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    NPDB Guidebook NPDB Guidebook Document Transcript

    • NPDB GuidebookNational Practitioner Data Bank
    • NPDB Guidebook Table of ContentsA. Introduction Preface................................................................................................................................... A-1 Background ........................................................................................................................... A-1 Title IV of Public Law 99-660.......................................................................................... A-2 Civil Liability Protection ...................................................................................................... A-2 Interpretation of NPDB Information..................................................................................... A-3 Confidentiality of NPDB Information .................................................................................. A-3 Disclosure of NPDB Information ......................................................................................... A-5 Coordination Between the NPDB and the HIPDB ............................................................... A-6 Official Language ................................................................................................................. A-6 User Fees............................................................................................................................... A-6B. Eligible Entities What is an Eligible Entity? ................................................................................................... B-1 Defining Health Care Entities........................................................................................... B-2 Hospitals ....................................................................................................................... B-2 Other Health Care Entities............................................................................................ B-2 Defining Professional Societies ........................................................................................ B-3 Defining State Licensing Boards ...................................................................................... B-3 Defining Medical Malpractice Payers .............................................................................. B-4 Registering with the NPDB .................................................................................................. B-4 Certifying Official............................................................................................................. B-4 Entity Recertification............................................................................................................ B-5 Data Bank Identification Numbers (DBIDs) ........................................................................ B-5 Deactivate a DBID........................................................................................................ B-5 Reactivate a DBID ........................................................................................................ B-6 User IDs ................................................................................................................................ B-6 Update Entity Information .................................................................................................... B-6 Lost Your DBID?.................................................................................................................. B-6 Organizations That May Report and Query on Behalf of Entities ....................................... B-6 Authorized Submitter........................................................................................................ B-7 Authorized Agents ............................................................................................................ B-7 Designating Authorized Agents........................................................................................ B-8 Questions and Answers..................................................................................................... B-9C. Health Care Practitioners Overview............................................................................................................................... C-1 Defining Health Care Practitioners....................................................................................... C-1 Practitioner Self-Query ......................................................................................................... C-4 Self-Querying on the Internet ............................................................................................... C-4 Subject Information in the NPDB......................................................................................... C-4 Questions and Answers......................................................................................................... C-5D. Queries Overview............................................................................................................................... D-1 Hospitals ........................................................................................................................... D-1 September 2001 i
    • Table of Contents NPDB Guidebook Residents and Interns ........................................................................................................ D-3 Professional Societies ....................................................................................................... D-3 State Licensing Boards ..................................................................................................... D-3 Types of Queries ................................................................................................................... D-5 Attorney Access .................................................................................................................... D-5 Authorized Agents ................................................................................................................ D-6 Submitting a Query to the NPDB ......................................................................................... D-6 Equipment Needed to Query Electronically ..................................................................... D-7 Querying Through an Authorized Agent .......................................................................... D-7 Query Processing .................................................................................................................. D-7 Subject Information .......................................................................................................... D-8 Subject Database............................................................................................................... D-8 Character Limits ............................................................................................................... D-8 Query Responses............................................................................................................... D-8 Query Response Availability ............................................................................................ D-9 Missing Query Responses................................................................................................. D-9 Correcting Query Information .............................................................................................. D-9 Failure to Query .................................................................................................................... D-9 Questions and Answers....................................................................................................... D-10E. Reports Overview................................................................................................................................E-1 Time Frame for Reporting to the NPDB............................................................................E-1 Civil Liability Protection ...................................................................................................E-1 Official Language ..............................................................................................................E-1 Computation of Time Periods............................................................................................E-1 Submitting Reports to the NPDB...........................................................................................E-2 Subject Information ...........................................................................................................E-2 When Subject Information Is Unknown ............................................................................E-2 Reporting Subject Social Security Numbers .....................................................................E-3 Incorrectly Identified Subject ............................................................................................E-3 Submitting Reports Via the IQRS .....................................................................................E-3 Draft Capability .............................................................................................................E-4 Submitting Reports to the NPDB Via ITP.........................................................................E-4 Types of Reports ....................................................................................................................E-4 Initial Report ......................................................................................................................E-4 Correction ..........................................................................................................................E-5 Void Previous Report.........................................................................................................E-5 Revision to Action .............................................................................................................E-5 Report Processing ..................................................................................................................E-6 Report Responses...................................................................................................................E-6 Missing Report Verification ..............................................................................................E-7 Reporting Medical Malpractice Payments.............................................................................E-8 Trigger Date for Reporting ................................................................................................E-8 Interpretation of Medical Malpractice Payment Information ............................................E-8 Sample Descriptions (for Illustrative Purposes Only) .......................................................E-9 ii September 2001
    • NPDB Guidebook Table of Contents Reporting of Payments by Individuals.............................................................................E-10 Payments for Corporations and Hospitals .......................................................................E-10 Deceased Practitioners.....................................................................................................E-11 Identifying Practitioners ..................................................................................................E-11 Insurance Policies that Cover More than One Practitioner .............................................E-11 One Settlement for More than One Practitioner ..............................................................E-11 Residents and Interns .......................................................................................................E-11 Students............................................................................................................................E-12 Practitioner Fee Refunds..................................................................................................E-12 Loss Adjustment Expenses ..............................................................................................E-12 Dismissal of a Defendant from a Lawsuit........................................................................E-12 High-Low Agreements.....................................................................................................E-13 Reporting by Authorized Agents .....................................................................................E-14 Payments by Multiple Payers ..........................................................................................E-14 Structured Settlements .....................................................................................................E-14 Subrogation-Type Payments............................................................................................E-15 Offshore Payers................................................................................................................E-15 Payments Made Prior to Settlement.................................................................................E-15 Reporting Adverse Clinical Privileges Actions ...................................................................E-17 Multiple Adverse Actions................................................................................................E-18 Denial of Applications .....................................................................................................E-18 Withdrawal of Applications.............................................................................................E-19 Investigations ...................................................................................................................E-19 Guidelines for Investigations .......................................................................................E-19 Summary Suspension.......................................................................................................E-19 Examples of Reportable and Non-Reportable Actions....................................................E-21 Reporting Adverse Licensure Actions.................................................................................E-24 Effective Date of Action ..................................................................................................E-24 Examples of Reportable Actions .....................................................................................E-24 Examples of Non-Reportable Actions .............................................................................E-25 Reporting Adverse Professional Society Membership Actions...........................................E-26 Reporting Requirements ..................................................................................................E-26 Reporting Medicare/Medicaid Exclusions ..........................................................................E-27 Sanctions for Failing to Report to the NPDB ......................................................................E-27 Medical Malpractice Payers.............................................................................................E-27 Hospitals and Other Health Care Entities ........................................................................E-28 State Boards .....................................................................................................................E-28 Professional Societies ......................................................................................................E-28 Questions and Answers....................................................................................................E-29F. Disputes The Dispute Process...............................................................................................................F-1 Subject Statements .............................................................................................................F-1 Subject Disputes ................................................................................................................F-2 Secretarial Review .................................................................................................................F-3 Pertinent Documentation ...................................................................................................F-4 September 2001 iii
