Information Validation
Physician information
Notes:
- The terms "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 three years.
- Limitations: Self-reported information.
Gender
- Source: The practitioner's initial credentialing application.
- Frequency of validation: Verified at initial credentialing and re-credentialing, every three 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 three 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 three 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 three 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 of initial credentialing and re-credentialing, every three 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(s) 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 three 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 three 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 three 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 three 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, Centers for Disease Control and Prevention (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.