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