    • Table of Contents NPDB Guidebook Secretarial Review Results ................................................................................................F-4 Report Accurate as Submitted ...........................................................................................F-4 Report Inaccurate as Submitted .........................................................................................F-5 Dispute Outside the Scope of Secretarial Review .............................................................F-5 Secretarial Review Overview ........................................................................................F-5 Reconsideration of the Secretary’s Decisions on Disputes ...............................................F-6 Improper Requests for Secretarial Review ........................................................................F-6 Examples of Disputes ............................................................................................................F-6 Due Process - Alleged Denial ............................................................................................F-6 Due Process - Legal Action Pending .................................................................................F-6 Licensure Completion - Trigger Date ................................................................................F-7 Narrative Description - Inaccurate.....................................................................................F-7 Narrative Description - Legal Sufficiency.........................................................................F-7 Narrative Description - Misleading ...................................................................................F-8 Privileges - Resignation and Surrender While Under Investigation..................................F-8 Privileges - Suspension and Hospital Motivation ...............................................................F-9 Professional Review - Alternative Employment Termination Procedure .........................F-9 Residency Status ................................................................................................................F-9 Responsibility for Treatment .............................................................................................F-9 Settlement - Subject Disagrees ........................................................................................F-10 Settlement - Subject Dismissed from Lawsuit.................................................................F-10 Suspension - Indefinite Length ........................................................................................F-10 Suspension - Summary ....................................................................................................F-10 Questions and Answers....................................................................................................F-11G. Fees Query Fees ............................................................................................................................ G-1 Entity Query Fees ............................................................................................................. G-1 Self-Query Fees ................................................................................................................ G-1 Methods of Payment ............................................................................................................. G-1 Account Discrepancies ......................................................................................................... G-3 Credits and Debits................................................................................................................. G-4 Bankruptcy............................................................................................................................ G-4 Questions and Answers......................................................................................................... G-4H. Information Sources NPDB-HIPDB Web Site Assistance..................................................................................... H-1 NPDB-HIPDB Customer Service Center ............................................................................. H-1 Data Bank Addresses ............................................................................................................ H-2 Interpretation of NPDB Statutes and Regulations ................................................................ H-2 The Privacy Act and the NPDB ............................................................................................ H-2 The Freedom of Information Act and the NPDB.................................................................. H-3 Federal Employer Identification Number ............................................................................. H-3 State Medical and Dental Boards.......................................................................................... H-3 iv September 2001
    • NPDB Guidebook Table of ContentsAPPENDIX A: GlossaryAPPENDIX B: Laws and RegulationsAPPENDIX C: AbbreviationsSeptember 2001 v
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    • NPDB Guidebook Chapter A IntroductionPreface opened in September 1990. This comprehensive Guidebook is for both newThe National Practitioner Data Bank and experienced entities that are eligible toGuidebook is meant to serve as a resource participate in the NPDB; it supersedes allfor the users of the National Practitioner previous versions.Data Bank (NPDB). It is one of a numberof efforts to inform the United States Backgroundhealth care community about the NPDBand what is required to comply with the The legislation that led to the creation ofrequirements established by Title IV of the NPDB was enacted because the U.S.Public Law 99-660, the Health Care Congress perceived that the increasingQuality Improvement Act of 1986, as occurrence of medical malpracticeamended. This Guidebook contains litigation and the need to improve theinformation that authorized users need to quality of medical care had becomeinteract with the NPDB. Authorized users nationwide problems that warrantedinclude State licensing authorities; greater efforts than those that could bemedical malpractice payers; hospitals and undertaken by any individual State.other health care entities; and physicians, Effective professional peer review candentists, and other licensed health care restrict the ability of incompetentpractitioners. practitioners to move from State to State without disclosure or discovery ofFinal regulations governing the NPDB previous damaging or incompetentwere published in the Federal Register on performance. The Congress felt that theOctober 17, 1989, and are codified at 45 threat of private money damage liabilityCFR Part 60. The U.S. Department of under Federal laws, including trebleHealth and Human Services (HHS) is damage liability under Federal antitrustresponsible for implementing the NPDB. law, unreasonably discouraged physicians and dentists from participating in effectiveThis Guidebook is divided into broad professional peer review. Therefore,topical sections. This introduction Congress sought to provide incentive andcontains general information on the protection for physicians and dentistsNPDB, which includes its history, the laws engaging in effective professional peerand regulations that govern it, and other review.information for authorized users. ChapterH, Information Sources, provides a variety Hearings were held in the U.S. House ofof sources to facilitate user interaction Representatives on the proposedwith the NPDB. The Glossary, included legislation, the Health Care Qualityas Appendix A, defines terms helpful in Improvement Act of 1986, on March 18understanding NPDB operations, and July 15, 1986, by the Subcommitteeincluding querying and reporting on Health and the Environment,requirements. Committee on Energy and Commerce, and on October 8 and 9, 1986, by theThis edition of the NPDB Guidebook Subcommittee on Civil and Constitutionalreflects the entire range of NPDB policies Rights, Committee on the Judiciary. Atand operations, including those that have these public hearings, testimony was givenchanged or expanded since the NPDB by physicians, attorneys, insuranceSeptember 2001 A-1
    • Chapter A Introduction NPDB Guidebookofficials, representatives of health care rights actions and antitrust actions broughtassociations, and others. The Health Care by Federal and State Governments.Quality Improvement Act of 1986 wasincorporated as Title IV into legislation In order to receive immunity protection, arequiring States to develop, establish, and professional review action regarding theimplement State comprehensive mental professional competence or professionalhealth plans. This legislation became conduct of a physician or dentist must bePublic Law 99-660 when it was signed by taken:President Ronald Reagan onNovember 14, 1986. • In the reasonable belief that the action was in the furtherance of quality healthTitle IV of Public Law 99-660 care. • After a reasonable effort to obtain theThe intent of Title IV of Public Law facts of the matter.99-660 is to improve the quality of healthcare by encouraging State licensing • After adequate notice and hearingboards, hospitals and other health care procedures are afforded to theentities, and professional societies to physician or dentist involved or afteridentify and discipline those who engage such other procedures as are fair to thein unprofessional behavior; and to restrict physician or dentist under thethe ability of incompetent physicians, circumstances.dentists, and other health care practitionersto move from State to State without • In the reasonable belief that the actiondisclosure or discovery of previous was warranted by the facts known,medical malpractice payment and adverse after such reasonable effort to obtainaction history. Adverse actions can facts and after meeting the notice andinvolve licensure, clinical privileges, and hearing requirement.professional society memberships. Because the immunity provided by theCivil Liability Protection Health Care Quality Improvement Act is from liability rather than from suit, aTo encourage and support professional disciplined physician or dentist retains thereview activity of physicians and dentists, right to sue; however, the court may awardPart A of Title IV provides that the attorneys fees and court costs to theprofessional review bodies of hospitals defendants if the suit is determined to beand other health care entities, and persons frivolous, unreasonable, withoutserving on or otherwise assisting such foundation, or in bad faith.bodies, are offered immunity from privatedamages in civil suits under Federal or Title IV of Public Law 99-660, the HealthState law. Immunity provisions apply Care Quality Improvement Act of 1986,when professional review responsibilities led to the establishment of the NPDB, anare conducted with the reasonable belief of information clearinghouse, to collect andfurthering the quality of health care and release certain information related to thewith proper regard for due process. There professional competence and conduct ofare exceptions under the law for civil physicians, dentists, and, in some cases,A-2 September 2001
    • NPDB Guidebook Chapter A Introductionother health care practitioners. The settlement of a medical malpracticeestablishment of the NPDB represents an action or claim shall not be construed asimportant step by the U.S. Government to a presumption that medical malpracticeenhance professional review efforts by has occurred.making certain information concerningmedical malpractice payments and adverse The information in the NPDB should serveactions available to eligible entities and only to alert State licensing authorities andindividuals. health care entities that there may be a problem with a particular practitioner’sA web link to the NPDB Regulations professional competence or conduct.codified at 45 CFR Part 60 is referenced in NPDB information should be consideredAppendix B of this Guidebook. together with other relevant data in evaluating a practitioner’s credentialsInterpretation of NPDB (e.g., evidence of current competenceInformation through continuous quality improvement studies, peer recommendations, healthThe NPDB is primarily an alert or status, verification of training andflagging system. The information experience, and relationships with patientscontained in it is intended to direct and colleagues).discrete inquiry into and scrutiny ofspecific areas of a practitioner’s licensure, Confidentiality of NPDBprofessional society memberships, medical Informationmalpractice payment history, and record ofclinical privileges. NPDB information is Information reported to the NPDB isan important supplement to a considered confidential and shall not becomprehensive and careful review of a disclosed except as specified in the NPDBpractitioner’s professional credentials. regulations at 45 CFR Part 60. TheThe NPDB is intended to augment, not confidential receipt, storage, andreplace, traditional forms of credentials disclosure of information is an essentialreview. As a nationwide flagging system, ingredient of NPDB operations. Ait provides another resource to assist State comprehensive security system has beenlicensing boards, hospitals, and other designed to prevent manipulation of andhealth care entities in conducting access to the data by unauthorized staff orextensive, independent investigations of external sources. The facility in which thethe qualifications of the health care NPDB is housed meets HHS securitypractitioners they seek to license or hire, specifications, and NPDB staff haveor to whom they wish to grant clinical undergone in-depth background securityprivileges. investigations.Settlement of a medical malpractice claim The Office of Inspector General (OIG),may occur for a variety of reasons that do HHS, has been delegated the authority tonot necessarily reflect negatively on the impose civil money penalties on thoseprofessional competence or conduct of the who violate the confidentiality provisionsphysician, dentist, or other health care of Title IV. The civil money penalties forpractitioner. Thus, a payment made in violating the confidentiality provisions ofSeptember 2001 A-3
    • Chapter A Introduction NPDB GuidebookTitle IV are to be imposed in the same Information Act (FOIA), 5 USC §552, asmanner as other civil money penalties amended.pursuant to §1128A of the Social SecurityAct, 42 U.S.C. 1320a-7a. Regulations The confidentiality provisions of Title IVgoverning civil money penalties under do not prohibit an eligible entity receiving§1128A are set forth at 42 CFR Part 1003. information from the NPDB to disclose the information to others who are part ofFor each violation of confidentiality, a the peer review process, as long as thecivil money penalty of up to $11,000 can information is used for the purpose forbe levied. In any case in which it is which it was provided. Examples ofdetermined that more than one party was appropriate uses of NPDB informationresponsible for improperly disclosing include:confidential information, a penalty of upto the maximum $11,000 limit can be • A hospital may disclose theimposed against each responsible information it receives from the NPDBindividual, entity, or organization. to hospital officials responsible for reviewing a practitioners applicationPersons or entities who receive for a medical staff appointment orinformation from the NPDB either directly clinical privileges. In this case, bothor indirectly are subject to the the hospital officials who receive theconfidentiality provisions and the information and the hospital officialsimposition of a civil money penalty if they who subsequently review it during theviolate those provisions. When an employment process are subject to theauthorized agent is designated to handle confidentiality provisions of Title IV.NPDB queries, both the entity and theagent are required to maintain • A private accreditation entity canconfidentiality in accordance with Title IV review confidential information that arequirements. health care entity has obtained regarding its practitioners only if theThe Privacy Act, 5 USC §552a, protects purpose of the disclosure is to carrythe contents of Federal systems of records out peer review activity for that healthon individuals, like those contained in the care entity (i.e., the privateNPDB, from disclosure without the accreditation entity maintains a role inindividual’s consent, unless the disclosure the decision-making process foris for a routine use of the system of practitioner membership in the healthrecords as published annually in the care entity, which would make itsFederal Register. The published routine activities part of the peer reviewuses of NPDB information, which are process). If the private accreditationbased on the laws and the regulations entity’s activities are not consideredunder which the NPDB operates, do not part of the peer review process, theallow disclosure to the general public. private accreditation entity cannotThe limited access provision of the Health view any documents that the healthCare Quality Improvement Act of 1986, as care entity has obtained from theamended, supersedes the disclosure NPDB that show the results of anrequirements of the Freedom of NPDB query (e.g., match or no match), such as an NPDB report or theA-4 September 2001
    • NPDB Guidebook Chapter A Introduction query response document entitled, the NPDB are permitted to share that Response to Information Disclosure information with whomever they choose. Request. However, the health care entity would not be in violation of the Disclosure of NPDB Information confidentiality requirements if it discloses a copy of the Response to The Health Care Quality Improvement Act Information Disclosure Request to the of 1986, as amended, and its governing private accreditation entity, as long as regulations limit the disclosure of information that discloses the query information in the NPDB. Information is result is removed from the copy, (i.e., available to: so the document shows only the names on which queries were submitted). • Hospitals requesting information Additionally, if the health care entity concerning a practitioner on their obtains a release from a physician medical staff or to whom they have authorizing it to specifically release granted clinical privileges, or with confidential information it obtains respect to professional review activity. from the NPDB to the private accreditation entity, the health care • Health care entities (including entity may do so without violating the hospitals) that have entered or may be NPDB’s confidentiality restrictions. entering employment or affiliation relationships with a practitioner or toThe confidentiality provisions do not which the practitioner has applied forapply to the original documents or records clinical privileges or appointment tofrom which the reported information is the medical staff, or with respect toobtained. The NPDB’s confidentiality professional review activity.provisions do not impose any newconfidentiality requirements or restrictions • Practitioners requesting informationon those documents or records. Thus, about themselves.these confidentiality provisions do not baror restrict the release of the underlying • Boards of medical examiners or otherdocuments, or the information itself, by State licensing boards.the entity taking the adverse action ormaking the payment in settlement of a • Attorneys or individuals representingwritten medical malpractice complaint or themselves upon submission of proofclaim. For example, if a hospital that that a hospital failed to submit areported an adverse action against a mandatory query.physician pursuant to the provisions ofTitle IV receives a subpoena for the • Persons or entities requestingunderlying records, it may not refuse to information in a form which does notprovide the requested documents on the identify any particular entity orgrounds that Title IV bars the release of practitioner.the records or information. The Privacy Act protects the contents ofIndividual health care practitioners who Federal systems of records on individuals,obtain information about themselves from like those in the NPDB, from disclosureSeptember 2001 A-5
