Information Validation

Physician Information

NOTES:

• The term doctor, physician, and practitioner are used interchangeably in this section.

Name

• Source: The practitioner's initial credentialing application.
• Frequency of validation: Verified at initial credentialing and re-credentialing, every 3 years.
• Limitations: Self-reported information.

Gender

• Source: The practitioner's initial credentialing application.
• Frequency of validation: Verified at initial credentialing and re-credentialing, every 3 years.
• Limitations: Self-reported information.

Specialty

• Explanation: A focused area of medicine that a doctor has additional education and training beyond a general medical doctor license. See an explanation of each specific specialty.
• Source: The practitioner's initial credentialing application. It is verified by checking with the American Medical Association (AMA) or American Osteopathic Association (AOA) for board-certified physicians or through primary source verification from the specialty training school.
• Frequency of validation: Verified at initial credentialing and re-credentialing, every 3 years.
• Limitations:  None.

Hospital Affiliations

• Explanation: The facility (hospital) where he/she has admitting privileges.
• Source: The practitioner's initial credentialing application.
• Frequency of validation: Verified at initial credentialing and re-credentialing, every 3 years.
• Limitations: Self-reported information.

Medical Group Affiliations

• Explanation: A structured group of medical practitioners working together.
• Source: The practitioner's initial credentialing application.
• Frequency of validation: Verified at initial credentialing and re-credentialing, every 3 years. Also updated when notified by the practitioner that he/she is moving or adding a medical group affiliation.
• Limitations: Self-reported information.

Board Certification

• Explanation: Recognizes a doctor has met the requirements/standards of a nationally recognized specialty organization.
• Source: The practitioner's initial credentialing application and verified through the American Board of Medical Specialties (ABMS), the American Medical Association (AMA), or the American Osteopathic Association (AOA).
• Frequency of validation: Verified at initial credentialing and re-credentialing, every 3 years.
• Limitations: None.

Acceptance of New Patients

• Explanation: The doctor will see new patients in their practice.
• Source: The practitioner's initial credentialing application and updated as reported by practitioner.
• Frequency of validation: Verified at initial credentialing and updated when notified by the practitioner.
• Limitations: Self-reported information and requires change notification from the practitioner.

Language Spoken by the Practitioner or Clinical Staff

• Explanation: This is the language(s) spoken by the practitioner or clinical office staff.
• Source: The practitioner's initial credentialing application.
• Frequency of validation: Annually through validation process sent from Plan.
• Limitations: Self-reported information.

* The Plan offers telephonic interpretation services to all members and provider offices.

Office Location and Phone Numbers

• Source: The practitioner's initial credentialing application.
• Frequency of validation: Verified at initial credentialing and re-credentialing, every 3 years. Also updated when notified by the practitioner that he/she is moving.
• Limitations: Self-reported information.

Hospital Information

Name

• Source: The hospital’s initial credentialing application.
• Frequency of validation: Verified at initial credentialing and re-credentialing, every 3 years.
• Limitations: Self-reported information.

Location and Phone Number

• Source: The hospital’s initial credentialing application.
• Frequency of validation: Verified at initial credentialing and re-credentialing, every 3 years. Also updated when notified of any changes (within 30 days).
• Limitations: Self-reported information.

Accreditation

• Explanation: Certification that a hospital has met the requirements/standards of a nationally recognized accrediting body for hospitals.
• Source: The hospital's initial credentialing application. Verified by obtaining a copy of the hospital's current accreditation.
• Frequency of validation: Verified at initial credentialing and re-credentialing, every 3 years.
• Limitations: None.

Hospital Quality Data

• Explanation: Information on patient experiences, timely and effective care, complications and deaths, unplanned hospital visits, use of medical imaging, and payment and value of care.
• Source: The data on this site is obtained from the CASPER System, CDC National Healthcare Safety Network, Medicare and Veterans Health Administration claims, and the QIO Clinical Data Warehouse.
• Frequency of validation: Data updates occur quarterly.
• Limitations: None.