How It Works
TrustNav scores every provider across five validity dimensions using ten independent federal and state data sources, producing a composite validity score and actionable business label.
Four-Stage Architecture
- Data Ingest: Ten federal and state sources are ingested into the Evolyn kernel's normalized schema — NPPES (bulk + API), DORA, PECOS, MUP, Care Compare, OIG LEIE, SAM.gov, FHIR endpoints, and DOI Transparency in Coverage files.
- Evolyn Kernel: Manages the five-primitives architecture (nodes, assertions, evidence, entity couplings, trust scores) that feeds dimension scoring.
- Dimension Scoring: The
provider_validity_featuresmatview pre-computes all five dimension scores and composite validity for fast dashboard queries. - Validity Labels: Business rules map composite scores and hard overrides into eight actionable validity labels for carrier compliance workflows.
Five Validity Dimensions
Each provider is scored from 0.0 to 1.0 on five independent dimensions. The dimensions are designed to capture different facets of directory accuracy.
Identity
0.0 – 1.0Validates the provider exists as a legitimate, active healthcare entity.
Evidence Sources
- NPI status (active vs. deactivated)
- NPPES registration freshness (time since last update)
- Federal exclusion status (OIG LEIE / SAM.gov)
A deactivated NPI or federal exclusion automatically zeroes this score and triggers hard override to "Compliance Violation" or "Confirmed Invalid."
Licensure
0.0 – 1.0Verifies the provider holds valid credentials to practice in Colorado.
Evidence Sources
- Colorado DORA license status (Active, Expired, Revoked, etc.)
- PECOS Medicare enrollment status
- PECOS enrollment date (recency)
- 3-Tier Deterministic Entity Resolution: NPI-to-license crosswalk via (1) State License Number match, (2) Primary NPI Name match, (3) Federal NPPES Alias/Maiden Name match — no probabilistic or fuzzy matching
Active statuses include: Active, Active - Provisional, Active - With Conditions, and Active - Restricted.
Activity
0.0 – 1.0Measures whether the provider shows evidence of actively practicing medicine.
Evidence Sources
- Medicare billing volume (services, beneficiaries, payments)
- PECOS enrollment confirmation
- Open Payments industry relationships
Applies primarily to Medicare-eligible specialties. Non-Medicare taxonomies (counselors, chiropractors, PTs, etc.) are scored more leniently on this dimension.
Reachability
0.0 – 1.0Checks whether the provider can be reached at the locations listed in directories.
Evidence Sources
- NPPES address vs. Care Compare address consistency
- Multi-location coverage (secondary practice sites)
- City and ZIP code comparison across sources
Multi-location aware — a provider with multiple NPPES addresses is only flagged if Care Compare locations are not a subset of registered locations.
Network
0.0 – 1.0Evaluates the strength and breadth of the provider's network affiliations.
Evidence Sources
- Number of carrier networks listing the provider
- Presence in DOI-regulated carrier filings
- Active endpoint status in transparency files
A provider listed by multiple carriers has stronger network evidence. Providers not in any tracked network are labeled "Not In Network."
Composite Score
The composite score is a weighted average of the five dimension scores, providing a single 0.0–1.0 summary of directory validity.
Dimension weights: Identity (25%) · Licensure (25%) · Activity (20%) · Reachability (15%) · Network (15%)
Score interpretation:
≥ 0.8
Strong
0.5 – 0.8
Moderate
0.3 – 0.5
Weak
< 0.3
Critical
Hard overrides (deactivated NPI, federal exclusion) bypass the composite score and directly assign the most severe validity label regardless of other dimension scores.
Validity Labels
Each provider receives one of eight actionable labels based on their dimension scores and hard override conditions.
Trigger: Federal exclusion (OIG LEIE / SAM.gov) or deactivated NPI with active network listing
Recommended action: Immediate carrier notification required. Potential civil monetary penalties under the Social Security Act.
Trigger: Composite score below threshold with multiple hard failure signals
Recommended action: Remove from directory. Provider is almost certainly inactive or unable to practice.
