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ProviderCheck® utilizes a provider’s NPI number to return a Yes/No response for five key data points: Exclusions/Debarments, Medicare Enrollment (PECOS), Active Licensure, Active DEA Registration and Schedules, and NPI Data (NPI type, multiple NPI numbers used, and primary NPI number) for a specified date of service.
Prescription inquiries can be sent individually during the transaction with real-time results to protect your customers as well as eliminate loss on non-reimbursable prescriptions. ProviderCheck® can also integrate with your claims system to ensure that only valid claims are sent to government payers.
ProviderCheck® integrates with practice management software via an application interface (API) and can also be deployed as a web service for other practice applications or delivered as a system-importable data file.
The Verisys ProviderCheck® technology ensures a provider’s credentials meet all standards for prescribing by checking their NPI number and state against several primary data sources before transactions are approved.
ProviderCheck® results are split into the following categories: NPI Data, DEA, Exclusion, Medicare and State License.
NPI is a standard that meets the Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification. It is a unique, ten-digit number that is required to fill prescriptions and file healthcare claims. Through the ProviderCheck® API, you can verify if a provider’s credentials and NPI number is Active or Inactive and is the correct type (personal or business) to be used in a prescription or referral. ProviderCheck® can also return parts of the NPI board that have public relevance, including the provider’s name, specialty (taxonomy), and practicing addresses.
A DEA number is registered with the Drug Enforcement Administration (DEA). This number affirms whether the provider registered with the DEA as a prescriber, distributor, or wholesaler of controlled substances. DEA numbers are sometimes printed on prescription pads to indicate that a health care provider can write prescriptions for controlled substances. The DEA maintains a database of persons (including retired registrants) and organizations, certified and registered, who can handle controlled substances under the Controlled Substances Act.
This affirms whether the provider has an exclusion. State or federal health care programs will not pay for any items or services (ordered or prescribed) by an excluded provider or entity. Exclusions apply to all administrators and management services furnished by the excluded provider regardless of who submits the claim. Entities submitting insurance claims for excluded providers are subject to government fines and must reimburse the payer for the claim.
Medicare data shows whether the provider has any exclusions, sanctions, and/or revocations pertaining to federal health care plans, such as Medicare and Medicaid. It also includes all other programs that were funded, directly or indirectly, by the U.S. Government, with the exception of the Federal Employee Health Care Plans. The Medicare data will also show if a physician has chosen to opt-out of the Medicare or Medicaid program and will display this information separately.
A License Verification search uses data provided by state medical credentialing boards. ProviderCheck® verifies the provider’s taxonomy, requirements, and authorizations. Authorizations vary for different states. For example, a Physician’s Assistant (PA) in Texas cannot issue a prescription without authorization from a registered physician, but in Utah, the PA does not need a physician’s approval.
Verisys keeps your organization safe, secure, and compliant while meeting government standards and regulations. Dispense and file claims with real-time access to data, allowing your organization to operate with full transparency.