Information Validation

Physician Information

Name

  • Source:  This information is gathered from the practitioner’s initial credentialing application.
  • Frequency of validation:  This information is verified at the time of initial credentialing and at recredentialing, every 3 years. 
  • Limitations:  Self Reported

Gender

  • Source:  This information is gathered from the practitioner’s initial credentialing application.
  • Frequency of validation:  This information is verified at the time of initial credentialing and at recredentialing, every 3 years. 
  • Limitations:Self Reported

Specialty

  • Explanation:  An area of focused medicine in which a practitioner has attained education and training beyond a general medical doctor license.  Click here to see an explanation of each specific specialty.
  • Source:  This information is gathered from the practitioner’s initial credentialing application and verified via the American Medical Association (AMA) or American Osteopathy Association (AOA) for board certified physicians or through primary source verification from the school in which the provider received specialty training.  
  • Frequency of validation:  This information is verified at the time of initial credentialing and at recredentialing, every 3 years. 
  • Limitations:  None

Hospital Affiliations

  • Explanation:  The practitioner’s hospital affiliation is the facility where he/she has admitting privileges.   
  • Source:  This information is gathered from the practitioner’s initial credentialing application.  
  • Frequency of validation:  This information is verified at the time of initial credentialing and at recredentialing, every 3 years. 
  • Limitations:  This information is self-reported.

Medical Group Affiliations

  • Explanation:  The medical group affiliations are the various practices in which a practitioner participates. 
  • Source:  This information is gathered from the practitioner’s initial credentialing application. 
  • Frequency of validation:  This information is verified at the time of initial credentialing and at recredentialing, every 3 years.  It is also updated upon notification from the practitioner that he/she is moving or adding a medical group affiliation.
  • Limitations:  This information is self-reported.

Board Certification

  • Explanation:  A certification recognizing a physician has met the requirements/standards of a nationally recognized specialty board.    
  • Source:  This information is gathered from the practitioner’s initial credentialing application and verified through either the American Board of Medical Specialties (ABMS), the American Medical Association (AMA) or the American Osteopathy Association (AOA). 
  • Frequency of validation:  This information is verified at the time of initial credentialing by searching the ABMS, AMA, or the AOA website for board eligibility and again at recredentialing, every 3 years.  
  • Limitations:  None.

Acceptance of New Patients

  • Explanation:  Whether or not a practitioner will see new patients in their practice.
  • Source:  This information is gathered from the practitioner’s initial credentialing application and updated as the status is reported changed by the practitioner.
  • Frequency of validation:  This information is verified at the time of initial credentialing and upon notification of change by the practitioner. 
  • Limitations:  Self reported and requires notification from the practitioner of change in status.

Language spoken by the Practitioner, or Clinical Staff

  • Explanation: This is the language(s) spoken by the practitioner, clinical or office staff.   Practices offer language services to their patients through a variety of ways, including bilingual staff, onsite interpreters and remote video or telephone interpreters.     
  • Source: This information is gathered from the practitioner’s initial Council for Affordable Quality Healthcare (CAQH) credentialing application. The Plan offers telephonic interpretation services to all members and provider offices. 
  • Frequency of validation: It is updated each month as new multilingual practitioners are credentialed, or as practitioners leave the Plan.
  • Limitations: Information on practice language services is self-reported.

Office Location

  • Source:  This information is gathered from the practitioner’s initial credentialing application.
  • Frequency of validation:  It is updated upon notification of change by the practitioner.
  • Limitations:  This information is self reported.

Hospital Information

Facility Name

  • Source:  This information is gathered from the facility's application
  • Frequency of validation:  Upon initial application and receipt of notification from the facility that the name has changed.
  • Limitations:  This information is self-reported

Location

  • Source:  This information is gathered from the facility's application
  • Frequency of validation:  Upon initial application and receipt of notification from the facility that the location has changed.
  • Limitations:  This information is self-reported

Accreditation

  • Explanation:  Certification that a hospital has met the requirements/standards of a nationally recognized accrediting body for hospitals.   
  • Source:  This information is gathered from the hospital’s initial credentialing application and verified by obtaining a copy of the hospital’s current certification. 
  • Frequency of validation:  This information is verified at the time of initial credentialing and at recredentialing, every 3 years. 
  • Limitations:  None

