What provider data does Fonteum give health plans for directory accuracy?

Fonteum makes the same federal files CMS uses to define provider-directory accuracy standards directly accessible, drawn from a graph of 44 federal source families. CMS NPPES supplies NPI, taxonomy code, practice address, and entity type for 6.8M+ active providers, distributed as a weekly full-replacement file. CMS PECOS supplies the Medicare enrollment indicator and provider type. Every field carries its source name, last-checked date, and documented limitation through the provider_field_provenance layer, so a plan can show each directory entry traces to the CMS dataset rather than to a commercially assembled product. The CMS Interoperability and Patient Access Final Rule (CMS-9115-F) requires Medicare Advantage, Medicaid, CHIP, and Qualified Health Plan issuers to publish accurate, machine-readable provider directory data kept current against these primary sources — Fonteum is the upstream layer for that obligation. Fonteum is a source-provenanced data layer, not itself a certified provider directory or network-adequacy engine; it supplies the auditable federal inputs those systems consume.

How does Fonteum support the No Surprises Act 90-day directory requirement?

The No Surprises Act, enacted as part of the Consolidated Appropriations Act, 2021, requires health plans to re-check provider-directory information at least once every 90 days and to remove or flag entries that cannot be confirmed. Because Fonteum ingests CMS NPPES as a weekly full-replacement file and timestamps every field, a plan can reconcile its directory against the current federal record on whatever cadence its compliance calendar sets — well inside a 90-day window — and document the exact source file and date each reconciliation ran against. That timestamped chain is the evidence a plan needs to demonstrate it met the accuracy obligation, rather than asserting currency without a traceable source. The same approach maps to the REAL Act (Requiring Enhanced & Accurate Lists of Health Providers) directory-accuracy framework, which centers on reconciling plan directories to authoritative provider records.

What is cross-source NPI agreement scoring?

A single provider appears across several federal files — NPPES, PECOS, Care Compare, and others — and those files do not always agree on practice address, specialty, or active status. Cross-source NPI agreement is the degree to which the records keyed to one NPI corroborate each other across those independent federal sources. Fonteum exposes each underlying source value with its own provenance rather than collapsing them into one blended attribute, so a plan can see where NPPES and PECOS concur and where they diverge. A divergence — for example a practice address present in NPPES but absent from a facility record — is itself a material signal for directory accuracy work, because it marks an entry that warrants a closer look before it is published to members. The point is that the disagreement is visible and attributable to a named source, not silently resolved by an opaque vendor rule.

How does Fonteum support exclusion screening for network integrity?

CMS requires Medicare Advantage organizations and Medicaid managed-care plans to screen network providers against the OIG LEIE monthly, because payment to or employment of an excluded individual can trigger Civil Monetary Penalties under the Social Security Act. Fonteum ingests the OIG LEIE on the same monthly cadence the OIG publishes it — 68,055+ excluded individuals and entities — and joins it with SAM.gov exclusions, state Medicaid exclusion lists, OIG Corporate Integrity Agreements, and CMS Civil Money Penalties into a single 'excluded anywhere' check. A plan can query one NPI at /api/v1/exclusions or browse the surface at /sanctions, and every result carries the originating source name, the file's download date, and the methodology version. That means a screening determination is defensible: the plan can show which monthly file the result was drawn from, which is the standard an enforcement review expects.

Can a health plan integrate Fonteum data through an API?

Yes. Fonteum implements HL7 FHIR R4 against US Core 6.1.0, exposing 5 distinct USCDI v3 Provider resources: Practitioner, PractitionerRole, Organization, Location, and HealthcareService. SMART Backend Services authorization supports unattended system-to-system integration, so a plan's directory or screening platform can pull provider records without a human in the loop. The CapabilityStatement enumerating all five resources lives at /api/fhir/metadata. For population-scale loads — re-checking an entire network in one job — Fonteum supports HL7 FHIR Bulk Data Access via the $export operation, returning NDJSON. Each FHIR resource carries the same field-level federal provenance as the public surfaces, so an automated workflow inherits the same auditable chain a manual check would produce. The exclusion check is also available as a single-NPI REST call at /api/v1/exclusions for screening pipelines.

Is the data free, and what does the pilot tier add?

