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.