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Glossary

Provider data glossary

Plain definitions of the terms health plans, health systems and digital health teams use when they talk about provider data, from ghost networks to the No Surprises Act. Each one links to its primary sources.

A

Accepting new patients Accepting new patients, also called panel status, is the directory field that says whether a provider is taking on patients they haven't seen before. It is one of the…

C

CAQH CAQH is a nonprofit alliance of health plans whose portal, formerly called ProView, is where many US clinicians self-report and re-attest their credentials and practice… Care navigation Care navigation is helping a patient or plan member find and get to the right care: the right provider, in network, nearby, available and suited to their needs. It… Centers for Medicare & Medicaid Services (CMS) The Centers for Medicare & Medicaid Services (CMS) is the US federal agency, part of HHS, that runs Medicare and oversees Medicaid, CHIP and the federal health insurance… Claims data Claims data is the record of services billed to insurers: who provided care, where, when and what for. For provider data, it shows where providers actually practice and… CMS Certification Number (CCN) A CMS Certification Number (CCN) is the six-character number CMS assigns to facilities, such as hospitals, nursing homes and dialysis centers, that are certified to take… Credentialing Credentialing is the process a health plan or hospital uses to check a provider's qualifications, such as licenses, education, board certification, malpractice history… Credentials verification organization (CVO) A credentials verification organization (CVO) is a company that verifies providers' credentials, such as licenses, board certifications and education, with the primary…

D

Delegated credentialing Delegated credentialing is when a health plan lets a large provider group or health system credential its own clinicians, under the plan's standards and oversight,…

E

Electronic health record (EHR) An electronic health record (EHR) is the digital record of a patient's health information kept by a practice or hospital, including diagnoses, medications, results and…

F

FHIR FHIR (Fast Healthcare Interoperability Resources) is a standard from HL7 for exchanging healthcare data through web APIs. It defines common data formats, called…

G

Ghost network A ghost network is a health plan network that looks larger on paper than it is in practice: providers are listed as in-network and available, but have moved, retired,…

H

HEDIS HEDIS (Healthcare Effectiveness Data and Information Set) is a set of performance measures maintained by NCQA that health plans use to report on quality of care, such as… HIPAA HIPAA (the Health Insurance Portability and Accountability Act of 1996) is the US law that protects the privacy and security of patients' health information. It also…

I

In-network and out-of-network A provider is in-network when they have a contract with a health plan to see its members at agreed rates, and out-of-network when they don't. Network status decides what… Interoperability Interoperability is the ability of different health IT systems, such as EHRs, payer systems and apps, to exchange data and use it without special effort. Federal rules…

M

Medicaid managed care Medicaid managed care is when a state pays private health plans, called managed care organizations (MCOs), to deliver Medicaid benefits through their own provider… Medicare Advantage (MA) Medicare Advantage (MA), also called Medicare Part C, is the way people with Medicare can get their benefits through a private health plan approved by CMS, instead of… Medicare Plan Finder provider directory Under a 2025 CMS rule, Medicare Advantage plans send their provider directory data to CMS, which shows it in Medicare Plan Finder so people can check which doctors are… Medicare Star Ratings Medicare Star Ratings are CMS's 1 to 5 star scores for Medicare Advantage and Part D plans, updated every year. They combine measures of quality, member experience and… Model Context Protocol (MCP) The Model Context Protocol (MCP) is an open standard that lets AI assistants and agents connect to outside tools and data through MCP servers, so they can look up live…

N

National Provider Identifier (NPI) A National Provider Identifier (NPI) is a unique 10-digit number that identifies a US healthcare provider in standard transactions such as claims. It is required under… NCQA The National Committee for Quality Assurance (NCQA) is a private nonprofit that accredits health plans and other healthcare organizations and maintains the HEDIS quality… Network adequacy Network adequacy is whether a health plan's network has enough providers of each type, close enough to members, to give reasonable access to care. Medicare Advantage… No Surprises Act (NSA) The No Surprises Act is a US federal law, in effect since 2022, that protects patients from many surprise medical bills. It also requires health plans to verify provider… NPPES NPPES, the National Plan and Provider Enumeration System, is the CMS system that assigns National Provider Identifiers and publishes the NPI Registry. Its data is free…

P

Payer A payer is any organization that pays for healthcare services: commercial health insurers, Medicare and Medicaid, Medicare Advantage and Medicaid managed care plans, and… Practice location A practice location is an address where a provider actually sees patients. It is different from a billing or mailing address, and many providers are listed at more… Primary source verification (PSV) Primary source verification is checking a provider's credential directly with the organization that issued it, such as a state licensing board, medical school or… Provider abrasion Provider abrasion is the friction and frustration providers feel from repeated administrative requests from health plans, such as attestation reminders, roster requests… Provider affiliation A provider affiliation is a link between a clinician and an organization, such as the medical group they work for, the hospitals where they have privileges, or the… Provider attestation Provider attestation is when a provider confirms that the information held about them is correct, usually through a portal on a fixed schedule. It records what the… Provider data enrichment Provider data enrichment is adding missing details to provider records, and correcting wrong ones, using other sources. Examples include adding languages spoken,… Provider data management (PDM) Provider data management (PDM) is the work of collecting, checking, keeping current and sharing information about healthcare providers across an organization's systems,… Provider directory A provider directory is a health plan's list of the doctors, hospitals and other providers in its network, with the details members need to get care: name, specialty,… Provider directory accuracy Provider directory accuracy is how much of a directory is correct: whether each listed provider really practices at the listed location, can be reached at the listed… Provider Directory API A Provider Directory API is a public, standards-based way for apps to read a health plan's provider directory. CMS interoperability rules require it for Medicare… Provider record matching Provider record matching is working out which records, across different systems and sources, describe the same provider or practice location, so they can be merged into… Provider roster A provider roster is a file a provider group sends to a health plan listing its providers and their details, such as locations, specialties and panel status, so the plan… Provider taxonomy code A provider taxonomy code is a 10-character code from the National Uniform Claim Committee that describes a provider's type, classification and specialty. Providers…

R

REAL Health Providers Act The REAL Health Providers Act (Requiring Enhanced and Accurate Lists of Health Providers Act) is a 2026 US law that sets directory accuracy rules for Medicare Advantage… Referral leakage Referral leakage is when patients referred for care go to providers outside the referring health system or network, often because the right in-network provider was hard…

S

Sanctions and exclusion monitoring Sanctions and exclusion monitoring is regularly checking providers against government lists of people and organizations barred from federal healthcare programs, such as… Secret shopper survey A secret shopper survey tests a provider directory by calling listed providers as if booking care, then recording whether the listing was right: the location, phone… Surprise billing Surprise billing is when a patient gets an unexpected bill for out-of-network care they didn't choose or didn't know was out of network. Balance billing is the practice… Survivorship logic Survivorship logic is the set of rules that decides which value to keep when different sources disagree about the same provider, for example two different phone numbers,…

T

Tax Identification Number (TIN) A Tax Identification Number (TIN) is the number a practice or organization uses with the IRS, usually an Employer Identification Number. In provider data it identifies…

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