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provider medicare enrollment

prvdr_mcare_enrl
provider·Updated Jun 23, 2026

Definition

ISO-11179 Definition

The registration and approval process through which a healthcare provider becomes authorized to deliver services to Medicare beneficiaries and receive reimbursement from the Medicare program through the CMS Provider Enrollment Chain and Ownership System. Medicare enrollment requires providers to complete CMS Form 855 applications, submit supporting documentation, pass background screening including exclusion and sanction checks, and in some cases undergo site visits. CMS classifies providers into limited, moderate, and high screening levels with progressively rigorous requirements.

Medicare enrollment must be revalidated every five years for most provider types. Healthcare data teams build Medicare enrollment tracking systems that monitor PECOS enrollment status, revalidation deadlines, effective and deactivation dates, and enrollment changes across the provider network to ensure claims payment eligibility and compliance with CMS program integrity requirements.

Standard Abbreviation

prvdr_mcare_enrl

Category

provider

Production DDL — DIM_PROVIDER

DIM_PROVIDER.sql
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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