The federal datasets behind directory accuracy and screening — CMS NPPES, CMS PECOS, and the OIG LEIE with its companion exclusion lists — are published openly. The exclusion surface is browsable at /sanctions, and the research datasets, with CSV and JSON downloads plus methodology notes, are at /research. The FHIR R4 US Core 6.1.0 API and the HL7 bulk $export operation are documented at /docs/fhir. Free access reflects the doctrine that public-source federal data should stay public. The scoped pilot tier, starting at $2,500/mo, adds custom exports cut to a specific provider network — for example a combined NPPES-plus-PECOS-plus-exclusion file keyed to the NPIs you contract, delivered on your reconciliation cadence with the field-level provenance intact. The pilot is about scoping, delivery, and integration support, not about gating access to the underlying federal record.

FONTEUM · USE CASE · HEALTH PLANS

LEIE exclusions

Provider networks, reconciled to the federal record.

Directory accuracy from CMS NPPES + PECOS, plus exclusion screening across OIG, SAM, and state Medicaid — each field auditable to its federal source.

Request access →

Federal source stack

Directory · enrollment · exclusion screening

active providers
CMS NPPES
Directory accuracy backbone
active providers (~8M total NPI records) — NPI, taxonomy code, practice address, and entity type, distributed by CMS as a weekly full-replacement file. The authoritative federal identifier a plan's directory entries should reconcile against under the No Surprises Act and the REAL Act accuracy framework.
Source documentation →
exclusions
OIG LEIE + exclusion ring
Network-integrity screening
OIG HHS List of Excluded Individuals and Entities — excluded providers, refreshed monthly. Joined with SAM.gov, state Medicaid exclusion lists, OIG Corporate Integrity Agreements, and CMS Civil Money Penalties for a single “excluded anywhere” check at /sanctions and /api/v1/exclusions.
Source documentation →
Active enrollment status
CMS PECOS
Medicare enrollment status
CMS PECOS Physician and Practitioner Enrollment File — Medicare enrollment indicator, provider type, and reassignment data, cross-referenced against the NPPES NPI. One of 44 federal source families in the Fonteum graph, and the federal signal a Medicare Advantage plan needs to confirm a provider's active participation.
Source documentation →

Why source provenance matters for health plans

Auditable to the federal source — not a vendor's derived list

Directory accuracy CMS can trace

The CMS Interoperability and Patient Access Final Rule (CMS-9115-F) and the No Surprises Act 90-day requirement expect plans to keep directory data current against NPPES and PECOS. Fonteum makes those exact federal files accessible across active providers with per-field provenance — the directory entry traces to the CMS dataset, not to a vendor's derived product. NPPES is ingested as a weekly full-replacement file, so the reconciliation surface tracks the current federal record.

Exclusion screening on a monthly cadence

CMS requires Medicare Advantage and Medicaid plans to screen providers against the OIG LEIE monthly. Fonteum's LEIE ingest runs on the OIG's monthly publication schedule, covering excluded individuals and entities, and joins SAM.gov, state Medicaid lists, OIG Corporate Integrity Agreements, and CMS Civil Money Penalties into one “excluded anywhere” check. Every result includes the source citation, the download date, and the methodology version — so the screening audit trail is complete and the exact file version checked is provable.

Cross-source NPI agreement, made visible

Federal files keyed to the same NPI do not always agree on address, specialty, or status. Fonteum exposes each and value with its own provenance instead of collapsing them into one blended attribute, so a plan sees exactly where the sources concur and where they diverge. A divergence is a material directory-accuracy signal — it flags the entry to re-check before it reaches members — and it stays attributable to a named federal source rather than resolved by an opaque rule.

How it works

From federal portal to auditable directory record

Step 1 / Ingest

Ingest

Fonteum pulls directly from the federal portals on each source's native cadence — CMS NPPES as a weekly full-replacement file ( active providers), the OIG LEIE monthly ( exclusions) alongside SAM.gov and state Medicaid lists, and CMS PECOS enrollment on its publication schedule. No intermediary aggregator sits between the directory record and the government file, so a reconciliation reflects the current federal source rather than a stale vendor snapshot.

Step 2 / Provenance

Provenance

Every field is written with its source name, last-checked date, and documented limitation through the provider_field_provenance layer. The result is an auditable chain from each rendered fact — a practice address, an enrollment indicator, an exclusion flag — back to the exact CMS or OIG file and date it came from. That per-field chain of custody is the evidence a No Surprises Act audit or a CMS program-integrity review expects.

