Glossary
Term |
Definition |
Description of how the information is collected |
Resulting limitations |
Description of how often each item is validated |
| Provider Name | Provider's name |
The provider tells us his or her name. |
The provider tells us his or her name. We do not ensure that information is accurate at that time. | We collect this information during recredentialing. That happens every 2 years. We do not ensure that information is accurate, but staff do verify with the provider through routine provider visits at least once every 3 years. |
| Gender | Male or Female | The provider tells us his or her gender. |
The provider tells us his or her gender. We do not ensure that information is accurate at that time. |
Staff verify with the provider through routine provider visits at least once every 3 years. |
| Specialty | The area of medicine that a health care provider has a special interest in. |
The provider gives us that information. |
The provider gives us that information. |
We verify this information during initial credentialing, and during recredentialing. That happens every 2 years. We also make sure it's correct whenever the provider tells us about a change in hospital affiliation. Staff also verify with the provider through routine provider visits at least once every 3 years. |
| Hospital Affiliation(s) | The hospital(s) where the health care provider can admit patients. |
The provider gives us that information. The hospital makes sure it's accurate. |
We rely on the hospital to keep its records updated. |
We make sure this information is correct during recredentialing. That happens every 2 years. We also make sure it's correct whenever the provider tells us about a change in hospital affiliation. Staff also verify with the provider through routine provider visits at least once every 3 years. |
| Medical Group Affiliation(s), if applicable | If applicable, the group of clinicians the provider works with. |
If applicable, the provider or provider group gives us that information. | If applicable, the provider gives us that information. We do not ensure that information is accurate at that time. |
We collect this information during recredentialing. That happens every 2 years. We do not ensure that information is accurate. Staff verify medical group affiliation with the provider through routine provider visits at least once every 3 years. |
| Board Certification | A certification for health care providers who are trained in a medical specialty. Also given to those who pass special exams to prove how much they know about a specialty. Providers need to be board certified or seeking board certification. |
The provider gives us the information on the credentialing application. It is verified by the specialty board. | We rely on the specialty board to keep its records updated. |
We make sure the information is correct at each credentialing cycle. Then we make sure it's still correct each year if board certification ends between recredentialing cycles. |
| Accepting New Patients | The provider will see new patients who aren't already seen by him or her. | The provider gives us that information. |
The provider gives us that information. We do not ensure that information is accurate at that time. | We collect the information when the provider joins the network and when the provider wants to change new-patient status. Staff also verify with the provider through routine provider visits at least once every 3 years. |
| Languages | Languages spoken by the provider. |
The provider gives us that information. |
The provider gives us that information. We do not ensure that information is accurate at that time. | Staff verify languages spoken with the provider through routine provider visits at least once every 3 years. |
| Office Locations | Where the provider sees patients. | The provider gives us that information. |
The provider gives us that information. We do not ensure that information is accurate at that time. | We collect this information during recredentialing. That happens every 2 years. We do not ensure that information is accurate. Staff verify languages spoken with the provider through routine provider visits at least once every 3 years. |
| Facility Name | Name of a facility like a hospital or nursing home |
The facility gives us that information. The name the facility gives us is compared to the name on the state license to make sure it's correct. |
We rely on the state licensing agency to keep their records updated. | We make sure the information is correct during recredentialing. That happens every 3 years. |
| Location | Physical address of the facility |
The facility gives us that information. |
The facility gives us that information. We do not ensure that information is accurate at that time. | We make sure the information is correct during recredentialing. That happens every 3 years. |
| Accreditation | When a special outside group decides that a medical facility meets certain standards of care. |
The medical facility gives us the information on the credentialing application. It is verified by the accrediting group. |
We rely on the accrediting group to keep their records updated. |
We make sure the information is correct at the first credentialing. Then it's checked again during recredentialing. That happens every 3 years. |