Specialty Definitions
Allergy & Immunology: Diagnosis and treatment of hypersensitive states resulting from exposure to a particular allergen and diseases of the immune system.
Anesthesiology: The administration of anesthetics to cause insensibility to pain.
Audiology: The evaluation of the hearing function to detect hearing impairment and, if there is a hearing disorder, to determine the anatomical site involved and its cause.
Cardio & Thoracic Surgery A branch of medicine dealing with the use of surgery to treat diseases of the chest and lungs.
Cardiology: Diagnosis and treatment of diseases of the heart and blood vessels of adults.
Cardiovascular Disease: The study of the structure, function and diseases of the heart
Child & Adolescent Psychiatry: A branch of medicine concerned with the diagnosis, treatment and prevention of mental illness of children and adolescents
Chiropractic The non-drug treatment of musculoskeletal problems, including joint sprains and disk injuries
Clinical Neuropsychology: A science concerned with the integration of psychological observations on behavior and the mind with neurological observations on the brain and nervous system.
Clinical Psychology: Specialist in psychotherapy who works with individuals, groups or families to resolve problems.
Colon & Rectal Surgery: Surgery for the treatment of disorders of the large intestine and rectum.
Dermatology: Diagnosis and treatment of diseases of the skin
Dermatopathology: The study of the skin.
Electrophysiology: The study of the electrical aspects of the body or body parts.
Emergency Medicine: A medical specialty concerned with the care and treatment of acutely ill or injured patients who need immediate medical attention.
Endocrinology: The diagnosis and treatment of disorders of the internal (glands such as the thyroid and adrenal glands. Also includes diagnosis and treatment of diabetes, pituitary diseases, and menstrual and sexual problems.
Family Practice The field of medicine specializing in the treatment of all members of a family (children and adults) for the most common illnesses. The family practitioner is concerned with the total health care for the individual and family.
Gastroenterology Diagnosis and treatment of diseases and disorders of the digestive system including the stomach, intestines, colon, liver, gallbladder and the pancreas.
General Practice: A physician or group of physicians who provide general medical care.
Geriatric Medicine: The branch of medicine concerned with the physiological and pathological aspects of the elderly.
Gynecologic Oncology: Diagnosis and treatment of tumors and malignancies of the female reproductive organs, including the breasts.
Gynecology: A branch of medicine that deals with the diseases and routine physical care of the reproductive system of women.
Gynecology Surgery: Surgery for the diagnosis and treatment of diseases of the reproductive system of women.
Hand Surgery: Diagnosis and treatment of deformities and/or injuries of the hand and wrist.
Hematology: The study of blood, blood clotting mechanisms, bone marrow, lymph nodes and the disorders associated with them.
Hematology/Oncology Diagnosis and treatment of diseases of the blood, spleen, lymph glands, tumors and malignancies.
Infectious Disease: Diagnosis of acute and chronic infections, which may or may not be contagious.
Internal Medicine: Diagnosis and treatment, in adults, of the internal organs and functions of the body pertaining to the heart, circulatory system, lungs, digestive system, kidneys, nervous system and endocrine system.
Maternal & Fetal Medicine: The diagnosis and treatment of complications of pregnancy
Medical Oncology: The diagnosis and treatment of all types of cancer and other benign and malignant tumors
Neonatal-Perinatal Medicine: The branch of medicine concerned with the newborn shortly before and after birth.
Neonatology: A branch of medicine concerned with the care, development, and diseases of newborn infants.
Nephrology: Diagnosis and treatment of diseases of the kidneys, high blood pressure, fluid and mineral balance, and dialysis of body wastes when the kidneys do not function.
Neurological Surgery: Surgery for the diagnosis and treatment of diseases of the nervous system which include illnesses involving the brain, spinal cord, peripheral nerves and muscles.
Neurology: The study of the structure, functioning and diseases of the nervous system, including the brain, spinal cord and peripheral nerves.
Nurse Midwife: Professional nurses who have received postgraduate training in assisting women in childbirth.
Nurse Practitioner A registered nurse who through advanced training is qualified to assume some of the duties and responsibilities formerly assumed only by a physician.
Obstetrician: A specialist that deals with the medical science of child birth. 
Obstetrics & Gynecology: The branch of medicine concerned with the care of women during pregnancy and the diagnosis and treatment of diseases of the female reproductive system.
Occupational Medicine: A subspecialty of Preventive Medicine that focuses on the relationships among the health of workers, the ability to perform work, the arrangements of work, and the physical and chemical environments of the workplace