Trigger: Very low activity and licensure scores; no Medicare billing; stale or expired credentials
Recommended action: Investigate urgently. Contact provider to verify active practice status.
Trigger: Low reachability score; address mismatches between NPPES and Care Compare
Recommended action: Update directory listings. Provider may be active but listed at wrong location.
Trigger: Low network score; not in expected carrier filings despite listing
Recommended action: Verify network participation. May indicate stale carrier data.
Trigger: Mixed signals across dimensions; composite score in moderate range
Recommended action: Manual review recommended. Some signals warrant investigation.
Trigger: Good scores across most dimensions; minor gaps in some evidence
Recommended action: No immediate action. Monitor for changes.
Trigger: High scores across all dimensions; corroborated by multiple independent sources
Recommended action: Directory listing validated. Provider is active and reachable.
Ten Data Sources
Each source maps to one or more validity dimensions, providing independent evidence that is cross-referenced to build the composite picture.
NPPES Bulk
National Plan and Provider Enumeration System — the federal registry of all healthcare providers with NPIs.
NPPES Real-Time API
Live NPI Registry API checks for the most recent update timestamp and NPI status on individual provider records.
DORA Licensing
Colorado Department of Regulatory Agencies — the state authority for professional licensing.
PECOS
Provider Enrollment, Chain, and Ownership System — Medicare provider enrollment status and enrollment dates.
Medicare Utilization (MUP)
Medicare Provider Utilization and Payment Data — billing activity for Medicare providers.
Care Compare
CMS's own provider directory with address information for Medicare-enrolled providers.
OIG LEIE
Office of Inspector General List of Excluded Individuals/Entities — federally excluded providers barred from Medicare/Medicaid participation.
SAM.gov Exclusions
System for Award Management exclusion records — federal government-wide debarment and exclusion database.
FHIR Provider Directory (DaVinci PDex)
Payer-published FHIR R4 endpoints exposing real-time provider directory data under the CMS Interoperability and Patient Access rule.
DOI Transparency in Coverage
Machine-readable network files from 13 Colorado carriers published under the Transparency in Coverage rule, collected via the Colorado Division of Insurance.
Entity Coupling Model
Providers don't exist in isolation. The Evolyn kernel models three tiers of entity coupling:
- Organizational: Provider ↔ Practice group affiliations
- Specialty: Provider ↔ Specialty/taxonomy groupings
- Department: Provider ↔ Department within a health system
Validity signals propagate through these couplings — if multiple providers at the same practice address show low validity scores, the combined evidence strengthens each individual assessment.
Limitations
- Score calibration: Dimension scores reflect data availability, not ground truth. A low activity score means no Medicare billing evidence — the provider may bill through other payers.
- DORA scope: Licensure data covers Colorado only. Providers licensed in other states may show low licensure scores despite holding valid credentials elsewhere.
- PECOS coverage: Medicare enrollment data applies primarily to Medicare-eligible specialties. Non-Medicare taxonomies receive adjusted scoring.
- Address granularity: Reachability comparisons use city + ZIP code, not full street addresses. Some legitimate address variations may trigger discrepancies.
- Temporal lag: Federal data sources update at different frequencies (daily to annual). Scores may briefly lag real-world changes in provider status.
- Regional scope: Coverage is limited to Colorado in-network providers from DOI and federal Transparency in Coverage filings.
- No Medicare billing ≠ inactive provider: Many commercial-only practitioners do not participate in Medicare programs. A low activity score reflects absence of Medicare billing evidence, not necessarily absence of clinical practice. Non-Medicare taxonomies (counselors, chiropractors, PAs, etc.) are scored more leniently on this dimension.
- Multi-location practices: Providers practicing at multiple sites may trigger address discrepancy signals when secondary practice locations differ from the primary NPPES registration. The system accounts for NPPES secondary locations where available, but some legitimate multi-site practitioners may still show reduced reachability scores.
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