Information Validation

NOTES:

The term doctor, physician, and individual practitioner are used interchangeably in this section.

Source: The practitioner's most recent initial credentialing or re-credentialing application.
Frequency of validation: Verified at initial credentialing and re-credentialing, every 3 years.
Limitations: Self-reported information.

Source: The practitioner's most recent initial credentialing or re-credentialing application.
Frequency of validation: Verified at initial credentialing and re-credentialing, every 3 years.
Limitations: Self-reported information.

Explanation: A focused area of practice that a doctor has additional education and training beyond a general medical degree
Source: The practitioner's most recent initial credentialing or re-credentialing application.
Frequency of validation: Verified at initial credentialing and re-credentialing, every 3 years.
Limitations: Self-reported information.

Explanation: The HealthChoices Medicaid program includes coverage for these medically necessary mental health, substance abuse and behavioral services. Each service requires a specific Provider Type issued by the Commonwealth of Pennsylvania.
Source: The practitioner's most recent initial credentialing or re-credentialing application.
Frequency of validation: Verified at initial credentialing and re-credentialing, every 3 years.
Limitations: None.

Explanation: The facility (hospital) where he/she has admitting privileges, or a non-hospital agency/facility where he/she is employed or contracted.
Source: The practitioner's most recent initial credentialing or re-credentialing application.
Frequency of validation: Verified at initial credentialing and re-credentialing, every 3 years.
Limitations: Self-reported information.

Explanation: Recognizes a doctor has met the requirements/standards of a nationally recognized specialty organization.
Source: The practitioner's most recent initial credentialing or re-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.

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.

Explanation: This is the language(s) spoken by the practitioner or clinical office staff.
Source: The practitioner's most recent initial credentialing or re-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.

Source: The practitioner's most recent initial credentialing or re-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.

Name

Source: The hospital’s initial credentialing application.
Frequency of validation: Verified at initial credentialing and re-credentialing, every 3 years.
Limitations: Self-reported information

Location

Source: The hospital’s initial credentialing application.
Frequency of validation: Verified at initial credentialing and re-credentialing, every 3 years. Also updated when notified of any changes (within 30 days).
Limitations: Self-reported information.

Accreditation

Explanation: Certification that an agency/facility has met the requirements/standards of a nationally recognized accrediting body for hospitals.
Source: The agency’s/facility’s initial credentialing application. Verified by obtaining a copy of the agency’s/facility’s current accreditation.
Frequency of validation: Verified at initial credentialing and re-credentialing, every 3 years.
Limitations: None.