Glossary

This glossary contains terms that relate to NPDB, and the definitions apply only to their usage in conjunction with the NPDB and its policies and procedures.

Adverse action. (1) An action taken against a practitioner’s clinical privileges or medical staff membership in a health care entity, or (2) a licensure disciplinary action.

Adverse Action Report (AAR). The format used by health care entities and state

licensing boards to report an adverse action taken against a physician, dentist, or other

health care practitioner.

Authorized agent. An individual or organization that an eligible entity designates to query the NPDB on its behalf. In most cases, an authorized agent is an independent contractor to the requesting entity (for instance, a county medical society or state hospital association) used for centralized credentialing. An authorized agent cannot query the NPDB without designation from an eligible entity.

Board of medical examiners. A body or subdivision of such body that is designated by a state for licensing, monitoring, and disciplining physicians or dentists. This term includes boards of allopathic or osteopathic examiners, a composite board, a subdivision, or an equivalent body as determined by the state.

Clinical privileges. Privileges, membership on the medical staff, and other circumstances (including panel memberships) in which a physician, dentist, or other licensed health care practitioner is permitted to furnish medical care by a health care entity.

Continuous Query. 24 hours a day, 365 days a year. Continuous Query keeps entities informed about the adverse licensure, privileging, Medicare/Medicaid exclusions, civil and criminal convictions, and medical malpractice payments on their enrolled practitioners. By enrolling all practitioners with which one interacts, the entity receives email notifications within 24 hours of a report received by the NPDB. Continuous Query is only for querying on practitioners, not health care organizations, and meets legal and accreditation requirements for querying the NPDB.

NPDB Identification Number (DBID). A unique, 15-digit, identification number

assigned to eligible entities and authorized agents when they register with the NPDB.

Entities and agents need this number to query and report to the NPDB using the IQRS. The DBID must be included on all correspondence to the NPDB.

NPDB Content. The NPDB acts as a clearinghouse of information relating to medical malpractice payments, certain adverse actions taken against practitioners’ licenses, clinical privileges, and professional society memberships, and eligibility to participate in Medicare/Medicaid. Recently merged with the NPDB, the HIPDB formerly collected information regarding licensure and certification actions, exclusions from participation

in federal and state health care programs, criminal convictions, and civil judgments related to health care.

NPDB Eligible Entities. An entity that is entitled to query and/or report to the NPDB under the provisions of Title IV of Public Law 99-660, as specified in 45 CFR Part 60. Eligible entities must certify their eligibility to the NPDB in order to query and/or report.

NPDB Intended Use. NPDB information is intended to be used in combination with information from other sources in making determinations on granting clinical privileges or in employment, affiliation, or licensure decisions.

NPDB Requirements. NPDB querying and reporting requirements apply to physicians, dentists, other licensed health care practitioners, a federal or state government agency, or a health plan. The NPDB Overview provided in Supporting State A, Appendix Table A clarifies who reports, who queries, and what type of information is reported in order to develop a suitable survey of eligible users.

Department of Health and Human Services (DHHS). The government agency responsible for administration of the NPDB.

Dispute. A formal, written objection of the accuracy of a report or the fact that a specific event was reported to the NPDB. Disputes may be made only by the subject of a report.

Entity Registration Form. Allows entities to register for the NPDB. The information requested on this form provides the NPDB with essential information concerning your entity, such as your organization's name, address, Federal Taxpayer Identification Number (TIN), and ownership; your organization's authority to participate in the NPDB under each of the statutes governing the NPDBs (Title IV and Section 1921 of the Social Security Act for the NPDB); your organization's primary function or service; and, for those entities authorized by law to query the NPDB, whether queries are to be submitted to the NPDB. This information allows the NPDB to register your entity’s authorization to participate in the NPDB, to determine your entity’s reporting and/or querying requirements and restrictions, and to direct query and report responses appropriately.

Exclusions from Participation in Federal/State Health Care Programs. Federal and state agencies must report health care practitioners, providers, or suppliers excluded from participating in federal or state health care programs. The term “exclusion” means a temporary or permanent debarment of an individual or entity from participation in a federal or state health-related program, in accordance with which items or services furnished by such person or entity will not be reimbursed under any federal or state health-related program. Section 1128E limits the definition of federal or state health care programs to those programs defined in Sections 1128B(f) and 1128(h), respectively, of the Social Security Act. Exclusions from federal or state health care programs are reported under the Exclusion or Debarment category on the Adverse Action Report.

Fees. Entity Query Fees are charged for all queries submitted to the NPDB. The query fee is based on the cost of processing requests and providing information to eligible entities. The act of submitting a query to the NPDB is considered an agreement to pay the associated fee. A fee is assessed when a query is:

• Processed regardless of whether there is information on file regarding a subject;

• Rejected by the NPDB because it is improperly completed or lacks required information; and

• A practitioner may submit a self-query at any time. Self-query requests for individuals are automatically sent to the NPDB and are assessed a fee.

Federal or State Government Agency Entities. Federal or state government agencies include, but are not limited to, the following:

• The U.S. Department of Justice (e.g., the Federal Bureau of Investigation, the U.S. Attorney, the Drug Enforcement Administration).

• The U.S. Department of Health and Human Services (e.g., the Food and Drug Administration, the Health Care Financing Administration, the Office of Inspector General).

• Any other federal agency that either administers or provides payment for the delivery of health care services, including (but not limited to) the U.S. Department of Defense and the U.S. Department of Veterans Affairs.

• Federal and state law enforcement agencies, including states attorney generals and law enforcement investigators (e.g., county and district attorneys, and county police departments).

