Provider Data Information, Source and Frequency Validated

Accepting New Patients

Definition: The provider agrees to become a medical caregiver to a member that he or she has not previously seen.

Source: This information is self-reported and verified during the initial credentialing process and every two years the provider's re-credentialing application, which is a signed document in which the provider confirms the information is accurate and complete. This information may also be verified more often, if appropriate, outside of the re-credentialing process.

Frequency Validated: On initial credentialing and at least every two years at re-credentialing. Since a provider's office status may change at any time, members should check with the provider's office.

Board Certification

Definition: When a provider is board certified, this means that he or she has graduated from a medical school; completed residency (training in a hospital); trained under supervision in a specialty and passed exams given by a medical specialty board.

Source: This information is self-reported and verified during the initial credentialing process and every two years on the provider's re-credentialing application, which is a signed document in which the provider confirms the information is accurate and complete.

Frequency Validated: On initial credentialing and at least every two years, through one of the following primary sources:

• American Board of Medical Specialties (http://www.abms.org)
• American Osteopathic Association (http://www.osteopathic.org)
• American Board of Podiatric Orthopedics and Primary Podiatric Medicine (http://www.abpoppm.org)
• American Board of Podiatric Surgery (http://www.abps.org)
• American Board of Oral and Maxillofacial Surgery (http://www.aboms.org)
• Behavioral Analyst Certification Board (http://www.bacb.com)

Gender

Definition: Self explanatory.

Source: This information is self-reported and verified during the initial credentialing process, every two years on the provider’s re-credentialing application, which is a signed document in which the provider confirms the information is accurate and complete, as well as yearly outreach to the provider for data validation.

Frequency Validated: On initial credentialing and at least every two years at re-credentialing, as well as yearly outreach.

Hospital Affiliation

Definition: The HNE participating hospital where the provider has been granted privileges to provide medical care.

Source: This information is self-reported and verified during the initial credentialing process and every two years on the provider's re-credentialing application, which is a signed document in which the provider confirms the information is accurate and complete.

Frequency Validated: On initial credentialing and at least every two years at re-credentialing.

Language

Definition: Languages Spoken in Addition to English. List of languages spoken by the provider. The office staff may, or may not, speak the same or other languages as the provider.

Source: This information is self-reported and verified during the initial credentialing process and every two years or more often on the provider's re-credentialing application, which is a signed document in which the provider confirms the information is accurate and complete.

Frequency Validated: On initial credentialing and at least every two years at re-credentialing.

Last Name

Definition: Self explanatory.

Source: This information is self-reported and verified during the initial credentialing process, every two years on the provider’s re-credentialing application, which is a signed document in which the provider confirms the information is accurate and complete, as well as yearly outreach to the provider for data validation.

Frequency Validated: On initial credentialing and at least every two years at re-credentialing, as well as yearly outreach.

Office Location

Definition: A list of practice locations (street, city, state) at which the provider will see members.

Source: This information is self-reported and verified during the initial credentialing process and every two years or more often on the provider's re-credentialing application, which is a signed document in which the provider confirms the information is accurate and complete.

Frequency Validated: On initial credentialing and at least every two years at re-credentialing.

Practice Name (Medicare Group Affiliation)

Definition: The name of a group practice to which a provider belongs to or is associated with, if applicable.

Source: This information is self-reported and verified during the initial credentialing process, every two years on the provider’s re-credentialing application, which is a signed document in which the provider confirms the information is accurate and complete, as well as yearly outreach to the provider for data validation.

Frequency Validated: On initial credentialing and at least every two years at re-credentialing, as well as yearly outreach.

Specialty

Definition: The provider's special field of practice or expertise. The provider will only be listed in a requested specialty that Health New England can verify and that the provider has the education and training to support the requested specialty.

Source: This information is self-reported and verified during the initial credentialing process and every two years on the provider's re-credentialing application, which is a signed document in which the provider confirms the information is accurate and complete.

Frequency Validated: On initial credentialing and at least every two years at re-credentialing.

Hospital Accreditation Status

Definition: A process of evaluating an institution/facility to determine whether it meets the standards set up by the accrediting body, and granting recognition of the fact. Accreditation is a process performed by a non-governmental agency at the request of the institution.

Source: This information is self-reported and verified during the initial credentialing process and every three years on the facility re-credentialing application, which is a signed document in which the provider confirms the information is accurate and complete.

