriber NPIs.  In addition, 
the law requires the Secretary of the Department of Health and Human 
Services to establish procedures for determining the validity of Part D 
prescriber NPIs.  The law also requires OIG to submit to Congress a report 
on the effectiveness of these procedures no later than January 1, 2018.  
This evaluation report fulfills OIGs MACRA mandate. 
Based on an analysis of Medicare Part D PDE records for covered drugs 
submitted to CMS for 2016, we found that nearly all PDE records contained 
valid prescriber NPIs.  Of the 70 invalid prescriber identifiers, 1 NPI was not 
listed in the NPPES database, and the remaining 69 had been deactivated 
more than 1 year prior to dates of service on PDE records.  However, CMS 
currently has an edit in place to reject PDE records with dates of service of 
more than 1 year after a prescriber NPI has been deactivated.  For the PDE 
records associated with the 69 deactivated prescriber NPIs noted above, the 
dates of service occurred during a time when the edit was operating as an 
informational edit rather than a reject edit. 
We conclude that the system edits that CMS currently has in place are 
effective in ensuring the validity of the vast majority of Part D prescriber 
NPIs on PDE records.  To address cases similar to the invalid prescriber 
identifier we found that was not in NPPES, CMS reported that it will 
consider revising its edit logic or, if that is not possible, ensure that PDEs 
with invalid NPIs are excluded during the Part D payment reconciliation 
process. 
   
CMS Ensured Nearly All Part D Drug Records Contained Valid Prescriber Identifiers in 2016            10   
   
APPENDIX A: SECTION 507 OF MACRA 
Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), 
Public Law 114-10 
SEC. 507. REQUIRING VALID PRESCRIBER NATIONAL    
PROVIDER IDENTIFIERS ON PHARMACY CLAIMS. 
Section 1860D-4(c) of the Social Security Act (42 U.S.C. 1395w-
104(c)) is amended by adding at the end the following new paragraph: 
            (4) REQUIRING VALID PRESCRIBER NATIONAL PROVIDER IDENTIFIERS 
        ON PHARMACY CLAIMS. 
                    (A) IN GENERAL. For plan year 2016 and subsequent  
                plan years, the Secretary shall require a claim for a covered   
                part D drug for a part D eligible individual enrolled in a  
                prescription drug plan under this part or an MA-PD plan under 
                part C to include a prescriber National Provider Identifier 
                that is determined to be valid under the procedures established 
                under subparagraph (B)(i). 
                    (B) PROCEDURES. 
(i) VALIDITY OF PRESCRIBER NATIONAL PROVIDER 
IDENTIFIERS.The Secretary, in consultation with 
appropriate stakeholders, shall establish procedures for 
determining the validity of prescriber National Provider 
Identifiers under subparagraph (A). 
(ii) INFORMING BENEFICIARIES OF REASON FOR DENIAL. 
The Secretary shall establish procedures to ensure that, in 
the case that a claim for a covered part D drug of an 
individual described in subparagraph (A) is denied because 
the claim does not meet the requirements of this paragraph, 
the individual is properly informed at the point of service of 
the reason for the denial. 
                    (C) REPORT.Not later than January 1, 2018, the  
                Inspector General of the Department of Health and Human  
                Services shall submit to Congress a report on the effectiveness  
                of the procedures established under subparagraph (B)(i). 
   
CMS Ensured Nearly All Part D Drug Records Contained Valid Prescriber Identifiers in 2016            11   
   
ACKNOWLEDGMENTS 
Amy Sernyak served as the team leader for this study.  Others in the Office 
of Evaluation and Inspections who conducted the study include Karolina 
Pater.  Office of Evaluation and Inspections staff who provided support 
include Berivan Demir Neubert, Meghan Kearns, and Joe Chiarenzelli. 
This report was prepared under the direction of Linda Ragone, Regional 
Inspector General for Evaluation and Inspections in the Philadelphia 
regional office, and Tara Bernabe, Deputy Regional Inspector General. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
To obtain additional information concerning this report or to obtain copies, 
contact the Office of Public Affairs at Public.Affairs@oig.hhs.gov. 
 
 
CMS Ensured Nearly All Part D Drug Records Contained Valid Prescriber Identifiers in 2016            12   
Office of Inspector General
http://oig.hhs.gov  
 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95452, as  
amended, is  to protect the integrity of the Department of  Health and Human Services  
(HHS) programs, as  well  as the health  and welfare of individuals served by those programs.  
This statutory mission is carried  out through a nationwide network of audits, investigations,  
and inspections conducted by the following operating components: 
Office of Audit Services 
The Office  of  Audit Services  (OAS) provides auditing services  for HHS, either by  conducting  
audits  with its own audit resources or by  overseeing  audit work done by others.  Audits  
examine the performance of HHS programs and/or its grantees and contractors in carrying  
out their respective responsibilities and are intended  to provide independent assessments of 
HHS programs and operations.  These assessments help reduce waste, abuse, and  
mismanagement and promote economy and efficiency  throughout  HHS. 
Office of Evaluation and Inspections 
The Office  of  Evaluation and Inspections (OEI)  conducts national evaluations to  provide 
HHS, Congress, and the public with timely, useful, and reliable information on significant 
issues.  These evaluations focus on preventing fraud,  waste, or abuse  and promoting  
economy, efficiency, and effectiveness of departmental programs.  To promote impact, OEI 
reports also present practical recommendations for improving program operations.  
Office of Investigations 
The Office of Investigations (OI) conducts criminal, civil, and administrative investigations  
of fraud and misconduct  related to HHS programs, operations, and individuals.  With  
investigators working in all 50 States and the District of Columbia, OI  utilizes its resources 
by actively  coordinating with the Department  of Justice  and other Federal, State, and local 
law enforcement authorities.  The investigative efforts of OI often lead to  criminal 
convictions, administrative sanctions,  and/or  civil monetary  penalties.  
Office of Counsel to the Inspector General 
The Office of Counsel to the  Inspector  General (OCIG) provides general legal services to 
OIG, rendering  advice and opinions on HHS programs and operations and  providing all  
legal support for OIGs  internal operations.  OCIG represents  OIG in all civil and 
administrative fraud and  abuse cases involving HHS programs, including False Claims Act, 
program exclusion, and civil monetary penalty cases.  In  connection with these cases, OCIG 
also negotiates and monitors corporate integrity agreements.  OCIG renders advisory 
opinions, issues compliance program  guidance, publishes fraud alerts, and provides other  
guidance  to  the health care industry concerning the anti-kickback statute and other  OIG  
enforcement authorities.