• State Medicaid Fraud Control Units.

• Federal or state agencies responsible for the licensing or certification of health care practitioners, providers, and suppliers. Examples of such state agencies include Departments of Professional Regulation, Health, Social Services (including State Survey and Certification and Medicaid Single State agencies), Commerce, and Insurance.

Formal peer review process. The conduct of professional review activities through

formally adopted written procedures that provide for adequate notice and an opportunity for a hearing.

Health care entity. Defined as (1) a hospital; (2) an entity that provides health care services and follows a formal peer review process for the purpose of furthering quality health care; or (3) a professional society or a committee or agent thereof, including those at the national, state, or local level, of physicians, dentists, or other health care practitioners, that follows a formal peer review process for the purpose of furthering quality health care.

Health care practitioner. An individual other than a physician or dentist (1) who is

licensed or otherwise authorized by a state to provide health care services, or (2) who,

without state authority, holds himself or herself out to be authorized to provide health care services.

Health Plan. The term “health plan” refers to a plan, program or organization that provides health benefits, whether directly or through insurance, reimbursement or otherwise. Entities may be recognized as “health plans” if they meet the basic criterion of “providing health benefits.” Health plans include, but are not limited to:

• A policy of health insurance.

• A contract of a service benefit organization.

• A membership agreement with a health maintenance organization or other prepaid health plan.

• A plan, program, or agreement established, maintained, or made available by an employer or group of employers; a practitioner, provider, or supplier group; a third-party administrator; an integrated health care delivery system; an employee welfare association; a public service group or organization;

or a professional association.

• An insurance company, insurance service, or insurance organization that is licensed to engage in the business of selling health care insurance in a state, and which is subject to state law which regulates health insurance.

Health plans may include those plans funded by federal and state governments, including:

• Medicare.

• Medicaid.

• The U.S. Department of Defense.

• The U.S. Department of Veterans Affairs.

• The Bureau of Indian Affairs programs.

Hospital. [As described in Section 1861(e)(1) and (7) of the Social Security Act] — An

institution primarily engaged in providing, by or under the supervision of physicians, to

inpatients (1) diagnostic services and therapeutic services for medical diagnosis, treatment, and care of injured, disabled, or sick persons; or (2) rehabilitation services for the rehabilitation of injured, disabled, or sick persons, and, if required by state or local law, is licensed or is approved by the agency of the state or locality responsible for licensing hospitals as meeting the standards established for such licensing.

Initial Report. The original record of a medical malpractice payment or adverse action

submitted by a reporting entity. An eligible entity references an Initial Report (using the

DCN) when submitting a Correction, Void, or Revision to Action.

Integrated Querying and Reporting Service (IQRS). An electronic, Internet-based

system for querying and reporting to the NPDB.

Licensure disciplinary action. (1) revocation, suspension, restriction, or acceptance of

surrender of a license; and (2) censure, reprimand, or probation of a licensed physician or

dentist based on professional competence or professional conduct.

Matched response. A result of query processing. When the NPDB receives a properly completed query, the information is entered into the NPDB computer system. The computer system performs a validation process that matches subject (i.e., practitioner) identifying information submitted in the query with information previously reported to the NPDB. Information reported about a specific subject is released to an eligible querier

only if the identifying information provided in the query matches the information in a report.

Medical malpractice payer. An entity that makes a medical malpractice payment through an insurance policy or otherwise for the benefit of a practitioner.

Medical malpractice payment. A monetary exchange as a result of a settlement or

judgment of a written complaint or claim demanding payment based on a physician’s,

dentist’s, or other licensed health care practitioner’s provision of or failure to provide health care services, and may include, but is not limited to, the filing of a cause of action, based on the law of tort, brought in any state or federal court or other adjudicative body.

Medical Malpractice Payment Report. The format used by medical malpractice payers to report a medical malpractice payment made for the benefit of a physician, dentist, or other health care practitioner.

NPDB Customer Service Center. The Customer Service Center encompasses all the tools and services that the NPDBs use to support customers. Questions may be directed to Information Specialists at the Customer Service Center by e-mail at [email protected] or by phone at 1-800-767-6732 (TDD 1-703-802-9395).

Other Adjudicated Actions or Decisions. Federal and state government agencies and health plans must report adjudicated actions or decisions against health care practitioners, providers, and suppliers. The term “other adjudicated actions or decisions” means:

• formal or official final actions taken against a health care practitioner, provider, or supplier by a federal or state government agency or a health plan;

• which include the availability of a due process mechanism; and

• based on acts or omissions that affect or could affect the payment, provision, or delivery of a health care item or service.

Professional review activity. An activity of a health care entity with respect to an

individual physician, dentist, or other health care practitioner: (1) to determine whether the physician, dentist, or other health care practitioner may have clinical privileges with respect to, or membership in, the entity; (2) to determine the scope or conditions of such privileges or membership; or (3) to change or modify such privileges or membership.

Professional society. An association of physicians or dentists that follows a formal peer

review process for the purpose of furthering quality health care.

Query. A request for information submitted to the NPDB by an eligible entity or authorized agent via the IQRS or ICD format.

Report. Record of a medical malpractice payment or adverse action submitted to the NPDB by an eligible entity. Reports may be submitted via the IQRS or by ITP using the appropriate ICD format.

State licensing board. A generic term used to refer to state medical and dental boards, as well as those bodies responsible for licensing other health care practitioners.

State medical or dental board. A board of medical examiners.

45 Code of Federal Regulations Part 60 (45 CFR 60). Federal regulations that govern the NPDB.