    • Chapter A Introduction NPDB Guidebookwithout the individuals consent unless the Service (IQRS) is able to sort thedisclosure is for a routine use of the appropriate actions into the HIPDB, thesystem of records as published annually in NPDB, or both. Similarly, entitiesthe Federal Register. The published authorized to query both Data Banks haveroutine uses of NPDB information, which the option of querying both the NPDB andare consistent with the law and the the HIPDB with a single queryregulations under which it operates, do not submission.include disclosure to the general public. Official Language• The general public may not request information that identifies any The official language of the NPDB is particular entity or practitioner from English, and all documents submitted to the NPDB. the NPDB must be written in English. Documents submitted in any other• Medical malpractice payers may not language are not accepted. request information even though they are required to report. User FeesSee §60.11 of the NPDB Regulations. Alink to the NPDB Regulations is included User fees are assessed to cover thein Appendix B of this Guidebook. processing costs for all queries for NPDB information. Refer to the NPDB-HIPDB web site at www.npdb-hipdb.com forCoordination Between the NPDB details regarding the payment of NPDBand the HIPDB user fees.The Healthcare Integrity and ProtectionData Bank (HIPDB) was establishedthrough the Health Insurance Portabilityand Accountability Act of 1996 (HIPAA),Public Law 104-191. This law directed theSecretary of HHS and the U.S. AttorneyGeneral to create the HIPDB to combatfraud and abuse in health insurance andhealth care delivery. The HIPDB is anational data collection program forreporting and disclosing certain finaladverse actions taken against health carepractitioners, providers, and suppliers.To alleviate the burden on those entitiesthat must report to both the NPDB and theHIPDB, a system has been created toallow an entity that must report the sameadverse action to both Data Banks tosubmit the report only once. ThisIntegrated Querying and ReportingA-6 September 2001
    • NPDB Guidebook Chapter B Eligible EntitiesWhat is an Eligible Entity? To be eligible to report to the NPDB, an entity must be one of the following:Entities entitled to participate in the • An entity that makes a medicalNational Practitioner Data Bank are malpractice payment.defined in the provisions of Title IV ofPublic Law 99-660, the Health Care • A board of medical examiners or aQuality Improvement Act of 1986, as State licensing board taking an adverseamended, and in the regulations codified action against a physician or dentist.at 45 CFR Part 60. Eligible entities are • A health care entity that takes anresponsible for meeting Title IV reporting adverse clinical privileging action as aand/or querying requirements, as result of professional review.appropriate. Each eligible entity mustcertify its eligibility in order to report to • A professional society that takes anand/or query the NPDB. adverse membership action as a result of professional review.Information from the NPDB is available toState licensing boards, hospitals and other Each entity is responsible for determininghealth care entities, professional societies, its eligibility to participate in the NPDBcertain Federal agencies, and others as and must certify that eligibility to thespecified in the law. The NPDB collects NPDB in writing.information related to the professionalcompetence and conduct of physicians,dentists, and, in some cases, other healthcare practitioners.To be eligible to query the NPDB, anentity must be:• A board of medical examiners or other State licensing board.• A hospital.• A health care entity that provides health care services and follows a formal peer review process to further quality health care.• A professional society that follows a formal peer review process to further quality health care.September 2001 B-1
    • Chapter B Eligible Entities NPDB GuidebookDefining Health Care Entities The phrase “provides health care services” means the delivery of health care servicesHealth care entities include hospitals and through any of a broad array of coverageother organizations that provide health arrangements or other relationships withcare services and follow a formal peer practitioners either by employing themreview process in order to further quality directly, or through contractual or otherhealth care. See §60.3 of the NPDB arrangements. This definition specificallyRegulations. A link to the NPDB excludes indemnity insurers that have noRegulations is included in Appendix B of contractual or other arrangement withthis Guidebook. physicians, dentists, or other health care practitioners.Hospitals Examples of other health care entities mayA hospital is defined under Section include health maintenance organizations1861(e)(1) and (7) of the Social Security (HMOs), preferred provider organizationsAct as an institution primarily engaged in (PPOs), group practices, nursing homes,providing, by or under the supervision of rehabilitation centers, hospices, renalphysicians, to inpatients: diagnostic and dialysis centers, and free-standingtherapeutic services; rehabilitation ambulatory care and surgical serviceservices for medical diagnosis, treatment, centers.and care; or rehabilitation of injured,disabled, or sick persons. In addition to HMOs and PPOs, other managed care organizations mayHospitals must be licensed or approved as qualify as health care entities. A healthmeeting the standard established for care entity must provide health carelicensing by the State or applicable local services and follow a formal peer reviewlicensing authorities. process to further quality health care to satisfy the eligibility requirements ofOther Health Care Entities Title IV.A health care entity must provide health Examples of hospitals and other healthcare services and follow a formal peer care entities are listed in the table thatreview process to further quality health follows.care.B-2 September 2001
    • NPDB Guidebook Chapter B Eligible Entities Examples of Hospitals and Other Health Care Entities Hospitals Other Health Care Entities• All Federal and non-Federal short-term care • Ambulatory or outpatient care centers, even general and specialty hospitals that are licensed when otherwise part of a hospital. or otherwise authorized by the State. • “One-day surgery” centers, even when• All Federal and non-Federal long-term care otherwise part of a hospital. general and specialty hospitals that provide diagnostic and/or therapeutic care under the • Nursing homes that provide skilled nursing care supervision of a physician and/or psychologist, not under the supervision of a physician or that are licensed or otherwise authorized by the psychologist. State. • Hospices that provide care not under the• A long-term skilled nursing facility that is supervision of a physician or psychologist. licensed as a hospital by the State, as long as care is provided under the supervision of a • Nursing homes or hospices that provide only physician or psychologist. daily care.• A hospice that provides skilled nursing and comfort care under the supervision of a physician and which is licensed by the State.Defining Professional Societies society must qualify as a “health care entity” as defined in §60.3 of the NPDBA professional society is a membership regulations. To meet NPDB eligibilityassociation of physicians, dentists, or other requirements, a professional society musthealth care practitioners that follows a follow a formal peer review process forformal peer review process for the purpose the purpose of furthering quality healthof furthering quality health care. care.Examples of professional membership Defining State Licensing Boardssocieties may include national, State,county, and district medical and dental A State licensing board, or board ofsocieties and academies of medicine and medical examiners, is responsible fordentistry. Examples of professional licensing, monitoring, and discipliningorganizations that ordinarily do not meet physicians, dentists, or other health carethe definition of a professional society practitioners. A board of medicalinclude medical and surgical specialty examiners includes a medical or dentalcertification boards, independent practice board, a board of osteopathic examiners, aassociations (IPAs), and PPOs. composite board, a subdivision, or an equivalent body as determined by theProfessional societies are not State.automatically eligible to query and/orreport to the NPDB. A professionalSeptember 2001 B-3
    • Chapter B Eligible Entities NPDB GuidebookDefining Medical Malpractice Payers (e.g., entity type); and, for those entities authorized by law to query both DataA medical malpractice payer is an entity Banks, whether queries are to bethat makes a medical malpractice payment submitted to the NPDB only, to thefor the benefit of physicians, dentists, or HIPDB only, or to both Data Banks. Thisother health care practitioners in information allows the NPDB to registersettlement of or in satisfaction in whole or your entity’s authorization to participate inin part of, a claim or judgment against the NPDB, and to determine your entity’ssuch practitioner. reporting and/or querying requirements and restrictions.Registering with the NPDB Certifying OfficialEligible entities are responsible for A certifying official is the individualmeeting Title IV reporting and/or querying selected and empowered by an entity torequirements. Entities not currently certify the legitimacy of registration forregistered with the NPDB are responsible participation in the NPDB.for determining their eligibility andregistering with the NPDB by completing The Entity Registration form containsan Entity Registration form. A Data Bank certification information that must beIdentification Number (DBID), a user ID, completed by an entity’s certifyingand a password are issued to each official. The entity’s certifying officialsuccessfully registered entity. An entity certifies the legitimacy of the registrationthat does not have this information is not information provided to the NPDB. Theregistered with the NPDB and will be certification section must contain anunable to submit reports and queries. original ink signature and a signature date. Faxed, stamped, or photocopied signaturesThe Entity Registration form may be are unacceptable. The title of thedownloaded from the NPDB-HIPDB web certifying official, a telephone number,site at www.npdb-hipdb.com. The Entity and an e-mail address must also beRegistration form allows entities to provided.register simultaneously for both the NPDBand the Healthcare Integrity and Once the completed Entity RegistrationProtection Data Bank (HIPDB). The form is received and processed, the NPDBinformation requested on this form assigns a unique, confidential DBID andprovides the NPDB with essential password and sends an Entity Registrationinformation concerning your entity, such Verification document to the entity. Thisas your organizations name, address, document contains the entity’sFederal Taxpayer Identification Number confidential DBID, user ID, and password,(TIN), and type of ownership; your as well as the information that wasorganization’s authority to participate in provided to the NPDB on the Entitythe NPDB and the HIPDB under each of Registration form. The certifying officialthe statutes governing the Data Banks should read the document carefully and, if(Title IV for the NPDB; and Section the document contains any errors, follow1128E for the HIPDB); your the instructions provided on the documentorganization’s primary function or service for correcting the inaccurate information.B-4 September 2001
    • NPDB Guidebook Chapter B Eligible EntitiesThe certifying official may also designate amended, and its implementingan authorized agent to query and/or report regulations, 45 CFR Part 60. Each entityon behalf of the entity by completing an is responsible for determining whether itAuthorized Agent Designation form and meets the eligibility criteria and forsubmitting it to the NPDB. (Specific certifying its eligibility to the NPDB.responsibilities of authorized agents aredescribed on page B-7.) DBIDs are assigned only to entities that certify their eligibility to the NPDB and toEntity Recertification authorized agents who act on behalf of registered entities. DBIDs are notThe NPDB periodically requires entities to assigned to certifying officials,recertify their eligibility. At these times, authorized submitters or otherthe NPDB sends to each active entity the individuals associated with a reportingcurrent identification information on file or querying entity. However, entitieswith the NPDB. The entity’s certifying may create multiple user accounts (userofficial should review the information to IDs) for a given DBID (see the User IDensure that it is correct, indicate the section in this chapter). For each user IDentity’s applicable certification statement, that an entity establishes, the entity mustsign the document, and return it to the also create a separate password. For moreNPDB. information on establishing multiple user IDs, refer to the NPDB-HIPDB web site.Data Bank Identification Deactivate a DBIDNumbers (DBIDs) An eligible entity may request at any timeEach entity that registers with the NPDB that its current DBID be deactivated and ais assigned a unique DBID and password new DBID assigned by selecting theas well as an initial user ID. DBIDs are Assign New DBID or Deactivate DBIDused to identify registered entities and boxes on the Entity Registration form andauthorized agents, and must be provided completing the required sections. Foron all reports, queries, and correspondence instance, if you believe that your entity’ssubmitted to the NPDB. DBID has been compromised in any way, or if your entity merges with anotherA DBID is a link into the NPDB computer entity, you may wish to deactivate yoursystem and should be safeguarded to DBID and request a new one. You mustprevent inadvertent disclosure. It is provide your reason for requesting a newrevealed only to the entity or agent to DBID on the completed form when it iswhich it is assigned. In the event that your returned to the NPDB for processing.entity’s DBID is compromised, follow theinstructions in the Deactivate a DBID Additionally, if at any time, your entitysection. relinquishes eligibility to participate in the NPDB, your entity’s certifying officialThe assignment of a DBID is not a must notify the NPDB in writing torepresentation by HHS that an entity meets deactivate your entity’s DBID. The Entitythe eligibility criteria for participation in Registration form, which can be retrievedthe NPDB, as specified in the Health Care from the NPDB-HIPDB web site, must beQuality Improvement Act of 1986, asSeptember 2001 B-5
    • Chapter B Eligible Entities NPDB Guidebookused to request deactivation. The registration information changes, yourDeactivate DBID option must be checked entity’s certifying official should obtainand the required sections of the form and complete an Entity Registration formcompleted. The reason for deactivation from the website, and select the Changemust be provided on the completed form Entity Information option.when it is returned to the NPDB forprocessing. You may update selected profile information via the IQRS. After loggingReactivate a DBID in to the IQRS, you will see the Entity Registration Confirmation screen. SelectIf your entity’s DBID is currently inactive a button at the bottom of the screen calledand you determine that it should be active, Update Entity Profile. You will be able toyour entity’s certifying official should change the following information:complete an Entity Registration form. department name, mailing address, e-mailSelect the Reactivate an Entity option on address, and Taxpayer Identificationthe form to request that the DBID be Number (TIN). To update any other entityreactivated. The reason for reactivation information, complete and mail an Entitymust be provided on the completed form Registration form as described above.when it is returned to the NPDB forprocessing. When the NPDB receives updated entity information, the updated information isUser IDs processed into the NPDB computer system and an Entity Registration VerificationEntities can create multiple user accounts document, reflecting the changesso that multiple departments/people can submitted, is mailed to the entity’suse the same DBID for querying and certifying official. The certifying officialreporting. User IDs are created and should read the document carefully. If themaintained through the IQRS. The user document contains any errors, follow theID an entity receives when it initially instructions provided on the document forregisters with the Data Banks is the correcting the inaccurate information.administrator account. The administratoroversees all other user IDs and is the only Lost Your DBID?user that may add, update, and removeother user accounts (user IDs). If an entity If you cannot remember your DBID,has only one person who uses the IQRS, contact the NPDB-HIPDB Customerthe entity may choose to use the Service Center for assistance.administrator account as its regular useraccount. For more information onestablishing multiple users, see the Organizations That May ReportNPDB-HIPDB web site. and Query on Behalf of EntitiesUpdate Entity Information Authorized submitters or authorized agents may submit queries and reports andIf your entity’s name, address, statutory retrieve responses from the NPDB onauthority, organization type, certifying behalf of registered entities.official, or any other item of yourB-6 September 2001
