Understanding Your Monitoring Results

At ProviderTrust, our goal is to help healthcare organizations maintain compliance and ensure patient safety. This guide provides a comprehensive breakdown of the primary source monitoring we conduct and what each status result means for your organization.

Exclusions (OIG, SAM, and State Lists)

What it is: Federal and state agencies (such as the OIG and SAM) maintain lists of individuals or entities prohibited from participating in federally funded healthcare programs. Reasons for exclusion include fraud, patient abuse, licensing issues, or defaulting on student loans. View all Federal & State Exclusion Sources here. 

The Risk: Organizations that employ or contract with excluded parties face significant Civil Monetary Penalties (CMPs) and must return any federal payments associated with that party.

Monitoring Results:

• Match: The subject is confirmed to have at least one match against an exclusion record.

• No Match: No records were found for the subject in these sources.

• Suspected Match: A possible match was found that requires manual review to confirm identity.

• Insufficient Client Data: Missing name or required fields prevented a successful check.

For more information, check out: What is an Exclusion?

NPI Validation (NPPES)

What it is: This verifies the status of a National Provider Identifier (NPI) against the National Plan and Provider Enumeration System (NPPES).

Monitoring Results:

• NPI Active: The NPI is currently active and assigned.

• NPI Inactive: The NPI has been deactivated by NPPES.

• Not Found: The 10-digit NPI provided does not exist in the registry.

• Insufficient Data: The NPI provided is not 10 digits or contains invalid characters.

Learn more: How To Understand NPI Validation Statuses. 

OFAC (Specially Designated Nationals List)

What it is: Managed by the Department of the Treasury, this list includes individuals and groups (such as terrorists or narcotics traffickers) with whom U.S. personnel are strictly prohibited from doing business.

Monitoring Results:

• Match: Subject is confirmed on the SDN list.

• No Match: No records found.

• Suspected Match: A potential identity match that requires further investigation.

For more information, check out: What is OFAC?

CMS Preclusion List

What it is: A non-public list maintained by CMS. It includes providers and prescribers who are precluded from receiving payment for Medicare Advantage (Part C) or Part D drugs. This usually stems from a Medicare revocation or conduct detrimental to the program.

Note: Because this list is not public, clients are responsible for securely providing their copy of the list to ProviderTrust monthly via ShareFile. For a full breakdown of requirements and responsibilities, see: CMS Preclusions Screening.

Monitoring Results:

• Match: (Individuals) The NPI appears on the list. (Orgs) Either the NPI or EIN (or both) appears on a list entry.

• No Match: The identifier(s) do not appear on the Preclusion List.

• Insufficient Client Data: NPI or EIN was not provided or is incomplete.

Primary Source License Verification

What it is: License Verification is a monitoring service in which ProviderTrust verifies credential data directly with the primary source (e.g., a State Medical Board). We capture a time-stamped screenshot of the registry to ensure the provider is in good standing and notify you of any issues.

Learn More: For a complete overview of this service, see: What is License Verification?

Common License Statuses:

• Active: License is in good standing.

• Temporary / Board Pending: Subject has not yet met all requirements for a permanent license.

• Inactive / Expired / Fee Required: The license is no longer valid for practice.

• Suspended / Revoked / Surrendered: The license has been taken away or given up due to disciplinary action.

• Probation / Restricted: The provider may practice, but only under specific conditions.

• Board Actions Present: ProviderTrust will highlight any disciplinary actions or notes found on the provider’s record, even if the license is still active.

• Data Mismatch: The licensee's name on the registry does not match the name provided in the PT App.

Need help with an alert? For step-by-step instructions on managing these results, please read: How To: Review License Alerts.

Additional Verifications

SSDMF (Social Security Death Master File)

Validates an individual’s SSN against records of deceased individuals to prevent identity fraud.

• Match: SSN corresponds to a deceased individual.

• No Match: No death record found for this SSN.

For more information, check out: What is SSDMF?

Medicare Opt-Out

Identifies practitioners who have officially opted out of the Medicare program.

• Match: The subject has opted out; Medicare will not cover services provided by them.

• No Match: The subject is not on the opt-out list.

Need Help? If you encounter a "Suspected Match" or "Insufficient Data" status, please update the subject's profile with full legal names, SSNs, or NPIs so our team can complete the verification.

For more information, check out: What is Medicare Opt-Out?