Glossary
Healthcare data is full of acronyms. Here's what every term you'll see in these tools actually means — in plain language.
The one-line mental model
An NPI identifies anyone · a CCN identifies a facility · PECOS / PAC ID is about Medicare enrollment · Taxonomy is specialty · HCPCS / DRG / APC are what was billed · OIG / Revalidation are compliance checks.
How it all connects
Everything starts with a provider. Here's how the other terms hang off of them.
Registers in PECOS, which assigns a PAC ID and one or more Enrollment IDs.
Described by a Taxonomy code and professional Credentials (MD, NP…).
Using HCPCS/CPT codes, plus DRG (inpatient), APC (outpatient) & Part D drugs.
Must keep Revalidation current and stay off the OIG/LEIE exclusion list.
Jump to a category
Who is this? — Identifiers
Every provider and facility has a unique ID. These are the things you search by.
The universal 10-digit ID for any healthcare provider — every doctor, nurse, clinic, and hospital has one. This is the main thing you search by.
e.g. 1023456789
NPI-1 is an individual person. NPI-2 is an organization (clinic, hospital, group). On forms this may be labeled "Provider Type."
The ID for a facility (hospital, clinic) rather than a person. You look up and compare facilities by their CCN.
e.g. 450078
A provider's unique enrollment ID inside Medicare's enrollment system. Think of it as their "Medicare account number."
The same idea as a PAC ID, but for a group practice. Used to find everyone who bills under that group.
A specific Medicare enrollment record. One provider can have several — for example, one per state they practice in.
Medicare Enrollment
Before a provider can bill Medicare, they have to enroll. These terms come from that process.
Medicare's enrollment system — it tracks who is approved to bill Medicare. PAC IDs and Enrollment IDs come from here.
Whether the provider is currently approved to bill Medicare.
Medicare requires providers to re-confirm their information periodically. The Revalidation Due Date is the deadline; status shows as Compliant, Delinquent, or Not Required.
Whether a provider is allowed to order services or refer patients under Medicare — even if they don't bill Medicare directly.
Specialty & Credentials
What a provider is trained to do and how they're qualified.
A code describing a provider's specialty or role (e.g. Family Medicine, Registered Nurse). A provider can have up to 15; the main one is the Primary Taxonomy.
e.g. 207Q00000X = Family Medicine
The letters after a provider's name — MD, DO, PA, NP, and so on.
A provider who bills as an individual rather than through an organization.
Billing & Procedure Codes
Codes that describe what was actually done or prescribed — and how it's paid for.
Codes for what was done to a patient — a procedure, test, or visit. You can search providers by these codes.
e.g. 99213 = office visit
The Medicare prescription drug program. The Part D tool shows which drugs a provider prescribes.
How inpatient hospital stays are categorized for payment — bundled together by diagnosis.
The outpatient equivalent of a DRG — how outpatient procedures are grouped for payment.
Facilities & Programs
Facility types and the Medicare quality programs that affect their payments.
A community health center that serves underserved areas and receives special federal funding.
A clinic in a rural or underserved area with special Medicare status.
The number of Medicare-approved beds at a hospital.
Groups of providers who coordinate care and share savings under Medicare (the Shared Savings Program).
A program that adjusts hospital payments up or down based on quality scores.
Penalizes hospitals that have too many patients returning shortly after discharge.
Penalizes hospitals for infections or injuries that occur during a patient's stay.
Shortage Areas (HRSA)
HRSA designations that flag where there aren't enough providers — the basis for the BD prospecting and territory tools.
The federal agency for the healthcare safety net. It funds community health centers and designates shortage areas.
An area, population, or facility with too few providers in primary care, mental health, or dental care. Scored 0–26 — a higher score means a more severe shortage.
e.g. Score 18 (Primary Care)
A geography (MUA) or population group (MUP) with too little access to care, scored by the Index of Medical Underservice (IMU). A lower IMU means more underserved.
FQHCs, FQHC Look-Alikes, and Rural Health Clinics are automatically designated as facility HPSAs — so they always carry a shortage score.
The number of full-time-equivalent providers a designation needs to no longer be a shortage area. A rough measure of how big the hiring need is.
A federal program offering loan repayment and scholarships to providers who work in shortage areas — a recruiting incentive for employers located there.
Relationships Between Providers
How individual providers connect to groups and facilities.
When an individual provider lets a group bill on their behalf — they've reassigned their Medicare billing rights to the group.
Which hospitals or facilities a provider is connected to.
Which group practices a provider belongs to.
Compliance & Status
Checks that tell you whether a provider is in good standing.
A compliance blacklist maintained by the Office of Inspector General. A provider who is "excluded" cannot bill federal healthcare programs. The tools flag this automatically.
If present, the provider's NPI is no longer active.
The date the provider first received their NPI — i.e. when they entered the registry.
Data Sources & Systems
Where the data behind these tools comes from.
The official registry that issues NPIs. When you do a live NPI lookup, it's querying NPPES.
The federal agency. "CMS data" means Medicare enrollment, payments, facility information, and revalidation dates.
Medicare's enrollment system — the source of PAC IDs, Enrollment IDs, and revalidation dates.