    • NPDB Guidebook Chapter B Eligible EntitiesAuthorized Submitter organization (CVO), or organizations that may be used for centralized credentialingAn authorized submitter is the individual or professional oversight, such as theselected and empowered by a registered National Council of State Boards ofentity to certify the legitimacy of Nursing and the Federation ofinformation provided in a query or report Chiropractic Licensing Boards.to the NPDB. In most cases, theauthorized submitter is an employee of the Entities must ensure that certain guidelinesorganization submitting the report or are followed when designating anquery, such as an administrator, a risk authorized agent to query or report onmanager, or medical staff services their behalf. The entity should establish apersonnel. The NPDB does not assign written agreement with that authorizedDBIDs to authorized submitters. agent confirming the following:Entities are responsible for selecting their • The agent is authorized to conductauthorized submitter, and the submitter business in the State.may change at any time. Entities maychoose to have multiple submitters. For • The agent’s facilities are secure,example, an entity may designate a ensuring the confidentiality of NPDBparticular individual within the responses.organization to be the authorized submitterfor reporting and another individual to be • The agent is explicitly prohibited fromthe authorized submitter for querying. using information obtained from theThe authorized submitter is often the NPDB for any purpose other than thatindividual designated by the organization for which the disclosure was made.to submit and retrieve report and/or query For example, two different health careresponses from the NPDB. However, entities designate the same authorizedpersonnel may be designated as desired. agent to query the NPDB on theirEntities are not required to register the behalf. Both health care entities wishauthorized submitter or to identify that to request information on the sameperson by name to the NPDB in advance, practitioner. The authorized agentalthough the authorized submitter must must query the NPDB separately onprovide his or her name, title and phone behalf of each health care entity. Thenumber at the time a query or report is response to an NPDB query submittedsubmitted. for one health care entity cannot be shared with another health care entity.Authorized Agents • The agent is aware of the sanctionsRegistered entities may elect to have that can be taken against the agent ifoutside organizations query or report to information is requested, used, orthe NPDB on their behalf. Such an disclosed in violation of NPDBorganization is referred to as an authorized provisions.agent. In most cases, an authorized agentis an independent contractor used for • Authorized agents are not eligible tocentralized credentialing, for example, a access information in the NPDB undercounty medical society, a State hospital their own authority. Theseassociation, a credentials verificationSeptember 2001 B-7
    • Chapter B Eligible Entities NPDB Guidebook organizations and other organizations the NPDB, the agent must obtain an that do not meet the statute’s specific Authorized Agent Registration form from query eligibility criteria may only the NPDB-HIPDB web site. Once the interact with the NPDB as authorized agent is registered, a DBID and a agents. Authorized agents may only password is assigned to that agent, and the query the NPDB with the authorization entity can designate that agent to report of an eligible entity (i.e., the eligible and query on its behalf. entity must designate the authorized agent to act on its behalf by NPDB responses to reports and queries completing the Authorized Agent submitted by an authorized agent will be Designation form) for specifically routed to either the eligible entity or its designated and limited purposes. authorized agent, as indicated by the entity on the Authorized Agent DesignationThe authorized agent must have a copy of form. If the entity wishes to retrievethe most recent Guidebook (which responses itself from the Integratedincludes the regulations and the civil Querying and Reporting Service, the entitymoney penalty regulations of the Office of must have access to the Internet (i.e., anInspector General (OIG), HHS, at 42 CFR Internet Service Provider) and anPart 1003) and should be aware of the appropriate web browser. Requirementssanctions that can be taken if information for using the Integrated Querying andis requested, used, or disclosed in Reporting Service can be found on theviolation of NPDB provisions. The NPDB-HIPDB web site.Health Care Quality Improvement Act andthe OIG’s civil money penalty regulation In addition, a plug-in or stand-aloneauthorizes a penalty of up to $11,000 for program that can read files in Portableeach violation. Document Format (PDF) is required, such as Adobe Acrobat Reader 4.0.Designating Authorized Agents An authorized agent should have only oneBefore an authorized agent may act on DBID, even though more than one entitybehalf of an entity, the entity must may designate the agent to query anddesignate the agent to interact with the report to the NPDB. If an authorizedNPDB on its behalf. Registered entities agent has been issued more than onethat want to designate an authorized agent DBID, the authorized agent should obtainshould obtain an Authorized Agent an Authorized Agent Registration formDesignation form from the NPDB-HIPDB from the NPDB-HIPDB web site, indicateweb site. The entity must complete the which DBID it intends to use, and requestform, providing the authorized agent’s that any other DBIDs be deactivated.name, DBID (if known), address, andtelephone number; and the entity’s Any changes to an authorized agentresponse routing and fee payment designation, such as a change to responsepreferences, and return it to the NPDB. routing or termination of an authorized agent’s authorization to query and reportAuthorized agents must be registered with on an entity’s behalf, must be submittedthe NPDB before they can be designated by the entity. If changes in an authorizedto report and/or query on behalf of eligible agent designation are required, the entityentities. If the agent is not registered with should obtain an Authorized AgentB-8 September 2001
    • NPDB Guidebook Chapter B Eligible EntitiesDesignation form from the NPDB-HIPDB 3. Does my organization have to notifyweb site, select the Update Previous Agent the NPDB when we have a newDesignation option on the form, complete certifying official?the form as directed, and return it to theNPDB. Yes. The eligible entity gives the certifying official authority to certifyAll forms should be mailed to the NPDB: the legitimacy of registration NPDB-HIPDB information provided to the NPDB. P.O. Box 10832 The person authorized by the entity to Chantilly, VA 20153-0832 act as the certifying official may change at any time at the discretion ofQuestions and Answers the entity. However, the NPDB makes a record of the staff title and name of the individual assigned as the1. How do I know if my organization is certifying official and should be an eligible entity? notified when changes occur. See §60.3, Definitions, of the NPDB 4. My hospital merged with another Regulations. A link to the NPDB Regulations is included in Appendix B hospital, and both have medical staff of this Guidebook. offices. Should we continue to query separately using two different2. Can the NPDB certify or verify that DBIDs? my organization is eligible to report or query? If the hospitals maintain separate medical staff credentialing, the Each entity must determine its own hospitals should query separately. eligibility to participate in the NPDB. If by applying to one hospital a The assignment of a DBID is not a practitioner is granted privileges to representation by HHS that your practice at both institutions, one organization meets the eligibility hospital should query on behalf of criteria for participation in the NPDB, both institutions. However, both as specified in the Health Care Quality hospitals should be aware that if one Improvement Act of 1986, as amended, DBID is deactivated, the NPDB will and its implementing regulations, 45 maintain only one hospital address and CFR Part 60. The NPDB Regulations, only one “electronic address.” For included as Appendix B, describe the more information on query responses, criteria for eligibility. Other see Chapter D, Queries. informational materials designed to help you determine your organization’s eligibility can be obtained from the NPDB-HIPDB web site.September 2001 B-9
    • Chapter B Eligible Entities NPDB Guidebook5. My organization provides a resource 8. Can my organization have more that identifies practitioners who than one DBID? meet minimum standards as established by the organization. If you have multiple departments or Does producing this list make my people who handle NPDB querying organization eligible to participate and/or reporting, you may register in the NPDB? each department or person separately and receive separate DBIDs for each In order to be eligible to participate in one. However, departments or people the NPDB, an organization must meet with different DBID cannot assist one the definition of a State licensing another other (i.e., one department board, a hospital, or other health care cannot download a response from a entity, including a professional society, query entered by another department as defined in this Guidebook. If your with a different DBID). Also, special organization does not confer rights or care must be taken to be sure that the responsibilities of membership on a same query or report is not submitted practitioner and conduct formal peer twice. review, it does not meet the definition of a professional society as described Rather than registering for multiple in the NPDB Regulations and is not DBIDs, an entity may choose instead eligible to participate in the NPDB. to simply create multiple user accounts (i.e., user IDs) under the organization’s6. If my organization queries the DBID. Using the IQRS, an entity can NPDB, is it also required to report? establish as many user accounts as Conversely, if my organization necessary, and can deactivate those reports to the NPDB, is it accounts itself when needed without automatically eligible to query? deactivating its DBID. Not necessarily. See Chapters D and E, Queries and Reports, respectively, for discussions on querying and reporting eligibility criteria.7. Are PPOs eligible to participate in the NPDB? PPOs would normally be considered as “providing” health care services. If a PPO conducts formal peer review to further quality health care, it would be eligible to participate in the NPDB.B-10 September 2001
    • NPDB Guidebook Chapter C Health Care PractitionersOverview Any individual who, without authority, holds himself or herself out to be anNPDB querying and reporting authorized physician or dentist isrequirements apply to physicians, dentists, considered a physician or dentist.and other licensed health carepractitioners. The NPDB acts as a Other health care practitioners areclearinghouse of information relating to defined as individuals other thanmedical malpractice payments, certain physicians or dentists who are licensedadverse actions taken against or otherwise authorized (certified orpractitioners’ licenses, clinical privileges, registered) by a State to provide healthand professional society memberships, and care services; or individuals who, withouteligibility to participate in authority, hold themselves out to be soMedicare/Medicaid. NPDB information is licensed or authorized. For examples, seeintended to be used in combination with the list on page C-3 entitled Examples ofinformation from other sources in making Other Health Care Practitioners.determinations on granting clinicalprivileges or in employment, affiliation, or The licensing or authorization of otherlicensure decisions. Table C-1, NPDB health care practitioners to provide healthRequirements Affecting Physicians, care services varies from State to State.Dentists, and Other Health Care Each entity that reports to or queries thePractitioners, summarizes Title IV NPDB is responsible for determiningrequirements affecting physicians, which categories of health caredentists, and other health care practitioners are licensed or otherwisepractitioners. authorized by their State to provide health care services.Defining Health Care Currently, there is no NPDB requirementPractitioners to query or report on other health care practitioners who are not licensed orA physician is defined as a doctor of otherwise authorized by a State to providemedicine or osteopathy who is legally health care services, unless the individualauthorized by a State to practice medicine holds himself or herself to be soor surgery. A dentist is defined as a authorized.doctor of dental surgery, doctor of dentalmedicine, or the equivalent, who is legallyauthorized by a State to practice dentistry.September 2001 C-1
    • Chapter C Health Care Practitioners NPDB Guidebook Table C-1. NPDB Requirements Affecting Physicians, Dentists, and Other Health Care PractitionersEntity Reporting to the NPDB Querying the NPDBState Medical and Must report certain adverse licensure actions May query at any time.Dental Boards related to professional competence or professional conduct and revisions to such actions for physicians and dentists.Other State Licensing Do not report. May query at any time.BoardsHospitals and Other Must report (1) professional review actions Hospitals must query when screeningHealth Care Entities related to professional competence or applicants for a medical staff appointment professional conduct that adversely affect or granting/adding to/expanding clinical clinical privileges of a physician or dentist privileges, and every 2 years on health care for more than 30 days; (2) a physician’s or practitioners on the medical staff or who dentist’s voluntary surrender or restriction of have clinical privileges. Hospitals may clinical privileges while under investigation query at other times, as they deem for professional competence or professional necessary. Other health care entities may conduct or in return for not conducting an query when screening applicants for a investigation; and (3) revisions to such medical staff appointment or granting actions. May report on other health care affiliation, clinical privileges, and in practitioners. support of professional review activity.Professional Societies Must report professional review actions, May query when screening an applicant for based on reasons relating to professional membership or affiliation, and in support of competence or conduct, that adversely affect professional review activity. professional society memberships and revisions to such actions for physicians and dentists. May report on other health care practitioners.Medical Malpractice Must report payments made for the benefit of May not query the NPDB.Payers physicians, dentists, and other health care practitioners in settlement of or in satisfaction in whole or in part of a claim or judgment against such practitioner.Health Care Do not report on their own behalf. May self-query the NPDB at any time.PractitionersOffice of Inspector Reports exclusions from the May not query the NPDB.General (OIG), HHS Medicare/Medicaid programs against physicians, dentists, and other health care practitioners. C-2 September 2001
    • NPDB Guidebook Chapter C Health Care Practitioners Examples of Other Health Care PractitionersThe following list of health care practitioners other than physicians and dentists is providedsolely for illustration. The inclusion or exclusion of any health care occupational groupshould not be interpreted as a mandate or a waiver of compliance to Data Bank reportingrequirements, since licensure and certification requirements vary from State to State.Chiropractor Physician Assistant Physician Assistant, AllopathicCounselor Physician Assistant, OsteopathicCounselor, Mental HealthProfessional Counselor Podiatric Service ProviderProfessional Counselor, Alcohol PodiatristProfessional Counselor, Family/Marriage Podiatric AssistantProfessional Counselor, Substance Abuse Psychologist, ClinicalDental Service ProviderDental Assistant Rehabilitative, Respiratory, and RestorativeDental Hygienist Service ProviderDenturist Art/Recreation Therapist Massage TherapistDietician/Nutritionist Occupational TherapistDietician Occupational Therapy AssistantNutritionist Physical Therapist Physical Therapy AssistantEmergency Medical Technician (EMT) Rehabilitation TherapistEMT, Basic Respiratory TherapistEMT, Cardiac/Critical Care Respiratory Therapy TechnicianEMT, Intermediate EMT, Paramedic Social WorkerNurse/Advanced Practice NurseRegistered (Professional) Nurse Speech, Language, and Hearing ServiceNurse Anesthetist ProviderNurse Midwife AudiologistNurse Practitioner Speech/Language PathologistLicensed Practical or Vocational Nurse TechnologistNurses Aide/Home Health Aide Medical TechnologistNurses Aide CytotechnologistHome Health Aide (Homemaker) Nuclear Medicine Technologist Radiation Therapy TechnologistEye and Vision Service Provider Radiologic TechnologistOcularistOptician Other Health Care PractitionerOptometrist Acupuncturist Athletic TrainerPharmacy Service Provider HomeopathPharmacist Medical AssistantPharmacist, Nuclear Midwife, Lay (Non-nurse)Pharmacy Assistant Naturopath Orthotics/Prosthetics Fitter Perfusionist Psychiatric TechnicianSeptember 2001 C-3
