Information Validation

Physician Information

NOTES:

  • The term doctor, physician, and practitioner are used interchangeably in this section.
  • Credentialing information is gathered through the Council for Affordable Quality Healthcare (CAQH) credentialing application or the Pennsylvania Standard Application.

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 of 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

  • 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

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.