Step 3 / Deliver

Deliver

Directory and screening data is available free as public research at /research and /sanctions, through the FHIR R4 US Core 6.1.0 API with SMART Backend Services auth for automated reconciliation, via the single-NPI exclusion check at /api/v1/exclusions, and via HL7 bulk $export for re-checking an entire network in one NDJSON job. Scoped pilot exports — NPPES, PECOS, and exclusion data keyed to your network's NPIs — start at $2,500/mo with the field-level provenance intact.

FAQ

Common questions

What provider data does Fonteum give health plans for directory accuracy?: Fonteum makes the same federal files CMS uses to define provider-directory accuracy standards directly accessible, drawn from a graph of 44 federal source families. CMS NPPES supplies NPI, taxonomy code, practice address, and entity type for active providers, distributed as a weekly full-replacement file. CMS PECOS supplies the Medicare enrollment indicator and provider type. Every field carries its source name, last-checked date, and documented limitation through the provider_field_provenance layer, so a plan can show each directory entry traces to the CMS dataset rather than to a commercially assembled product. The CMS Interoperability and Patient Access Final Rule (CMS-9115-F) requires Medicare Advantage, Medicaid, CHIP, and Qualified Health Plan issuers to publish accurate, machine-readable provider directory data kept current against these primary sources — Fonteum is the upstream layer for that obligation. Fonteum is a source-provenanced data layer, not itself a certified provider directory or network-adequacy engine; it supplies the auditable federal inputs those systems consume.
How does Fonteum support the No Surprises Act 90-day directory requirement?: The No Surprises Act, enacted as part of the Consolidated Appropriations Act, 2021, requires health plans to re-check provider-directory information at least once every 90 days and to remove or flag entries that cannot be confirmed. Because Fonteum ingests CMS NPPES as a weekly full-replacement file and timestamps every field, a plan can reconcile its directory against the current federal record on whatever cadence its compliance calendar sets — well inside a 90-day window — and document the exact source file and date each reconciliation ran against. That timestamped chain is the evidence a plan needs to demonstrate it met the accuracy obligation, rather than asserting currency without a traceable source. The same approach maps to the REAL Act (Requiring Enhanced & Accurate Lists of Health Providers) directory-accuracy framework, which centers on reconciling plan directories to authoritative provider records.
What is cross-source NPI agreement scoring?: A single provider appears across several federal files — NPPES, PECOS, Care Compare, and others — and those files do not always agree on practice address, specialty, or active status. Cross-source NPI agreement is the degree to which the records keyed to one NPI corroborate each other across those independent federal sources. Fonteum exposes each underlying source value with its own provenance rather than collapsing them into one blended attribute, so a plan can see where NPPES and PECOS concur and where they diverge. A divergence — for example a practice address present in NPPES but absent from a facility record — is itself a material signal for directory accuracy work, because it marks an entry that warrants a closer look before it is published to members. The point is that the disagreement is visible and attributable to a named source, not silently resolved by an opaque vendor rule.
How does Fonteum support exclusion screening for network integrity?: CMS requires Medicare Advantage organizations and Medicaid managed-care plans to screen network providers against the OIG LEIE monthly, because payment to or employment of an excluded individual can trigger Civil Monetary Penalties under the Social Security Act. Fonteum ingests the OIG LEIE on the same monthly cadence the OIG publishes it — excluded individuals and entities — and joins it with SAM.gov exclusions, state Medicaid exclusion lists, OIG Corporate Integrity Agreements, and CMS Civil Money Penalties into a single “excluded anywhere” check. A plan can query one NPI at /api/v1/exclusions or browse the surface at /sanctions, and every result carries the originating source name, the file's download date, and the methodology version. That means a screening determination is defensible: the plan can show which monthly file the result was drawn from, which is the standard an enforcement review expects.
Can a health plan integrate Fonteum data through an API?: Yes. Fonteum implements HL7 FHIR R4 against US Core 6.1.0, exposing 5 distinct USCDI v3 Provider resources: Practitioner, PractitionerRole, Organization, Location, and HealthcareService. SMART Backend Services authorization supports unattended system-to-system integration, so a plan's directory or screening platform can pull provider records without a human in the loop. The CapabilityStatement enumerating all five resources lives at /api/fhir/metadata. For population-scale loads — re-checking an entire network in one job — Fonteum supports HL7 FHIR Bulk Data Access via the $export operation, returning NDJSON. Each FHIR resource carries the same field-level federal provenance as the public surfaces, so an automated workflow inherits the same auditable chain a manual check would produce. The exclusion check is also available as a single-NPI REST call at /api/v1/exclusions for screening pipelines.
Is the data free, and what does the pilot tier add?: The federal datasets behind directory accuracy and screening — CMS NPPES, CMS PECOS, and the OIG LEIE with its companion exclusion lists — are published openly. The exclusion surface is browsable at /sanctions, and the research datasets, with CSV and JSON downloads plus methodology notes, are at /research. The FHIR R4 US Core 6.1.0 API and the HL7 bulk $export operation are documented at /docs/fhir. Free access reflects the doctrine that public-source federal data should stay public. The scoped pilot tier, starting at $2,500/mo, adds custom exports cut to a specific provider network — for example a combined NPPES-plus-PECOS-plus-exclusion file keyed to the NPIs you contract, delivered on your reconciliation cadence with the field-level provenance intact. The pilot is about scoping, delivery, and integration support, not about gating access to the underlying federal record.