    • Chapter C Health Care Practitioners NPDB GuidebookPractitioner Self-Query Self-Querying on the InternetA self-query is a practitioner’s request for The NPDB-HIPDB employs the latestinformation about himself or herself. technology, along with variousPractitioners may self-query the NPDB implementation measures, to provide aand the HIPDB at any time secure environment for querying,by visiting the NPDB-HIPDB web site at reporting, data storage, and retrieval.www.npdb-hipdb.com. All self-query Security features include firewallapplications must be submitted through protection from unauthorized access andthe NPDB-HIPDB web site. Previous encryption of transmitted data to preventpaper versions of the Self-Query form unauthorized use.will be rejected. Practitioners who do nothave access to the Internet may call the Practitioners complete and transmit theirNPDB-HIPDB Customer Service Center self-queries to the NPDB-HIPDB on-line;for assistance. For detailed instructions however, a self-query is not officiallyon self-querying, see the Fact Sheet on submitted until a signed and notarizedSelf-Querying, available at paper copy is received by the Data Banks.www.npdb-hipdb.com. A formatted copy of the self-query is generated immediately after electronicA practitioner who submits a self-query to transmission. To complete the self-querythe Data Banks will receive via U.S. mail process, practitioners must print theeither a response notifying them that no formatted copy, sign and date it in theinformation exists in the Data Banks, or a presence of a notary public, and mail thecopy of all report information submitted notarized self-query to the addressby eligible reporting entities. All specified.practitioner self-queries will be processedagainst both the NPDB and the HIPDB. Once a properly signed and notarized self-As part of their self-query response, query is received by the Data Banks, itsubjects of an Adverse Action Report or typically is processed within one businessMedical Malpractice Payment Report day and returned to the practitioner viasubmitted to the NPDB will receive a list U.S. mail. The practitioner may view theof all queriers to whom the reported processing status of his or her self-queryinformation has been disclosed with the request via the NPDB-HIPDB web site atresponse. www.npdb-hipdb.com.All Self-Query forms must be signed and Subject Information in the NPDBnotarized, and all fields in thenotarization section must be completed. The NPDB is committed to maintainingThe NPDB-HIPDB will reject any self- accurate information and ensuring thatquery received without signature and subjects are informed when medicalnotarization or with an incomplete malpractice payments or adverse actionsnotarization. are reported about them. When the NPDB receives a report, the information isA fee will be charged for each self-query processed by the NPDB computer systemsubmitted. For more information on self- exactly as submitted by the reportingquery fees, refer to Chapter G, Fees.C-4 September 2001
    • NPDB Guidebook Chapter C Health Care Practitionersentity. Reporting entities are responsible 2. I am a practitioner who personallyfor the accuracy of the information they refunded a fee to a patient. Is thisreport. refund reportable to the NPDB?When the NPDB processes a report, a No. A refund from a practitioner’sReport Verification Document is made personal funds is not reportable.available to the reporting entity for However, if the refund is paid by anretrieval from the Integrated Querying and insurer or any entity other than anReporting Service (IQRS), and a individual practitioner (including aNotification of a Report in the Data professional services corporationBank(s) is sent to the subject. The subject comprised of a sole practitioner), theshould review the report for accuracy, refund is reportable. For moreincluding current address, telephone information concerning NPDBnumber, and place of employment. reporting requirements, see Chapter E, Reports.Subjects may not submit changes toreports. If any information in a report is 3. Can a hospital, State licensinginaccurate, the subject must contact the board, or medical malpracticereporting entity to request that it file a insurer require that I give themcorrection to the report. the results of a self-query?If the reporting entity refuses to correct the The response you receive to a self-report, the subject of a report may: query is yours to do with as you wish. Various licensing, credentialing, and• Add a statement to the report. insuring entities may require a copy• Initiate a dispute of the report. of your query before you may• Add a statement and initiate a dispute. participate in their programs. Any arrangement between you and one ofFor more information about the NPDB these entities is voluntary. HHS doesdispute process, see Chapter F, Disputes. not regulate such arrangements. However, a copy of a subject self-Questions and Answers query does not satisfy a hospitals legal requirement to query.1. How do I correct my address if it is wrong in a report? You must contact the reporting entity (identified in both the Notification of a Report in the NPDB and Self-Query Response document) and request that the entity correct the address on the report. If the entity does not honor your request to correct the inaccurate address, you can dispute the report.September 2001 C-5
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    • NPDB Guidebook Chapter D QueriesOverview • Health care practitioners may self-The NPDB is a resource to assist State query at any time.licensing boards, hospitals, and otherhealth care entities in investigating the • Plaintiff’s attorneys may query underqualifications of the health care certain limited circumstances. Seepractitioners they seek to license or hire, NPDB Regulations §60.11(a)(5) oror to whom they wish to grant membership Table D-1, Title IV Queryingor clinical privileges. The NPDB Requirements, on page D-4.disseminates certain information toeligible entities on medical malpractice • Medical malpractice payers may notpayments, Medicare/Medicaid exclusions, query at any time.adverse licensure actions, adverse clinicalprivileges actions, and adverse Hospitalsprofessional society membership actionsfor physicians, dentists, and other health Hospitals are the only health care entitiescare practitioners who are licensed or with mandatory requirements for queryingotherwise authorized by a State to provide the NPDB. Each hospital must requesthealth care services. information from the NPDB as follows:• Hospitals must query when a • When a physician, dentist, or other practitioner applies for privileges or health care practitioner applies for medical staff membership and every 2 medical staff appointment (courtesy or years on practitioners on the medical otherwise) or for clinical privileges at staff or holding privileges. the hospital. • Every 2 years (biennially) on all• Other health care entities, including physicians, dentists, and other health professional societies, may query care practitioners who are on its when entering an employment or medical staff (courtesy or otherwise) affiliation relationship with a or who hold clinical privileges at the practitioner or in conjunction with hospital. professional review activities.• State licensing boards may query at any time.September 2001 D-1
    • Chapter D Queries NPDB Guidebook MANDATORY QUERYING Hospitals Application Every 2 years for to medical those on medical staff or for staff or with clinical clinical privileges privilegesThe biennial query may be done in each time a locum tenens practitioneraccordance with regular medical staff makes an application for temporaryreappointment and clinical privilege privileges, not each time the practitionerredelineation. Hospitals are not required comes to the facility. To reduce the queryto query more than once every 2 years burden, hospitals that frequently useon a practitioner who is continuously on particular locum tenens practitioners maystaff. Hospitals with annual choose to appoint such practitioners toreappointment are not required to their consultant staff or other appropriatequery annually. Hospitals may query the staff category in accordance with theirNPDB at any time they wish with respect bylaws and then query on them when theyto professional review activity. query on their full staff biennially.Hospitals are also required to query the Hospitals are required to query onNPDB when a practitioner wishes to courtesy staff considered part of theadd to or expand existing privileges and medical staff, even if afforded only non-when a practitioner submits an clinical professional courtesies such as useapplication for temporary privileges. of the medical library and continuingFor example, if a practitioner applies for education facilities. If a hospital extendstemporary clinical privileges four times in non-clinical practice courtesies withoutone year, the hospital must query the first appointing practitioners to a medicalNPDB on each of those four occasions. staff category, querying is not required onA hospital is required to query the NPDB those practitioners.D-2 September 2001
    • NPDB Guidebook Chapter D QueriesResidents and Interns residents or interns when such individuals are appointed to the medical staff orHealth care entities are not required to granted clinical privileges to practicequery the NPDB on medical and dental outside the parameters of the formalresidents, interns, or staff fellows medical education program (for example,(housestaff), even though they are often moonlighting in the intensive care unit orlicensed, because they are trainees in Emergency Department of that hospital).structured programs of supervisedgraduate medical education, rather than Professional Societiesmembers of the medical staff. Professional societies that meet Title IVThere is no difference between the eligibility requirements may requesthousestaff of the clinical facility belonging information from the NPDB whento the formal education program and the screening applicants for membership orhousestaff rotating to a clinical facility affiliation and in support of professionalproviding a clinical training site for the review activities.formal educational program. Hospitalsare not required to query the NPDB on State Licensing Boardshousestaff providing services as part oftheir formal clinical education. However, State licensing boards may requesthospitals are required to query on information from the NPDB at any time. OPTIONAL QUERYING STATE LICENSING BOARDS PROFESSIONAL SOCIETIES (with formal peer review) OTHER HEALTH CARE ENTITIES (with formal peer review) PRACTIONERS (on own files) HOSPITALS (as needed, in addition to mandatory queries) PLAINTIFF’S ATTORNEY (with HHS authorization)September 2001 D-3
    • Chapter D Queries NPDB Guidebook Table D-1. Title IV Querying RequirementsENTITY REQUIREMENTHospitalsScreening applicants for medical staff appointment or granting of clinical Must queryprivileges; every 2 years for physicians, dentists or other health carepractitioners on the medical staff or granted clinical privileges.At other times as they deem necessary. May queryState Licensing Boards (including Medical and Dental)When they deem necessary. May queryOther Health Care EntitiesScreening applicants for medical staff appointment, membership or May queryaffiliation, or granting of clinical privileges; supporting professionalreview activities.Professional SocietiesScreening applicants for membership or affiliation; supporting May queryprofessional review activities.Plaintiff’s AttorneysPlaintiff’s attorney or plaintiff representing himself or herself who has May queryfiled a medical malpractice action or claim in a State or Federal court orother adjudicative body against a hospital when evidence is submitted toHHS which reveals that the hospital failed to make a required query ofthe NPDB on the practitioner(s) also named in the action or claim.Physicians, Dentists, and Other Health Care PractitionersRegarding their own files. May queryMedical Malpractice Payers May not query D-4 September 2001
    • NPDB Guidebook Chapter D QueriesTypes of Queries Attorney AccessTitle IV of Public Law 99-660, the Health A plaintiff’s attorney or a plaintiffCare Quality Improvement Act of 1986, as representing himself or herself isamended, prescribes the following types of permitted to obtain information from thequeries: NPDB under the following limited conditions:• Privileging or Employment: for use by a hospital or other health care • A medical malpractice action or claim entity, including a professional society, must have been filed by the plaintiff when screening applicants for medical against a hospital in a State or Federal staff appointment, granting of clinical court or other adjudicative body, and privileges, membership, or professional affiliation. • The subject on whom the information is requested must be named in the• Professional Review Activity: for use action or claim. by a hospital or other health care entity, including a professional society, Obtaining NPDB information on the when conducting professional review specified subject is permitted only after activity. evidence is submitted to HHS demonstrating that the hospital failed to submit a mandatory query to the NPDB• Mandatory 2-Year: for use by a regarding the subject named by the hospital when submitting biennial plaintiff in the action. This evidence is not queries on physicians, dentists, or available to the plaintiff through the other health care practitioners on their NPDB. Evidence that the hospital failed medical staff or to whom clinical to request information from the NPDB privileges have been granted. must be obtained by the plaintiff from the hospital through discovery in the litigation• State Licensing Board: for use by process. State boards of medical examiners, State boards of dentistry, or other State A plaintiff’s attorney must submit all of licensing bodies. the following to the NPDB:• Self-Query: for use by a physician, • A letter requesting authorization to dentist, or other health care obtain information. practitioner. • Supporting evidence that the hospital• Other: for use by a plaintiff’s attorney did not make a mandatory query to the or the Secretary of HHS, as authorized NPDB regarding the subject named by by Title IV. the plaintiff in the action or claim. • Identifying information about the subject on whom the attorney wishes to query.September 2001 D-5
    • Chapter D Queries NPDB GuidebookExamples of evidence may include a Authorized Agentsdeposition, a response to aninterrogatory, and admission or other Eligible entities may elect to have anevidence of the failure of a hospital to authorized agent query the NPDB on theirrequest information. The plaintiff’s behalf. Authorized agents must query theattorney must submit a separate request for NPDB separately on behalf of eachinformation disclosure for each subject eligible entity. The response to an NPDBnamed in the action or claim. query submitted for one entity cannot be disclosed to another entity. For moreThe approval of a plaintiff’s attorney information on authorized agents, see pagequery is limited to a one-time-only B-7.disclosure; the approval of such a requestdoes not allow a plaintiff’s attorney to Submitting a Query to the NPDBobtain NPDB information on a continuingbasis. Subsequent disclosures of NPDB Eligible entities prepare and submitinformation require the plaintiff’s attorney queries using the Integrated Querying andto initiate a new request. A fee is assessed Reporting Service (IQRS) atwhen the NPDB discloses such www.npdb-hipdb.com. A DBID, a userinformation. ID, and a unique password are used by eligible entities and their authorized agentsAn approved query request entitles the to report and retrieve query responses viaplaintiff’s attorney to receive only that the World Wide Web. Internet accessinformation available in the NPDB at the with a web browser is required for usingtime the hospital was required to query but the IQRS.did not. It also includes information onany reports that were subsequently voided. The IQRS does not accept an incomplete query (one that is missing requiredThere are limitations on the use of information or is improperly completed).information obtained by the plaintiff in a Such queries are rejected. Entities arejudicial proceeding. Specifically, the encouraged to gather as much informationinformation obtained from the NPDB on as possible as part of the applicationthe subject can only be used with respect process, to make the completion of theto a legal action or claim against the query easier.hospital, not against the subject. Anyfurther disclosure or use violates the Entities may submit queries usingconfidentiality provisions of Title IV, and electronic transaction file submission, alsosubjects the plaintiff’s attorney and/or known as the ICD Transfer Program (ITP).plaintiff to a civil money penalty of up to The ITP is a program that transmits$11,000. Interface Control Document (ICD) query submission files and receives queryDefense attorneys are not permitted access response files from the NPDB-HIPDB.to the NPDB under Title IV because the All data are transmitted over an Internetdefendant subject is permitted to self- Secure Socket Layer (SSL) connection.query the NPDB. Submitting queries using the ITP is an alternative for those entities that generateD-6 September 2001
    • NPDB Guidebook Chapter D Queriesqueries from custom (third-party) or other Querying Through an Authorizedspecial purpose software. Entities that Agentchoose to query via the ITP must providedata in the format specified in the NPDB- The NPDB’s response to a queryHIPDB Interface Control Document (ICD) submitted by an authorized agent onfor Query Transactions. Information behalf of an entity is based upon twoabout querying via the ITP is available at eligibility standards: (1) the entity must bewww.npdb-hipdb.com. entitled to receive the information, and (2) the agent must be authorized to receiveEntities that are authorized and registered that information on behalf of that entity.to query both the NPDB and the Both the entity and the agent must beHealthcare Integrity and Protection Data properly registered with the NPDB prior toBank (HIPDB) may elect to query both the authorized agent’s query submission.Data Banks simultaneously with a singlequery submission. Entities that wish to Authorized agents cannot use a queryquery both Data Banks should indicate this response on behalf of more than onepreference on their Entity Registration entity. NPDB regulations specify thatform. information received from the NPDB must be used solely for the purpose for which itEquipment Needed to Query was provided. If two different entitiesElectronically designate the same authorized agent to query the NPDB on their behalf, and bothRequirements for using the IQRS can be entities wish to request information on thefound on the NPDB-HIPDB web site. same subject, the authorized agent mustEntities must use the appropriate version query the NPDB separately on behalf ofof either Internet Explorer or Netscape each entity. The response to a queryCommunicator to query the NPDB. submitted for one entity cannot beEntities can determine their browser’s disclosed to another entity.version number by starting their browser,selecting Help from the main menu, then Query Processingselecting About Communicator or AboutInternet Explorer, as appropriate. When the NPDB receives a properly completed query, the information isYou also need a program that can read entered into the NPDB computer system.files in Portable Document Format (PDF) The computer system performs a(i.e., files with a .pdf extension), such as validation process that matches subjectAdobe Acrobat Reader 4.0 (or higher). (i.e., practitioner) identifying informationDownload the latest version of the free submitted in the query with informationAcrobat Reader at http://www.adobe.com. previously reported to the NPDB.These guidelines explain the minimum Information reported about a specificrequirements necessary to access the subject is released to an eligible querierIQRS. To improve reliability, the NPDB only if the identifying informationrecommends that you use the most recent provided in the query matches theversion of each browser available for your information in a report.operating system.September 2001 D-7
