Credentialing & provider-data enrichment
Enrich a roster with identity, enrollment, taxonomy, and exclusion status from one API.
Open →The short answer
What data goes into provider credentialing?
Credentialing confirms that a provider is who they say they are and is eligible to practice and bill: identity and specialty from NPPES, Medicare eligibility from PECOS, and a clean exclusion screen. The hard part is that each fact lives in a different federal file with a different refresh cadence.
Fonteum returns supported fields with the available source and observation metadata. Historical reconstruction is possible only when the named source has a retained version after tracking began; provider-wide replay is not universal.
Build the file
The use-case pages and tools that assemble a credentialing or enrollment record from federal data.
Payer credentialing
The health-plan path: credential and re-credential against dated federal records.
Open →Look up an NPI
Pull a provider's source-traced identity and taxonomy by name or number.
Open →Look up a MIPS score
Read a clinician's CMS quality score as a credentialing signal.
Open →The underlying datasets
CMS PECOS Medicare enrollment
Who is approved to bill Medicare and in what role, keyed to the NPI and dated to source.
Open →The NPPES provider registry
Assigned NPIs and available submitted taxonomy and address fields for enumerated Type 1 and Type 2 records; not a licensure or credentialing decision.
Open →OIG LEIE — exclusion status
The exclusion check that belongs in every credentialing file.
Open →Run the exclusion screen
Screen a provider against the OIG LEIE, SAM.gov, and state Medicaid lists in one pass.
Open →Research on enrollment & licensure
Studies on the moving parts of a credentialing file — enrollment, revalidation, and license status.
Who can bill Medicare, by specialty
What PECOS enrollment shows about the active billing population.
Open →The Medicare revalidation backlog
Where enrollment revalidation is overdue and what it signals.
Open →State licensing coverage
Coverage and limitations for public state licensing records in Fonteum's data catalog.
Open →The Medicare deactivation spike
A dated look at NPI deactivations relevant to re-credentialing.
Open →Key terms
Provider enrollment, defined
Getting a provider approved to bill a federal program.
Open →PECOS, defined
Medicare's provider enrollment system.
Open →Provider taxonomy codes
The NUCC code set behind a provider's stated specialty.
Open →PTAN, defined
The Provider Transaction Access Number tied to Medicare enrollment.
Open →MIPS, defined
The Merit-based Incentive Payment System quality score.
Open →Pull it from the platform
The capability layer
REST, MCP, FHIR R4, and snapshots over the provider graph.
Open →The provider API
Resolve a provider and return enrollment, taxonomy, and exclusion status in one call.
Open →How source metadata is exposed
The nullable provenance schema used where credentialing fields carry source metadata.
Open →Common questions
Answers in one line each
- What data does provider credentialing rely on?
- At minimum: identity and specialty from NPPES, Medicare eligibility from PECOS, license status, and a clean exclusion screen against the OIG LEIE and SAM.gov. Each lives in a separate federal file, so the work is resolving them to one provider and keeping each dated to its source.
- Does Fonteum replace primary-source confirmation?
- No. Fonteum returns federal records traced to the exact source file and snapshot date, so a credentialing team can confirm a fact against its primary source rather than a stale copy. It is the dated, source-chained record beneath the file — not a substitute for the credentialing decision itself.
- Why does exclusion screening belong in credentialing?
- Credentialing confirms eligibility to practice and bill, and an excluded provider is barred from both. Screening against the OIG LEIE, SAM.gov, and state Medicaid lists at credentialing and re-credentialing — and monthly in between — keeps an excluded party from slipping into the network. See the exclusion-screening guide for the full workflow.
- How current is the enrollment data?
- Each source has its own published cadence, while production responses show the available observation date. Provider-wide historical replay is not universal; a re-credentialing review can use a past version only when that source and subject have a retained captured row.
Go deeper
The other pillar guides
START HERE
Build a credentialing file you can re-derive.
Request access to query supported identity, enrollment, taxonomy, and exclusion records with the source and observation metadata available for each response.