Request access →

Request a directory-accuracy pilot.

Scope a custom NPPES + PECOS + exclusion export for your provider network. Free public data at /research and /sanctions. Pilot tier from $2,500/mo.

Request access →or read the FHIR R4 docs →

FONTEUM · PILOT

Run a 90-day pilot. Public data only. No PHI.

Request access → Read the methodology

Provider networks, reconciled to the federal record.

Directory accuracy from CMS NPPES + PECOS, plus exclusion screening across OIG, SAM, and state Medicaid — each field auditable to its federal source.

Request access →

Federal source stack

Directory · enrollment · exclusion screening

active providers
CMS NPPES
Directory accuracy backbone
active providers (~8M total NPI records) — NPI, taxonomy code, practice address, and entity type, distributed by CMS as a weekly full-replacement file. The authoritative federal identifier a plan's directory entries should reconcile against under the No Surprises Act and the REAL Act accuracy framework.
Source documentation →
exclusions
OIG LEIE + exclusion ring
Network-integrity screening
OIG HHS List of Excluded Individuals and Entities — excluded providers, refreshed monthly. Joined with SAM.gov, state Medicaid exclusion lists, OIG Corporate Integrity Agreements, and CMS Civil Money Penalties for a single “excluded anywhere” check at /sanctions and /api/v1/exclusions.
Source documentation →
Active enrollment status
CMS PECOS
Medicare enrollment status
CMS PECOS Physician and Practitioner Enrollment File — Medicare enrollment indicator, provider type, and reassignment data, cross-referenced against the NPPES NPI. One of 44 federal source families in the Fonteum graph, and the federal signal a Medicare Advantage plan needs to confirm a provider's active participation.
Source documentation →

