Ad Hoc Profile Requests

Due to the various data sources and mapping in healthcare, ProviderTrust is providing a method to check a billing provider’s status with limited information (an NPI). DynamicNPI™ is the solution to accelerate these checks and ensure that all providers they interact with are eligible to provide care and receive payment.

The Client will provide

NPI

ProviderTrust will return

1. NPI Validation
2. Federal Exclusions
3. State Sanctions
4. CMS Preclusion List
5. Medicare Opt Out

Primary Source Verification results

1. Primary Source State License screenshot at Credentialing
2. Ongoing State License Expiration Date
3. Ongoing State License Board Actions
4. DEA (State Controlled Substance as applicable)
5. Board Certification
   1. American Board of Medical Specialties (ABMS - MD, DO)*

What is ProviderTrust’s current SLA(s)?

ProviderTrust will perform monthly checks for monitoring and primary source verification services. The limitations and considerations are below.

Limitations/Considerations

1. Provider Types
   1. ProviderTrust can only guarantee the following results for NPI Validation, Federal Exclusions, State Sanctions, CMS Preclusion List, and Medicare Opt-Out for these provider types as grouped by the National Uniform Claim Committee (NUCC):
      1. "Student, Health Care", Agencies, Ambulatory Health Care Facilities, Group, Hospitals, Residential Treatment Facilities, Nursing Service Related Providers, Technologists, Technicians & Other Technical Service Providers, Hospital Units, Laboratories, Suppliers, Managed Care Organizations, Nursing & Custodial Care Facilities, Transportation Services, Respite Care Facility.
   2. The client will initiate a query or provide an NPI at least 7 business days before the event deadline, which will be determined at implementation.
   3. Assuming the Client provides an accurate NPI and Primary Source data is available, ProviderTrust will take, on average, up to 7 days to return verified data. ProviderTrust will not require longer than 7 days most of the time, but it reserves the right to take longer than 7 days to return verified data.
   4. If NPPES makes an NPI available for the first time within ninety (90) days of the query, ProviderTrust will take all reasonable actions to acquire the required credential data but is limited to Primary Source availability.
2. Verifications
   1. For verifications requiring payment, the client must manually initiate primary source verifications required within 180 days of credentialing (or NCQA's updated standards), such as with the American Osteopathic Association.
3. Data Return
   1. Provider Profile by NPI
      1. If ProviderTrust does not find a profile for a 10-digit number (such as an NPI), the client will not be charged for the search. However, they will incur charges if the client consistently performs a search with incorrect formatting. Please refer to the provider type limitation/consideration clause for recent medical school graduates.
   2. State License 
      1. An NPI is the minimum data for ProviderTrust to perform monthly Board Action and License Expiration Tracking services. To ensure ProviderTrust is returning/tracking against all anticipated board actions and license expiration dates, the Client will share with ProviderTrust provider network data, including but not limited to license number, license issuer, and license type.
      2. If ProviderTrust does not return an expected verified license result, the client can send the credential information to ProviderTrust for verification and inclusion in the verified ProviderTrust profile response.
      3. The client acknowledges that certain Boards charge an access fee to verify a license or certification. In the event of such an access fee, ProviderTrust will pass this fee through as a direct cost to the Client. The client shall reimburse ProviderTrust for all public record access fees incurred by ProviderTrust as a pass-through fee in performing services on behalf of the Client. Such expenses shall be itemized by invoice to the Client.
   3. DEA
      1. ProviderTrust is authorized to access this source regularly. Delays in verifying the credentials require the DEA to update its data.
   4. Board Certification
      1. ProviderTrust can return the American Board of Medical Specialties certificate to the client.