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: at initial credentialing, and every three years at recredentialing.
- Limitation: self-reported information.
Gender
- Source: the practitioner's initial credentialing application.
- Frequency of validation: at initial credentialing, and every three years at recredentialing.
- Limitation: self-reported information.
Specialty
- Explanation: a focused area of medicine in which 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. We verify the specialty by checking with the American Medical Association (AMA) or American Osteopathic Association (AOA) for board-certified physicians or checking the primary source from the specialty training school.
- Frequency of validation: at initial credentialing, and every three years at recredentialing.
- Limitation: none.
Hospital affiliations
- Explanation: the facility (hospital) where the practitioner has admitting privileges.
- Source: the practitioner's initial credentialing application.
- Frequency of validation: at initial credentialing, and every three years at recredentialing.
- Limitation: 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: at initial credentialing, and every three years at recredentialing. Also updated when notified by the practitioner that they are moving or adding a medical group affiliation.
- Limitation: self-reported information.
Board certification
- Explanation: recognizes that a doctor has met the requirements and 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: at initial credentialing, and every three years at recredentialing.
- Limitations: none.
Acceptance of new patients
- Explanation: when the doctor will see new patients in their practice.
- Source: the practitioner's initial credentialing application and updated as reported by the practitioner.
- Frequency of validation: at initial credentialing and updated as reported by the practitioner.
- Limitations: self-reported information and requires change notification from the practitioner.
Language spoken by the practitioner, or clinical staff
- Explanation: the language(s) spoken by the practitioner or clinical office staff.
- Source: the practitioner's initial credentialing application.
- Frequency of validation: annually through a validation process sent from the health plan.
- Limitation: self-reported information.
* The health 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: at initial credentialing, and every three years at recredentialing. Also updated when notified by the practitioner that they are moving.
- Limitation: self-reported information.
Hospital information
Name
- Source: the hospital’s initial credentialing application.
- Frequency of validation: at initial credentialing, and every three years at recredentialing.
- Limitation: self-reported information.
Location and phone number
- Source: the hospital’s initial credentialing application.
- Frequency of validation: at initial credentialing, and every three years at recredentialing. Also updated when notified of any changes (within 30 days).
- Limitation: self-reported information.
Accreditation
- Explanation: certification that a hospital has met the requirements and 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: at initial credentialing, and every three years at recredentialing.
- 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 CASPER System, Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network, Medicare and Veterans Health Administration claims, and the Quality Improvement Organization (QIO) Clinical Data Warehouse.
- Frequency of validation: quarterly.
- Limitations: none.