Eligibility Inspection Results
The Eligibility inspection results indicate whether the provider is eligible to be practicing. Accurate indicates the Provider passed the Eligibility inspection and is eligible. Inaccurate indicates the Provider failed the Eligibility inspection. In the event the Provider fails the Eligibility inspection, the recommended action is either Suppress or Investigate.
The recommended action is to suppress the provider (remove the provider from the network) when the Eligibility inspector flags the provider as follows:
NPI Deactivated: The Provider’s National Provider Identifier is no longer active.
Medicare Opt-out: The Provider opted out of Medicare.
Medicare Precluded: Medicare removed doctor from approved list.
OIG Excluded: The Office of Inspector General removed doctor from approved list.
The recommended action is to investigate the provider when the Eligibility inspector flags the provider as follows:
Provider License: The Provider’s license has expired.
Provider Retired: The Provider is no longer practicing.
The recommended action is to Investigate in these two cases because it is possible that the provider will renew the expired license or will resume practicing. If investigation reveals that the provider will never renew their license or return to practice, then you should remove the provider from the network.