    • Chapter D Queries NPDB GuidebookEach query processed by the NPDB database is a feature of the IQRS thatcomputer system is assigned a unique Data offers an easy method for maintainingBank Control Number (DCN). The DCN information about the subjects on whomis used by the NPDB to locate the query you routinely query or report, (e.g., Socialwithin the computer system and is Security Numbers, dates of birth, licenseprominently displayed on an electronic numbers).response. If a question arises concerning aparticular query, the entity must reference You may import a pre-existing QPRACthe DCN in any correspondence to the subject database into the IQRS, eliminatingNPDB. the need to retype subject data. For information, see the Fact Sheet onSubject Information Creating and Maintaining a Subject Database, available at www.npdb-hipdb.com.When submitting a query, the entity isrequired to provide certain subject Character Limitsinformation. The NPDB computersystem does not allow entities to submit Each field in a query (such as Subjectqueries that do not include information Name, Work Address, and Licensein all mandatory fields. An entity’s lack Number) is limited to a certain number ofof mandatory information does not characters, including spaces andrelieve it of querying requirements for punctuation. The IQRS software does notthe purposes of Title IV. allow the entity to use more than the allotted number of characters. The NPDBA subject’s Social Security Number (SSN) does not change any informationshould be provided if known, but only if it submitted in a query.was obtained in accordance with Section 7of the Privacy Act of 1974, which states Query Responsesthat disclosure of an individual’s SSN isvoluntary unless otherwise provided by In general, query responses are availablelaw. Disclosure of an individual’s SSN electronically within an average of 4 to 6for the purposes of this program is hours of receipt by the NPDB. Undervoluntary. The NPDB uses SSNs only to certain circumstances, additionalverify the identity of individuals, and processing may be required. Entities thatSSNs will be disclosed only as authorized submit queries using the IQRS shouldby the Health Care Quality Improvement retrieve their query responses from theAct of 1986, as amended. The inclusion of IQRS. Queries marked Completed havethis information helps to ensure the been processed and are available foraccurate identification of the subject of the retrieval. Queries marked Pending havereport. not yet been processed. Queries marked Partially Completed require additionalSubject Database processing time. Queries marked Rejected have one or more errors; they have beenYou may establish a subject database to processed and a document describing thecomplete your querying and reporting error(s) is available for retrieval.obligations more efficiently. The subjectD-8 September 2001
    • NPDB Guidebook Chapter D QueriesEntities that submit queries via the ITP Ideally, information from the NPDB willmust retrieve their query responses using be considered during the credentialingthe file transfer program specified in the process. However, the NPDB law doesITP instructions. ITP responses are not require querying entities to receiveformatted in the Interface Control query responses from the NPDB beforeDocument (ICD) for Query Transactions proceeding with the granting of clinicalaccording to the specifications of the privileges, hiring, appointment to theappropriate ICD. Subjects who self-query medical staff, issuance of licenses, orwill receive paper responses sent by First approval of memberships. Because theClass U.S. Mail. NPDB is one of several resources for the credentials review process, entities mayWhen there is no information in the NPDB act on applications according to theirabout a subject, the entity receives in established criteria and informationresponse to a query only the identifying obtained from other sources.subject information provided in the queryand a notification that no information Missing Query Responsesabout the subject is contained in theNPDB. Query information submitted by If you do not receive a query responsethe entity is not retained on subjects for within 2 to 3 business days of submission,whom there is no record in the NPDB. please contact the NPDB-HIPDB Customer Service Center to request aEntities that submit 10 or fewer subject query status. Please do not resubmit anames receive separate response files for query on the subject in question, as thiseach query. When the number of subject will result in duplicate transactions andnames submitted is 11 or more, batch duplicate query fees.downloading consolidates query files sothat a single file can contain multiple Correcting Query Informationresponses and hold up to 1 megabyte ofdata. Along with the query response files, If the information you submitted in aentities also receive a list of all the subject query does not accurately identify thenames queried and the file number where subject on whom you intended to query,each response is located. This list helps to your query will not match NPDB reportsquickly identify the location of a specific submitted with correct identifyingsubject query response. information. To query the NPDB with the proper identifying information onQuery Response Availability the subject, submit a new, correctly completed query to the NPDB.Query responses are available via theIQRS or ITP 4 to 6 hours after the query isprocessed. Entities must retrieve Failure to Queryresponses within 30 days of processing, or Any hospital that does not query on athey will be forced to re-submit their practitioner (1) at the time the practitionerqueries. Entities that wish to save query applies for a position on its medical staffresponses should download them or for clinical privileges (initial orimmediately and save them to their hard expanded) at the hospital, and (2) every 2drives.September 2001 D-9
    • Chapter D Queries NPDB Guidebookyears concerning any practitioner who is However, if the resident or intern ison its medical staff or has clinical being considered for clinical privilegesprivileges at the hospital, is presumed to outside of his or her structuredhave knowledge of any information program, the hospital must query.reported to the NPDB concerning the Note that medical malpracticepractitioner. A hospital’s failure to query payments made on behalf of andon a practitioner may give a plaintiff’s adverse licensure actions taken againstattorney or plaintiff representing himself residents and interns must be reported.or herself access to NPDB information onthat practitioner for use in litigation 3. Is my hospital required to query onagainst the hospital. all of our nurses?Questions and Answers If an individual belongs to the medical staff or has clinical privileges at your1. Should I query on the members of hospital and if that individual is my hospital’s Allied Health licensed or otherwise authorized Practitioner Staff? (either registered or certified) by a State to provide health care services, If the Allied Health Practitioners are the hospital is required to query on granted clinical privileges or medical that individual. Examples of nursing staff membership, yes. For example, staff who frequently are granted if your hospital grants clinical individual privileges and meet this privileges to nurse practitioners, you definition may include certified nurse must query on them. Each hospital anesthetists and nurse practitioners. must determine, based on State law and on its own by-laws, which 4. Are hospitals required to document practitioners are licensed by its State and maintain records of their and credentialed as part of the medical requests for information? staff or granted clinical privileges. The intent of the statute is to require Hospitals are not specifically required querying on medical staff members or by the NPDB’s implementing privilege holders who are individually regulations to do so. credentialed by the hospital. 5. How long should my organization2. Are hospitals required to query the keep query responses on file? NPDB on medical and dental interns and residents? While the NPDB regulations require hospitals to query the NPDB, they do No. Since interns and residents are not specify that query responses be trainees in structured programs of kept on file by requesting entities. supervised graduate medical education Please note, however, that your query and are not (generally) members of the response may be used as proof that medical staff in a formal sense, there is your organization queried the NPDB no requirement to query on them. on the practitioners. Hospitals may choose to query on residents and interns if they desire.D-10 September 2001
    • NPDB Guidebook Chapter D Queries6. If I cannot find or did not receive a liquidation, even under a debtor-in- response to a query, may I request a possession, it must continue to query copy from the NPDB? the NPDB. If it is in liquidation solely for the purpose of sale of assets No. The NPDB currently does not and there is no ongoing business as a have the capability to produce hospital, there is no reason to query duplicate responses. If you did not and your DBID will be deactivated. receive a response to a query and were Your organization is responsible for not charged for the query, the query notifying the NPDB of your status. If has not been processed by the NPDB the hospital comes under new and should be resubmitted. Once ownership, the new owner must processed by the NPDB, query register with the NPDB and is responses will be maintained in the responsible for fulfilling its reporting IQRS for 30 days. After 30 days, the and querying obligations. responses will be deleted from the IQRS and the entity will have to 9. My hospital is in Chapter 9 resubmit the query to receive a bankruptcy. Can it continue to response. If you did not receive a query the NPDB? response to a query but were charged for it, see the Missing Query Yes. Your hospital will be charged Responses section in this chapter of for any queries submitted after the the Guidebook. NPDB receives notice of the filing of the Petition for Bankruptcy.7. May self-queries be used to satisfy Organizations that have an obligation requirements for peer review and to query (i.e., hospitals) must still employment? meet their querying obligations. Subjects may share the information 10. My hospital is in Chapter 11 contained in their own self-query bankruptcy. Can it continue to responses with whomever they query the NPDB? choose; however, such shared information does not satisfy a Yes. Your organization will be hospital’s legal requirement to query charged for any queries submitted the NPDB whenever a physician, after the NPDB receives notice of the dentist, or other health care filing of the Petition for Bankruptcy. practitioner applies for clinical Organizations that have an obligation privileges or a medical staff to query (i.e., hospitals) must still appointment. meet their querying obligations.8. My hospital is in Chapter 7 bankruptcy. Can it continue to query the NPDB? If your hospital still has ongoing business and is functioning as a hospital while concluding itsSeptember 2001 D-11
    • Chapter D Queries NPDB Guidebook11. My hospital has been liquidated by 13. If I decide to designate an the State. Can it continue to query authorized agent or change from the NPDB? one agent to another, how long will it take before the authorized agent If your hospital still has ongoing can query for my hospital? business and is functioning as a hospital while concluding its If the authorized agent is already liquidation, it must continue to query registered with the NPDB and has the NPDB. Once the liquidation been assigned a DBID, the NPDB will process is concluded or your send notification documents to your organization has no ongoing business organization and the authorized agent. as a hospital, there is no reason to You should check the documents to query and your DBID will be ensure that all information is correct. deactivated. Your organization is Your authorized agent will be able to responsible for notifying the NPDB of query on your organization’s behalf its status. If the hospital comes under immediately upon receipt of the new ownership, the new owner must notification documents. register with the NPDB and is responsible for fulfilling its reporting and querying obligations.12. Can I designate more than one authorized agent to query for my hospital? Yes. The NPDB computer system can now accommodate multiple authorized agents for each querying entity.D-12 September 2001
    • NPDB Guidebook Chapter E ReportsOverview Civil Liability ProtectionThe NPDB acts primarily as a flagging The immunity provisions in thesystem; its principal purpose is to facilitate Healthcare Quality and Improvement Acta comprehensive review of professional of 1986 protect individuals, entities, andcredentials. Information on medical their authorized agents from being heldmalpractice payments, certain adverse liable in civil actions for reports made tolicensure actions, adverse clinical the NPDB unless they have actualprivilege actions, adverse professional knowledge of falsity of the information.society membership actions and Medicare/ The statute provides the same immunity toMedicaid exclusions is collected from and HHS in maintaining the NPDB. For moredisseminated to eligible entities. NPDB information on civil liability protection,information should be considered with refer to page A-2.other relevant information in evaluating apractitioner’s credentials. Official LanguageEligible entities are responsible for The NPDB’s official language is English.meeting specific querying and/or reporting All reports must be submitted in English.requirements and must register with the Files submitted in any other language orNPDB in order to query or report to the containing non-alphanumeric charactersNPDB. (e.g., tildes, accents, umlauts) are not accepted.The information required to be reported tothe NPDB is applicable to physicians, Computation of Time Periodsdentists, and, in some cases, other healthcare practitioners who are licensed or In computing any period of timeotherwise authorized by a State to provide prescribed or allowed by the NPDB statutehealth care services. or regulations, the date of the act or event in question shall not be included. The dayTime Frame for Reporting to the NPDB following the date of the act or event is Day 1 for purposes of computation. TheMandated NPDB reporters must report last day of the period so computed shall bemedical malpractice payments and included. Saturdays, Sundays, and Federaladverse actions taken on or after holidays are to be included in theSeptember 1, 1990. This is the date that calculation of time periods. However, ifthe NPDB commenced operation. With the end date for submitting a report fallsthe exception of reports on Medicare/ on a Saturday, Sunday, or Federal holiday,Medicaid Exclusions, the NPDB the due date is the next Federal work day.cannot accept any report with a date of This method of computation of timepayment or a date of action prior to periods is consistent with Federal Rule ofSeptember 1, 1990. Civil Procedure 6.September 2001 E-1
    • Chapter E Reports NPDB Guidebook Table E-1. NPDB Reporting Requirements Entity Physicians and Other Health Care Dentists PractitionersMedical Malpractice Payers Must report Must reportPayment resulting from written claim or judgment.Reports must be submitted to the NPDB and appropriateState licensing board within 30 days of a payment.State Licensing Boards Must report Currently no reportingLicensure disciplinary action based on reasons related to requirementsprofessional competence or conduct. Reports must besubmitted to the NPDB within 30 days of the action.Hospitals and Other Health Care Entities Must report May reportProfessional review action, based on reasons related toprofessional competence or conduct, adversely affectingclinical privileges for a period longer than 30 days; orvoluntary surrender or restriction of clinical privilegeswhile under, or to avoid, investigation. Reports must besubmitted to the NPDB and appropriate State licensingboard within 15 days of the action.Professional Societies Must report May reportProfessional review action, based on reasons relating toprofessional competence or conduct, adversely affectingmembership. Reports must be submitted to the NPDBand appropriate State licensing board within 15 days ofthe action.HHS Office of Inspector General Must report Must reportExclusions from Medicaid/Medicare and other Federalprograms. Exclusions are reported monthly.Submitting Reports to the NPDB When Subject Information Is UnknownSubject Information As indicated previously, the NPDB computer system does not allow reports toWhen submitting a report to the NPDB, be submitted without all mandatorythe reporting entity is required to provide subject information. The NPDB suggestscertain subject information. The NPDB that each reporting entity review thecomputer system does not allow entities mandatory fields information and make anto submit reports that do not include effort to collect this information for eachinformation in all mandatory fields. An practitioner before there is a cause to fileentity’s lack of mandatory information a report (i.e., during the applicationdoes not relieve the entity of reporting process). An incomplete report (one thatrequirements for the purposes of Title is missing required information or isIV. All required fields in a subject’s improperly completed) is not accepted. Ifrecord must be completed before a report you are having trouble filing yourcan be generated. Entities should provide electronic report, please contact theas much information as possible, even in NPDB-HIPDB Customer Service Center.the fields that are not required.E-2 September 2001
