Medicaid Enrollees
Validation of Information
Physician Information
Notes
- The term doctor, physician, provider and practitioner are used interchangeably in this section.
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 / provider has additional education and training beyond a general medical license. See Specialty definitions
- 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
Specialty
- Explanation: A focused area of medicine that a doctor / provider has additional education and training beyond a general medical license. See Specialty definitions
- 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 with written validation from the listed facility.
- Frequency of validation: Verified at initial credentialing and re-credentialing, every 3 years.
- Limitations: Self-reported information.
Medical Group Affiliations
- Explanation: Two or more providers that work together in the same office.
- Source: The practitioner's initial credentialing application.
- Frequency of validation: Verified at initial credentialing and re-credentialing, every 3 years. Also updated when provided with written notification 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
Accepting New Patients
- Explanation: The provider will see new patients.
- 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 written notification of change 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: Obtained at initial credentialing and updated when notified by the practitioner.
- Limitations: Self-reported information.
*CareFirst CHPDC offers telephonic interpretation services to all enrollees 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 in writing by the practitioner that he/she is moving.
- Limitations: Self-reported information.
Hospital Information
- Source: Initial contract request.
- Frequency of validation: Verified upon contract initiation and every 3 years. Also updated when notified in writing of any changes (within 30 days).
- Limitations: Self-reported information.
Location
- Source: The hospital’s initial contract request.
- Frequency of validation: Verified upon contract initiation and every 3 years. Also updated when notified in writing of any changes (within 30 days).
- Limitations: Self-reported information.
Accreditation
- Explanation: Certification that a hospital has met the requirements/standards of a nationally recognized accrediting body for hospitals, such as The Joint Commission.
- Source: Verified directly with the accrediting body.
- Frequency of validation: Verified upon contract initiation and every 3 years.
- Limitations: None
CareFirst (CHPDC)
Community Health Plan
District of Columbia
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