Why source provenance matters for health plans

Auditable to the federal source — not a vendor's derived list

Directory accuracy CMS can trace

Exclusion screening on a monthly cadence

Cross-source NPI agreement, made visible

How it works

From federal portal to auditable directory record

Step 1 / Ingest

Ingest

Step 2 / Provenance

Provenance

Step 3 / Deliver

Deliver

FAQ

Common questions

What provider data does Fonteum give health plans for directory accuracy?: Fonteum makes the same federal files CMS uses to define provider-directory accuracy standards directly accessible, drawn from a graph of 44 federal source families. CMS NPPES supplies NPI, taxonomy code, practice address, and entity type for active providers, distributed as a weekly full-replacement file. CMS PECOS supplies the Medicare enrollment indicator and provider type. Every field carries its source name, last-checked date, and documented limitation through the provider_field_provenance layer, so a plan can show each directory entry traces to the CMS dataset rather than to a commercially assembled product. The CMS Interoperability and Patient Access Final Rule (CMS-9115-F) requires Medicare Advantage, Medicaid, CHIP, and Qualified Health Plan issuers to publish accurate, machine-readable provider directory data kept current against these primary sources — Fonteum is the upstream layer for that obligation. Fonteum is a source-provenanced data layer, not itself a certified provider directory or network-adequacy engine; it supplies the auditable federal inputs those systems consume.
How does Fonteum support the No Surprises Act 90-day directory requirement?: The No Surprises Act, enacted as part of the Consolidated Appropriations Act, 2021, requires health plans to re-check provider-directory information at least once every 90 days and to remove or flag entries that cannot be confirmed. Because Fonteum ingests CMS NPPES as a weekly full-replacement file and timestamps every field, a plan can reconcile its directory against the current federal record on whatever cadence its compliance calendar sets — well inside a 90-day window — and document the exact source file and date each reconciliation ran against. That timestamped chain is the evidence a plan needs to demonstrate it met the accuracy obligation, rather than asserting currency without a traceable source. The same approach maps to the REAL Act (Requiring Enhanced & Accurate Lists of Health Providers) directory-accuracy framework, which centers on reconciling plan directories to authoritative provider records.
What is cross-source NPI agreement scoring?: A single provider appears across several federal files — NPPES, PECOS, Care Compare, and others — and those files do not always agree on practice address, specialty, or active status. Cross-source NPI agreement is the degree to which the records keyed to one NPI corroborate each other across those independent federal sources. Fonteum exposes each underlying source value with its own provenance rather than collapsing them into one blended attribute, so a plan can see where NPPES and PECOS concur and where they diverge. A divergence — for example a practice address present in NPPES but absent from a facility record — is itself a material signal for directory accuracy work, because it marks an entry that warrants a closer look before it is published to members. The point is that the disagreement is visible and attributable to a named source, not silently resolved by an opaque vendor rule.
How does Fonteum support exclusion screening for network integrity?: CMS requires Medicare Advantage organizations and Medicaid managed-care plans to screen network providers against the OIG LEIE monthly, because payment to or employment of an excluded individual can trigger Civil Monetary Penalties under the Social Security Act. Fonteum ingests the OIG LEIE on the same monthly cadence the OIG publishes it — excluded individuals and entities — and joins it with SAM.gov exclusions, state Medicaid exclusion lists, OIG Corporate Integrity Agreements, and CMS Civil Money Penalties into a single “excluded anywhere” check. A plan can query one NPI at /api/v1/exclusions or browse the surface at /sanctions, and every result carries the originating source name, the file's download date, and the methodology version. That means a screening determination is defensible: the plan can show which monthly file the result was drawn from, which is the standard an enforcement review expects.
Can a health plan integrate Fonteum data through an API?: Yes. Fonteum implements HL7 FHIR R4 against US Core 6.1.0, exposing 5 distinct USCDI v3 Provider resources: Practitioner, PractitionerRole, Organization, Location, and HealthcareService. SMART Backend Services authorization supports unattended system-to-system integration, so a plan's directory or screening platform can pull provider records without a human in the loop. The CapabilityStatement enumerating all five resources lives at /api/fhir/metadata. For population-scale loads — re-checking an entire network in one job — Fonteum supports HL7 FHIR Bulk Data Access via the $export operation, returning NDJSON. Each FHIR resource carries the same field-level federal provenance as the public surfaces, so an automated workflow inherits the same auditable chain a manual check would produce. The exclusion check is also available as a single-NPI REST call at /api/v1/exclusions for screening pipelines.
Is the data free, and what does the pilot tier add?: The federal datasets behind directory accuracy and screening — CMS NPPES, CMS PECOS, and the OIG LEIE with its companion exclusion lists — are published openly. The exclusion surface is browsable at /sanctions, and the research datasets, with CSV and JSON downloads plus methodology notes, are at /research. The FHIR R4 US Core 6.1.0 API and the HL7 bulk $export operation are documented at /docs/fhir. Free access reflects the doctrine that public-source federal data should stay public. The scoped pilot tier, starting at $2,500/mo, adds custom exports cut to a specific provider network — for example a combined NPPES-plus-PECOS-plus-exclusion file keyed to the NPIs you contract, delivered on your reconciliation cadence with the field-level provenance intact. The pilot is about scoping, delivery, and integration support, not about gating access to the underlying federal record.

Request access →

Request a directory-accuracy pilot.

Scope a custom NPPES + PECOS + exclusion export for your provider network. Free public data at /research and /sanctions. Pilot tier from $2,500/mo.

Request access →or read the FHIR R4 docs →

FONTEUM · PILOT

Run a 90-day pilot. Public data only. No PHI.

Request access → Read the methodology