    • NPDB Guidebook Chapter E ReportsReporting Subject Social Security www.npdb-hipdb.com. Once logged ontoNumbers the site, the entity may enter and submit report information to the NPDB.Under Title IV, a subject’s Social SecurityNumber (SSN) should be provided if Medical malpractice payments areknown when reporting medical submitted using the Medical Malpracticemalpractice payments, adverse clinical Payment Report (MMPR) format. Clinicalprivileges and professional society actions, privileges, professional society andbut only if obtained in accordance with licensure actions, as well asSection 7 of the Privacy Act of 1974, Medicare/Medicaid exclusions arewhich provides that disclosure of an submitted using the Adverse Actionindividual’s SSN is voluntary unless Report (AAR) format.otherwise provided by law. Disclosure ofan individual’s SSN for the purposes of Both the MMPR and the AAR formats inthe NPDB is voluntary. the IQRS capture all the necessary information for report submission.The NPDB will use SSNs only to verify Sufficient space is provided in the fields tothe identity of individuals, and SSNs are allow entry of multiple practitioner licensedisclosed only as authorized by the Health numbers, Federal Drug EnforcementCare Quality Improvement Act of 1986, as Administration (DEA) numbers,amended. The inclusion of this informa- professional schools, and hospitaltion, wherever possible, is encouraged affiliations. The IQRS allows for a 2,000-because it helps to ensure the accurate character description of the acts oridentification of the subject of the report. omissions and, in the case of MMPRs, a description of the judgment or settlementAn SSN is required for adverse statements.licensure actions, as these reports arealso mandated for inclusion in the Subject information does not need to beHIPDB under Section 1128E of the reentered into a report format if an entitySocial Security Act. Section 1128E maintains a subject database on the IQRS.requires that SSNs be provided as part The IQRS retrieves all pertinentof the reporting process. information from the entity’s subject database into the appropriate reportIncorrectly Identified Subject screens; however, if a record in the subject database is incomplete (i.e., information isIf an entity reports information for the missing in required fields), the IQRS doeswrong subject, the reporting entity must not allow a report to be generated for thatsubmit a Void of the incorrect report and subject until the missing information issubmit a new Initial report for the correct added. For more information on subjectsubject. See page E-5 for more databases, see the Fact Sheet on Creatinginformation on Void reports. and Maintaining a Subject Database, available at www.npdb-hipdb.com.Submitting Reports Via the IQRS Each data field on the report input screensEligible entities may prepare and submit is limited to a certain number ofreports using the IQRS at characters, including spaces andSeptember 2001 E-3
    • Chapter E Reports NPDB Guidebookpunctuation. For example, the narrative Submitting Reports to the NPDB Viadescription fields allow 2,000 characters, ITPincluding spaces and punctuation. Anycharacters over 2,000 are truncated. If a reporting entity does not have accessDrafting your narrative in accordance with to the IQRS, or prefers to generate reportsthe character limits will avoid the need to using custom software, the entity maycorrect a truncated narrative once the choose to submit reports via an electronicreport is accepted by the NPDB. transaction file submission (known as ICD Transfer Program [ITP]). This method ofUpon submitting the report to the NPDB, reporting requires the entity to submit datathe entity will receive a Temporary Record using a format specified by the NPDB.of Submission document with a Interface Control Documents (ICDs)confirmation number. The confirmation specify the format for ITP reportnumber can be used to verify that the submissions of MMPRs and AARs. Theseentity submitted the report. Within 4 to 6 documents are available at www.npdb-hours of receipt, the NPDB will make hipdb.com. See page D-6 for anavailable to the reporting entity an official explanation of ITP.Report Verification Document. Thereporting entity must verify the report data Types of Reportson the Report Verification Document andcorrect any erroneous information on-line. Initial ReportThe subject of the report will receive acopy of the submitted report by mail from The first record of a medical malpracticethe NPDB. Each NPDB reporter must payment or adverse action submitted tomail a copy of the paper report to the and processed by the NPDB is consideredappropriate State licensing board. the Initial report. An Initial report is the current version of the report until aDraft Capability Correction, Void, or Revision to Action is submitted.The IQRS includes a Draft report featurefor entering report data into input screens, When the NPDB processes an Initialthen saving the document in draft status. report, a Temporary Record of SubmissionThe draft version of a report can be document is available to print or save untilmodified later. Draft reports may be saved the official Report Verification Documenton the IQRS server for a maximum of 30 is retrieved by the reporting entity fromdays before they are automatically deleted. the IQRS. A Notification of a Report inReports saved as drafts are not considered the NPDB-HIPDB is mailed to the subject.official report submissions. Draft reports The reporting entity and the subjectmust be completed, submitted, and should review the report information tosuccessfully processed by the NPDB to ensure that it is correct. The reportingfulfill Title IV reporting requirements. entity should also print and mail a copy of the Initial report to the appropriate State licensing board.E-4 September 2001
    • NPDB Guidebook Chapter E ReportsCorrection When the NPDB processes a Void, a Temporary Record of Submission isA Correction is a change intended to available to print or save until the officialsupersede the contents of the current void verification is retrieved from theversion of a report. The reporting entity IQRS. A Report Revised, Voided, ormust submit a Correction as soon as Status Changed document is mailed to thepossible after the discovery of an error or subject and all queriers who received theomission in a report. A Correction may be previous version of the report within thesubmitted to replace the current version of past 3 years. The reporting entity and thea report as often as necessary. practitioner should review the information to ensure that the correct report wasWhen the NPDB processes a Correction, a voided, and queriers should note that theTemporary Record of Submission report was voided. The reporting entitydocument is available to print or save until should also print and mail a copy of thethe official Report Verification Document Void to the appropriate State licensingis retrieved from the IQRS. A Report board.Revised, Voided, or Status Changeddocument is mailed to the subject and all Example: A State Medical Board submitsqueriers who received the previous version an AAR when it revokes a physician’sof the report within the past 3 years. The license. Six months later, the revocation isreporting entity and the subject should overturned by a State court. The Statereview the information to ensure that it is Medical Board should submit a Void ofcorrect, and queriers should note the the Initial Report.changed report. The reporting entityshould also print and mail a copy of the Revision to ActionCorrection to the appropriate Statelicensing board. A Revision to Action reports an action that relates to and/or modifies an adverseExample: A hospital submits a clinical action previously reported to the NPDB.privileges action to the NPDB. Upon It is treated as a second and separatereceiving the Report Verification action by the NPDB, but it does not negateDocument, the hospital identifies an error the original action that was taken. Thein the subject’s address. The hospital entity that reports an initial adverse actionsubmits a Correction to the Initial Report, must also report any revision to thatincluding the correct address. action.Void Previous Report A Revision to Action report should be submitted for the following reasons:A Void is the retraction of a report in itsentirety. An example of a Void is the • Additional sanctions have been takenreversal of a professional review action. against the subject based on aThe report is removed from the subject’s previously reported incident.disclosable record. A Void may besubmitted by the reporting entity at any • The length of action has been extendedtime. or reduced.September 2001 E-5
    • Chapter E Reports NPDB Guidebook• The original suspension or reported action, the hospital must submit a probationary period has ended. new report using the Revision to Action option in the IQRS. The Initial report• Licensure, clinical privileges, documents that the hospital suspended the professional society membership, or subject’s clinical privileges, and the program participation has been Revision to Action documents that the reinstated. hospital made a subsequent revision to the action.A Revision to Action should not bereported unless the initial action was Example: A hospital submits an AARreported to the NPDB. When submitting a when it revokes an oral surgeon’s clinicalRevision to Action, the reporter must privileges. Two years later, the oralreference the Data Bank Control Number surgeon’s clinical privileges are reinstated.(DCN) on the report of the action being Since this action modifies the originalmodified. action, the hospital must submit a Revision to Action. The Initial reportA Revision to Action is separate and documents that the hospital revoked thedistinct from a Correction. For example, oral surgeon’s clinical privileges, and theif the hospital in the above example enters Revision to Action documents that thethe Date of Action incorrectly, a hospital made a revision to the action.Correction must be submitted to make thenecessary change, and the Correction Report Processingoverwrites the Initial report. A Revisionto Action is treated as an addendum to the When the NPDB receives a report, theInitial report. information is entered into the NPDB computer system. Each version of a reportWhen the NPDB processes a Revision to processed by the NPDB computer systemAction, a Temporary Record of is assigned a unique DCN. This number isSubmission document is available to print used to locate the report within the NPDBor save until the official Report computer system. The DCN isVerification Document is retrieved from prominently displayed in the electronicthe IQRS. A Notification of a Report in Report Verification Document. The DCNthe NPDB is mailed to the subject assigned to the most current version of thepractitioner. The reporting entity and the report must always be referenced in anypractitioner should review the information subsequent action involving the report.to ensure that it is correct. The reportingentity should also print and mail a copy ofthe Revision to Action to the appropriate Report ResponsesState licensing board. Each time a report is successfully submitted to the IQRS and processed byExample: A hospital submits an AAR the NPDB, a Report Verificationwhen it suspends a practitioner’s clinical Document is stored for the reporting entityprivileges for 90 days. The suspension is to retrieve through the IQRS. Reports arelater reduced to 45 days. Since this is a generally processed within 4 to 6 hours ofnew action that modifies a previouslyE-6 September 2001
    • NPDB Guidebook Chapter E Reportsreceipt. Once viewed, the report output is Missing Report Verificationmaintained on the server for 30 daysbefore it is automatically deleted. Reports will be available electronically within an average of 4 to 6 hours ofEntities should print or save the report receipt by the NPDB. Under certainoutput before automatic deletion occurs. circumstances, additional processing may be required. Entities should not re-submitEntities that submit reports via the ITP reports on the subject in question, sincemust retrieve their report responses using this will result in duplicate reports. If youthe file transfer program specified in the do not receive your response within 2 to 3ITP instructions. ITP responses are business days of submission, please callformatted according to the specifications the NPDB-HIPDB Customer Serviceof the appropriate ICD. As with responses Center.downloaded from the IQRS, entities mustreview their report verifications to ensure If your original report is not processed, thethat the information is correct and that NPDB will require a new report. Thecopies of the reports are mailed to the NPDB will process the report and provideappropriate State licensing boards. you with a DCN. If you need to make a change to the report, use the DCN and the appropriate procedures explained in this Guidebook to submit a Correction or a Void.September 2001 E-7
    • Chapter E Reports NPDB Guidebook REPORTING MEDICAL MALPRACTICE PAYMENTS Report Verification Document Entity’s Report Medical Malpractice Payments Subject Notification Document COPY OF REPORT TO STATE BOARDReporting Medical Malpractice based on the law of tort in any State orPayments Federal court or other adjudicative body, such as a claims arbitration board.Each entity that makes a payment for the Trigger Date for Reportingbenefit of a physician, dentist, or otherhealth care practitioner in settlement of, or Reports must be submitted to the NPDBin satisfaction in whole or in part of, a and the appropriate State licensing boardsclaim or judgment against that practitioner within 30 days of the date that a paymentmust report the payment information to the is made (the date of the payment check).NPDB. A payment made as a result of a The report must be submitted regardless ofsuit or claim solely against an entity (for how the matter was settled (for instance,example, a hospital, clinic, or group prac- court judgment, out-of-court settlement, ortice) and that does not identify an arbitration). The 30-day periodindividual practitioner is not reportable commences on the day following the dateunder the NPDB’s current regulations. of payment.Eligible entities must report when a lump Interpretation of Medical Malpracticesum payment is made or when the first of Payment Informationmultiple payments is made. Medicalmalpractice payments are limited to As stated in 427(d) of the Health Careexchanges of money and must be the result Quality Improvement Act of 1986, asof a written complaint or claim demanding amended (Title IV of Public Law 99-660),monetary payment for damages. The and in 60.7(d) of the NPDB regulations,written complaint or claim must be based “[A] payment in settlement of a medicalon a practitioner’s provision of or failure malpractice action or claim shall not beto provide health care services. A written construed as creating a presumption thatcomplaint or claim can include, but is not medical malpractice has occurred.”limited to, the filing of a cause of actionE-8 September 2001
    • NPDB Guidebook Chapter E ReportsThe Secretary of HHS understands that • Patient Type – generally an indicationsome medical malpractice claims of inpatient or outpatient status;(particularly those referred to as nuisance choose inpatient, outpatient, or both.claims) may be settled for convenience,not as a reflection on the professional • Initial Event (Medical Condition ofcompetence or professional conduct of a the Patient) – choose the words thatpractitioner. best describe the diagnosis with which the claimant presented for treatment.Reporting entities should provide a To report the diagnosis, the reportersdetailed narrative to describe the acts or should use the actual condition fromomissions and injuries or illnesses upon which the patient suffered. When thewhich the medical malpractice action or patient has more than one condition,claim was based. This narrative may be a the reporter should use the conditionmaximum of 2,000 characters including that is most applicable to thespaces and punctuation. Any characters generation of the claim.over 2,000 are truncated. • Procedure Performed – the treatmentNarrative descriptions should include rendered by the insured to the patienteight general categories of information: for the medical condition describedage, sex, patient type, initial event under “Medical Condition of the(medical condition of the patient), Patient.” If more than one procedureprocedure performed, claimant’s was used, the procedure that is mostallegation, associated legal and other significant to the claim’s generationissues, and outcome. Narratives cannot should be used.contain patient names or names of otherhealth care practitioners, plaintiffs, • Claimant’s Allegation – thewitnesses, or any other individuals occurrence that precipitated the claiminvolved in the case. Guidelines for these of medical and/or legal damages; thecategories follow: time sequence in relation to the initial event is relevant.• Age – age of claimant at the time of the initial event; age is expressed in • Associated Legal and Other Issues – years if the claimant is 1 year of age or any associated issues that have an older, in months from 1 month through impact on the claim. 11 months; and in days if the claimant is less than 1 month of age. Unknown • Outcome – a description of the may be used if applicable. outcome resulting from the initial event and the claimant’s allegation.• Sex – male, female, and disputed; disputed may be used in claims Sample Descriptions for Illustrative involving individuals whose sex has Purposes Only: been physically altered or who are physically one sex but live outwardly A 65-year-old male outpatient had a as the other. prostate exam by Dr. A. Six months later, the patient was diagnosed by Dr. B withSeptember 2001 E-9