Frequency Validated: On initial credentialing and at least every three years through one or the following primary sources:

• AAAHC: Accreditation Association for Ambulatory Health Care, Inc. (http://www.aaahc.org)
• AABB: Advancing Transfusion and Cellular Therapies Worldwide (http://www.aabb.org)
• AASM: American Academy of Sleep Medicine (http://www.aasmnet.org)
• ABC: American Board for Certification in Orthotics, Prosthetics & Pedorthics (http://www.abcop.org)
• ACHC: Accreditation Commission for Health Care (http://www.achc.org)
• ACR: American College of Radiology (http://www.acr.org)
• BOC: Board of Certification / Accreditation (http://www.bocusa.org)
• CAP: College of American Pathologists (http://www.cap.org)
• CARF: Commission on Accreditation of Rehabilitation Facilities (http://www.carf.org)
• CHAP: Community Health Accreditation Partner (http://www.chapinc.org)
• CLIA: Clinical Laboratory Improvement Amendments (https://www.cms.gov/clia)
• COA: Council on Accreditation (http://coanet.org)
• DNVGL: Det Norske Veritas Germanischer Lloyd DNV GL Healthcare (http://dnvglhealthcare.com)
• HFAP: Healthcare Facilities Accreditation Program (http://www.hfap.org)
• IAC: Intersocietal Accreditation Commission (http://www.intersocietal.org)
• The Joint Commission (formerly JCAHO: Joint Commission on Accreditation of Healthcare Organizations) (http://www.jointcommission.org)

Hospital Location and Phone Number

Definition: A list of hospital locations (street, city, state) at which the hospital will see members.

Source: This information is self-reported and verified during the initial credentialing process and every three years on the hospital’s re-credentialing application, which is a signed document in which the hospital confirms the information is accurate and complete, as well as regular outreach to the hospital for data validation.

Frequency Validated: On initial credentialing and at least every three years at re-credentialing, as well as regular outreach.

Hospital Name

Definition: Self explanatory.

Source: This information is self-reported and verified during the initial credentialing process and every three years on the hospital’s re-credentialing application, which is a signed document in which the hospital confirms the information is accurate and complete, as well as yearly outreach to the hospital for data validation.

Frequency Validated: On initial credentialing and at least every three years at re-credentialing, as well as yearly outreach.

Hospital Quality Data from Recognized Sources

Definition: Detailed information about a hospital’s performance and how it compares to similar organizations. Hospital Quality Data is intended to provide consumers with quality of care information in order to make more informed decisions about their healthcare.

Source: This information is self-reported and verified during the initial credentialing process and every three years on the facility re-credentialing application, which is a signed document in which the provider confirms the information is accurate and complete.

Frequency: On initial credentialing and at least every three years through one or the following sources:

• The Joint Commission (formerly JCAHO: Joint Commission on Accreditation of Healthcare Organizations):
  • The Summary of Quality Information provides a high level overview of important quality of care indicators at a hospital. These quality of care indicators are important factors to take into consideration when selecting a health care organization.
• CMS Hospital Compare: https://www.medicare.gov/hospitalcompare/search.html
  • Hospital Compare is a consumer-oriented website that provides information on how well hospitals provide recommended care to their patients. This information can help consumers make informed decisions about health care. Hospital Compare allows consumers to select multiple hospitals and directly compare performance measure information related to heart attack, heart failure, pneumonia, surgery and other conditions. These results are organized by:
    • Patient Survey Results
    • Timely and Effective Care
    • Readmissions, Complications, and Deaths
    • Use of Medical Imaging
    • Linking Quality to Payment
    • Medicare Volume
• Leap Frog: https://www.leapfroggroup.org/
  • The Leapfrog initiatives have been built upon the fact that hospital performance transparency is critical to the optimal functioning of the healthcare marketplace. Leapfrog's public reporting initiatives offer valuable benchmarking capabilities to hospitals, as well as provide consumers and purchasers of healthcare with the quality and safety they need to make informed choices about their, or their employees', care.

Facility Name

Definition: Self explanatory.

Source: This information is self-reported and verified during the initial credentialing process, every two years on the provider’s re-credentialing application, which is a signed document in which the provider confirms the information is accurate and complete, as well as yearly outreach to the provider for data validation.

Frequency Validated: On initial credentialing and at least every two years at re-credentialing, as well as yearly outreach.

Office Location

Definition: A list of practice locations (street, city, state) at which the provider will see members.

Source: This information is self-reported and verified during the initial credentialing process and every two years or more often on the provider's re-credentialing application, which is a signed document in which the provider confirms the information is accurate and complete.

Frequency Validated: On initial credentialing and at least every two years at re-credentialing.