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.
Who is required to have a National Provider Identifier (NPI)?
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 who are organizations, including physician groups, hospitals, nursing homes, and the corporation formed when an individual incorporates him/herself.
What are Federal Exclusions?
A Federal Exclusion is an administrative action taken against an individual or entity (such as a provider or vendor) by the Dept. of Health and Human Services (HHS), Office of Inspector General (OIG). The HHS OIG is in charge of enforcing exclusions against individuals or entities.
What are State Medicaid Exclusions?
Individual states maintain a Medicaid Exclusion or Terminated list as well as federal. Employers need to search these in addition to the OIG LEIE and the SAM.gov. Today, there are 42 states that have a state Medicaid exclusion list.
What is the Medicare Opt-Out List?
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.
What is the CMS Preclusion List?
A list of 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.