NPI Number Instant Lookup

NPI and Exclusion List Frequently Asked Questions

What is the National Plan and Provider Enumeration System (NPPES)?
NPPES is a database administered by the Centers for Medicare and Medicaid Services (CMS) to improve the efficiency and effectiveness of the electronic transmission of health information by standardizing the format of unique identification for healthcare providers and health plans.

According to the Centers for Medicare and Medicaid Services (CMS), there are two types of healthcare providers in terms of NPI – Type 1 and Type 2.

Type 1 NPI Providers: Healthcare providers who are individuals, including physicians, dentists, and all sole proprietors. An individual is eligible for only one NPI.

Type 2 NPI Providers: Healthcare providers which are organizations, including physician groups, hospitals, nursing homes, and the corporation formed when an individual incorporates him/herself.

Learn how to apply for an NPI number.

There are two federal exclusion databases: 1) the Office of the Inspector General’s (OIG) List of Excluded Individuals and Entities (LEIE) and 2) the General Services Administration System for Award Management’s (GSA exclusion list. Additionally, there are 44 state Medicaid/Medicare exclusion lists.

An excluded individual or entity is ineligible to receive any money (directly or indirectly) from federal healthcare programs like Medicare or Medicaid. Parties can be excluded for several reasons ranging from financial fraud to patient abuse.

Learn about the differences amongst exclusion lists and how and how they maintain their databases.

Physicians and practitioners who do not wish to enroll in the Medicare program may “opt-out” of Medicare. This means that neither the physician/practitioner nor the beneficiary submits the bill to Medicare for services rendered. Instead, the beneficiary pays the physician/practitioner out-of-pocket and neither party is reimbursed by Medicare. Learn more about the Medicare Opt Out List.

The CMS Preclusion List shows the providers and prescribers who are precluded from receiving payment for Medicare Advantage (MA) items and services or Part D drugs furnished or prescribed to Medicare beneficiaries.

Learn more about the CMS Preclusion List.

Related Resources

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