Occupational Therapy: The development of adaptive skills, increased performance capacity, and those factors that may impede or restrict ability to function.
Oncology: The study of tumors.
Ophthalmology: Diagnosis and treatment of diseases and disorders of the eye.
Orthopedic Surgery: Surgery for correction of deformities and treatment of disorders in joints, muscles, tendons, ligaments, cartilage and related structures.
Orthopedic: Diagnosis and treatment of disorders in joints, muscles, tendons, ligaments, cartilage and related structures.
Otolaryngology: Diagnosis and treatment of diseases and disorders of the ear, nose and throat.
Pain Medicine: The process of providing medical care that alleviates or reduces pain.
Pathology: The branch of medicine concerned with disease, especially its structure and its functional effect on the body.
Pediatric Cardiology: Diagnosis and treatment of diseases of the heart and blood vessels of infants, children and adolescents.
Pediatric Endocrinology: The diagnosis and treatment of disorders of the internal (glands such as the thyroid and adrenal glands of infants, children and adolescents.
Pediatric Gastroenterology: Diagnosis and treatment of diseases and disorders of the digestive system including the stomach, intestines, colon, liver, gallbladder and the pancreas of infants, children and adolescents.
Pediatric Hematology-Oncology: Diagnosis and treatment of diseases of the blood, spleen, lymph glands, tumors and malignancies
Pediatric Infectious Disease: Diagnosis of acute and chronic infections, which may or may not be contagious of infants, children and adolescents.
Pediatric Nephrology: Diagnosis and treatment of diseases of the kidney of infants, children and adolescents
Pediatric Neurology: The study of the structure, functioning and diseases of the nervous system, including the brain, spinal cord and peripheral nerves in infants, children, and adolescents.
Pediatric Orthopaedics: Diagnosis and treatment of disorders in joints, muscles, tendons, ligaments, cartilage and related structures of infants, children and adolescents.
Pediatric Pulmonology: Diagnosis and treatment of diseases of the lungs and other chest tissues of infants, children and adolescents.
Pediatric Surgery: Surgery dealing with a variety of problems, including disorders of the stomach, small intestine and colon as well as the liver, gallbladder and pancreas, and a wide variety of cancers in infants, children and adolescents.
Pediatric Urology A branch of medicine concerned with the diagnosis and treatment of diseases of the urinary tract in both sexes and the genital tract in the male.
Pediatrics: Diagnosis and treatment of the diseases of infants, children and adolescents.
Perinatology: A branch of medicine concerned with perinatal care.
Physical Medicine And Rehabilitation: Treatment of disease by physical agents such as heat, cold, light, electricity, manipulation or the use of mechanical devices for the restoration of physiologic function.
Physical Therapy: The evaluation and treatment of any person by the employment of the effective properties of physical measures, the performance of tests and measurements as an aid to evaluation
Plastic Surgery: Surgery concerned with the repair or restoration of defective or missing structures, frequently involving the transference of tissue from a part or person to another part or person.
Podiatry: Care and treatment of the foot
Psychiatry: A branch of medicine concerned with the diagnosis, treatment and prevention of mental illness.
Psychology: Specialist in psychotherapy who works with individuals, groups or families to resolve problems.
Pulmonary Disease: A subspecialty of internal medicine concerned with the study of the respiratory system. It is especially concerned with diagnosis and treatment of diseases and defects of the lungs and bronchial tree.
Radiation Oncology: The therapeutic applications of radiant energy and its modifiers to the treatment of disease, especially malignant tumors.
Radiology: Diagnosis and treatment of illnesses and injuries with the use of electromagnetic radiation, ultrasonics, and other forms of radiant energy
Rheumatology: A branch of medicine concerned with the diagnosis and treatment of arthritis.
Social Worker: An individual specializing in organized work intended to advance the social conditions of a community, and especially of the disadvantaged, by providing psychological counseling, guidance, and assistance, especially in the form of social services.
Speech Pathology: The study of communication or expression of thoughts in spoken words.
Sports Medicine The field of medicine concerned with physical fitness and the diagnosis and treatment of injuries sustained in sports activities.
Surgery: A surgical specialty that involves largely the surgical management of diseases of the bowel, gallbladder, stomach and other digestive organs.
Thoracic Surgery: A branch of medicine dealing with the use of surgery to treat diseases of the chest and lungs.
Urology: A branch of medicine concerned with the diagnosis and treatment of diseases of the urinary tract in both sexes and the genital tract in the male.
Vascular Surgery: A branch of medicine dealing with the use of surgery to treat diseases of the blood vessels.