provider exclusion
prvdr_excl_indDefinition
ISO-11179 Definition
An indicator identifying that a healthcare provider has been excluded from participation in Medicare, Medicaid, and other federal healthcare programs by the Office of Inspector General or CMS due to fraud, abuse, patient harm, felony convictions, or other disqualifying conduct. Excluded providers are listed on the OIG List of Excluded Individuals and Entities. Health plans and healthcare organizations that employ or contract with excluded providers risk substantial civil monetary penalties.
Exclusions may be mandatory for certain offenses or permissive at OIG discretion for other violations. Healthcare data teams implement automated exclusion screening workflows that check provider rosters against the OIG LEIE and state exclusion lists monthly, generate real-time alerts when newly excluded providers are identified in the network, and maintain exclusion screening audit logs to demonstrate compliance during CMS program integrity audits.
Standard Abbreviation
prvdr_excl_ind
Category
Production DDL — DIM_PROVIDER
CREATE OR REPLACE TABLE DIM_PROVIDER (
prvdr_key INTEGER NOT NULL -- surrogate key,
prvdr_npi VARCHAR(10) -- NPI number,
prvdr_tin VARCHAR(10) -- tax ID number,
prvdr_first_nm VARCHAR(100) -- first name,
prvdr_last_nm VARCHAR(100) -- last name,
prvdr_org_nm VARCHAR(255) -- organization name,
prvdr_typ_cd VARCHAR(20) -- provider type code,
prvdr_spclty_cd VARCHAR(10) -- specialty code,
prvdr_tax VARCHAR(10) -- taxonomy code,
prvdr_state_cd CHAR(2) -- state code,
prvdr_zip_cd VARCHAR(10) -- zip code,
prvdr_ntwk_sts VARCHAR(10) -- network status,
prvdr_accpt_pt_ind CHAR(1) -- accepting patients,
prvdr_excl_ind CHAR(1) -- exclusion indicator,
load_dt TIMESTAMP_NTZ NOT NULL -- load timestamp
);
Standard Snowflake DDL for the canonical provider table. Convert to BigQuery or Databricks →
Why This Term Matters
Provider data management is one of the most operationally complex data domains in healthcare because providers move, merge, and update their credentials continuously. A data engineer who understands provider terminology can build NPI validation, credentialing, and network adequacy pipelines that keep provider directories accurate and prevent claim rejections. Stale or incorrect provider data is a leading cause of prior authorization delays and CMS compliance findings.
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