    • Chapter E Reports NPDB Guidebookprostate cancer and underwent surgery. (Portions adopted from the Harvard RiskOne year later, the patient sued Dr. A for Management Foundation Sample Claimsalleged failure to diagnose. A settlement Descriptions.)was reached in the amount of $250,000. Reporting of Payments by IndividualsA 57-year-old female outpatient had amammogram. One year later, the patient Individual subjects are not required towas diagnosed with breast cancer and she report payments they make for their ownunderwent chemotherapy and radiation. benefit to the NPDB. On August 27,The patient sues the physician for alleged 1993, the Circuit Court of Appeals for thefailure to diagnose and treat. A settlement District of Columbia held that [445 (DCwas reached in the amount of $100,000. Cir. 3 F.3D 1993)] the NPDB regulation requiring each “person or entity” thatA 45-year-old male came to the makes a medical malpractice payment wasemergency department with complaints of invalid, insofar as it required individualsshoulder and chest pain, and he was to report such payments. The NPDBdischarged after evaluation. Six hours removed reports previously filed onlater, he had a cardiac arrest and could not medical malpractice payments made bybe resuscitated. The estate sued the individuals for their own benefit.treating emergency room physician foralleged failure to diagnose and treat. The A professional corporation or othercase went to trial and resulted in a verdict business entity comprised of a solein favor of the plaintiff for $1,000,000. practitioner that makes a payment for the benefit of a named practitioner must reportA 9-month-old girl was seen in a private that payment to the NPDB. However, if aoffice with fever and treated practitioner or other person, rather than asymptomatically. The next day she was professional corporation or other businessbrought to the hospital in convulsions. entity, makes a medical malpracticeHer parents allege that a delay in the payment out of personal funds, thediagnosis of meningitis caused permanent payment is not reportable.neurological damage. A settlement wasreached in the amount of $2,000,000. Payments for Corporations and HospitalsA 31-year-old pregnant woman wasadmitted to the hospital by her physician Medical malpractice payments madein the early stages of labor. After four solely for the benefit of a corporation suchhours, the woman began to show signs of as a clinic, group practice, or hospital arefetal distress. The hospital staff attempted currently not reportable to the NPDB. Ato contact the physician but could not payment made for the benefit of alocate her for four hours. The patient sued professional corporation or other businessthe physician, alleging that the physician’s entity that is comprised of a soleabandonment caused permanent practitioner is reportable if the paymentneurological damage to the child. A was made by the entity rather than by thesettlement was reached in the amount of sole practitioner out of personal funds.$2,000,000.E-10 September 2001
    • NPDB Guidebook Chapter E ReportsDeceased Practitioners named in the complaint, but not in the release or final adjudication, is required asOne of the principal objectives of the long as he or she is sufficiently describedNPDB is to restrict the ability of as to be individually identifiable.incompetent physicians to move fromState to State without disclosure or Insurance Policies that Cover Morediscovery of their previous damaging or than One Practitionerincompetent performance. The NPDBrequires reporting medical malpractice A medical malpractice payment madepayments made for the benefit of deceased under an insurance policy that covers morepractitioners (or for their benefit through than one practitioner should only betheir estates) because a fraudulent reported for the individual subject forpractitioner could assume the identity of a whose benefit the payment was made, notdeceased practitioner. for every practitioner named on the policy.When submitting an MMPR for a One Settlement for More than Onedeceased practitioner, check the deceased Practitionerblock on the appropriate MMPR screen inthe IQRS. The NPDB makes an electronic In the case of a payment made for thereport verification available to the benefit of multiple practitioners, wherein itreporting entity via the IQRS. is impossible to determine the amount paid for the benefit of each individualIdentifying Practitioners practitioner, the insurer must report, for each practitioner, the total (undivided)In order for a particular physician, dentist, amount of the initial payment and the totalor other health care practitioner to be number of practitioners on whose behalfnamed in an MMPR submitted to the the payment was made. In the case of aNPDB, the practitioner must be named in payment made for the benefit of multipleboth the written complaint or claim practitioners where it is possible todemanding monetary payment for apportion payment amounts to individualdamages and the settlement release or practitioners, the insurer must report, forfinal adjudication, if any. Practitioners each practitioner, the actual amount paidnamed in the release, but not in the written for the benefit of that practitioner.demand or as defendants in the lawsuit,are not reportable to the NPDB. A Residents and Internspractitioner named in the writtencomplaint or claim who is subsequently Reports must be submitted to the NPDBdismissed from the lawsuit and not named when medical malpractice payments arein the settlement release is not reportable made for the benefit of licensed residentsto the NPDB. In some States, the given or interns. Medical malpractice paymentsname of the practitioner does not have to made for the benefit of housestaff insuredappear in the release or final adjudication by their employers are also reportable toas long as the practitioner is sufficiently the NPDB.described in the settlement or finaladjudication as to be identifiable. In thoseStates, an NPDB report on the practitionerSeptember 2001 E-11
    • Chapter E Reports NPDB GuidebookStudents Loss Adjustment ExpensesPayments made for the benefit of medical Loss adjustment expenses (LAEs) refer toor dental students are not reportable to the expenses other than those in compensationNPDB. Unlicensed student providers of injuries, such as attorney’s fees, billableprovide health care services exclusively hours, copying, expert witness fees, andunder the supervision of licensed health deposition and transcript costs. If LAEscare professionals in a training are not included in the medicalenvironment. Students do not fall into the malpractice payment amount, they are not“other health care practitioner category;” required to be reported to the NPDB.other health care practitioners are licensedby a State and/or meet State registration or LAEs should be reported to the NPDBcertification requirements. only if they are included in a medical malpractice payment. ReportingPractitioner Fee Refunds requirements specify that the total amount of a medical malpractice payment and aIf a refund of a practitioner’s fee is made description and amount of the judgment orby an entity (including solo incorporated settlement and any conditions, includingpractitioners), that payment is reportable terms of payment should be reported to theto the NPDB. A refund made by an NPDB. LAEs should be itemized in theindividual is not reportable to the NPDB. description section of the report form.For purposes of NPDB reporting, medical Dismissal of a Defendant from amalpractice payments are limited to Lawsuitexchanges of money. A refund of a fee isreportable only if it results from a written A payment made to settle a medicalcomplaint or claim demanding monetary malpractice claim or action is notpayment for damages. The written reportable to the NPDB if the defendantcomplaint or claim must be based on a health care practitioner is dismissed fromphysician’s, dentist’s, or other health care the lawsuit prior to the settlement orpractitioner’s provision of, or failure to judgment. However, if the dismissalprovide, health care services. A written results from a condition in thecomplaint or claim may include, but is not settlement or release, then the payment islimited to, the filing of a cause of action reportable. In the first instance, there is nobased on the law of tort in any State or payment for the benefit of the health careFederal court or other adjudicative body, practitioner because the individual hassuch as a claims arbitration board. been dismissed from the action independently of the settlement orA waiver of a debt is not considered a release. In the latter instance, if thepayment and should not be reported to the practitioner is dismissed from the lawsuitNPDB. For example, if a patient has an in consideration of the payment beingadverse reaction to an injection and is made in settlement of the lawsuit, thewilling to accept a waiver of fee as payment can only be construed as asettlement, that waiver is not reportable to payment for the benefit of the health carethe NPDB.E-12 September 2001
    • NPDB Guidebook Chapter E Reportspractitioner and must be reported to the must have made a determinationNPDB. regarding liability at the trial or arbitration proceeding.Example: A health care practitioner isnamed in a lawsuit. The practitioner A payment made at the high end of theagrees to a payment on the condition that agreement is one made for the benefit ofhis or her name does not appear in the the practitioner and, therefore, must besettlement. The payment would be reported to the NPDB. When areportable to the NPDB. defendant practitioner has been found to be liable by a fact-finding authority,High-Low Agreements such as a judge, a jury, or by arbitration, any payment madeA “high-low” agreement, a contractual pursuant to that finding must beagreement between a plaintiff and a reported, regardless of the existence of adefendant’s insurer, defines the parameters high-low agreement.of a payment the plaintiff may receiveafter a trial or arbitration proceeding. If If a high-low agreement is in place, andthe finder of fact returns a defense verdict, the plaintiff and defendant settle the casethe defendant’s insurer agrees to pay the prior to trial, the existence of the high-low“low end” amount to the plaintiff. If the agreement does not alter the reportabilityfinder of fact returns a verdict for the of the settlement payment.plaintiff and against the defendant, thedefendant’s insurer agrees to pay the “high Example 1: A high-low agreement is inend” amount to the plaintiff. place prior to trial. The parties agree to a low end payment of $25,000 and a highA payment made at the low end of a end payment of $100,000. The jury findshigh/low agreement that is in place prior the defendant physician liable and awardsto a verdict or an arbitration decision $20,000 to the plaintiff in damages. Thiswould not be reportable to the NPDB only $20,000 payment is reportable because theif the fact-finder rules in favor of the jury found the defendant physician liable.defendant and assigns no liability to thedefendant practitioner. In this case, the Example 2: A high-low agreement is inpayment is not being made for the benefit place prior to binding arbitration. Theof the practitioner in settlement of a parties agree to a low end payment ofmedical malpractice claim. Rather, it is $50,000 and a high end payment ofbeing made pursuant to an independent $150,000. The arbitrator finds in favor ofcontract between the defendant’s insurer the defendant practitioner. However, dueand the plaintiff. The benefit to the to the existence of the high-lowinsurer is the limitation on its liability, agreement, the defendant’s insurer makeseven if the plaintiff wins at trial and is a payment of $50,000 to the plaintiff (theawarded a higher amount. The benefit to low end payment). This payment is notthe plaintiff is a guaranteed payment, even reportable since it is being made pursuantif there is no finding of liability against the to an independent contract between thepractitioner. Note: in order for the low- defendant’s insurer and the plaintiff.end payment to be exempted from thereporting requirements, the fact finderSeptember 2001 E-13
    • Chapter E Reports NPDB GuidebookExample 3: A high-low agreement is in DBID of the organization that made theplace prior to trial. The parties agree to a payment.low-end payment of $50,000 and a highend payment of $150,000. Before the fact For information on registering anfinder returns a verdict, the parties settle authorized agent or designating one, seethe case for $50,000. This payment is pages B-7 and B-8, respectively.reportable because it is made in settlementof the claim. Payments by Multiple PayersExample 4: A high-low agreement is in Any medical malpractice payer that makesplace prior to trial. The parties agree to a an indemnity payment for the benefit of alow-end payment of $50,000 and a high- practitioner must submit a report to theend payment of $100,000. Rather than go NPDB. Generally, primary insurers andto trial, the parties agree to binding excess insurers are obligated to make anarbitration to assess the amount of indemnity payment for the benefit of adamages the plaintiff will receive. The practitioner and so must submit a report toarbitrator awards the plaintiff $50,000. In the NPDB. Typically, reinsurers arethis case, the arbitration was conducted to obligated to make an indemnity paymentdetermine the amount of recovery by the directly to the primary insurer, not for theplaintiff, not whether or not the plaintiff benefit of the practitioner, and are notwill recover. Because no liability was to required to submit a report to the NPDB.be determined at this arbitrationproceeding, the payment is made in For example, if three primary insurerssettlement of the claim and is reportable. contribute to a payment, all three insurers are required to submit separate MMPRs toReporting by Authorized Agents the NPDB. Each insurer should describe the basis for their payment in the narrativeThe organization that makes the medical description of the settlement to avoid themalpractice payment is the organization impression of duplicate reporting.that must report medical malpracticepayments to the NPDB. Structured SettlementsA medical malpractice payer may choose A medical malpractice payer entering intoto use an adjusting company, claims a structured settlement agreement with aservicing company, or law firm, acting as life insurance or annuity company mustits authorized agent to complete and submit a payment report within 30 dayssubmit NPDB reports. An insurance after the lump sum payment is made bycompany may also wish to have all of its the payer to that company.NPDB correspondence related to reportshandled by an authorized agent. This is Payments made after the opening of thestrictly a matter of administrative policy NPDB (September 1, 1990) underby the medical malpractice payer. When annuities existing prior to the NPDBreporting a payment, the reporting entity opening are not reportable to the NPDB.information in the MMPR must becompleted using the name, address, andE-14 September 2001
    • NPDB Guidebook Chapter E ReportsSubrogation-Type Payments offshore insurer with an agent in the United States is subject to service (whichSubrogation-type payments made by one means that it can be served with a Federalinsurer to another are not required to be complaint); therefore, the reportingreported, provided that the insurer requirement can be enforced. It is not thereceiving the payment has previously NPDB’s responsibility to identify thesereported the total judgment or settlement companies; rather, it is the responsibilityto the NPDB. Subrogation often occurs of these companies to comply with thewhen there is a dispute between insurance statute and register with the NPDB.companies over whose professionalliability policy ought to respond to a Payments Made Prior to Settlementlawsuit. When a payment is made prior to aExample: A practitioner is insured in settlement or judgment, a report must be1991 by Insurer X and changes over to submitted within 30 days from the date theInsurer Y in 1992. Both policies provide payment was made. Since the totaloccurrence-type coverage. A medical amount of the payment is unknown, themalpractice lawsuit is filed in 1992. There medical malpractice payer should stateis a dispute over whether the alleged this in the narrative description section ofmedical malpractice occurred in late 1991 the report. When the settlement oror early 1992. Under the 1992 policy, judgment is finalized, the insurer mustInsurer Y agrees to defend the lawsuit but submit a Correction to the Initial Report.obtains an agreement from the practitionerthat it may pursue the practitioner’s legal When reporting medical malpracticeright to recover any indemnity and defense payment information, please be aware thatpayments that should have been paid leaving the Payment Result reason andunder Insurer X’s policy. This is a Date of Judgment or Settlement fields onsubrogation agreement. The jury the MMPR format blank indicates that thesubsequently determines that the incident payment was made prior to a judgment oroccurred in 1991 and awards $500,000 to settlement. When a payment is made as athe plaintiff. Insurer Y makes the result of a judgment or settlement, these$500,000 payment to the plaintiff and fields should be properly completed.reports it to the NPDB. Insurer Y seeks Likewise, the Adjudicative Body Casesubrogation of its indemnity and defense Number, Adjudicative Body Name, andpayments from Insurer X. Insurer X Court File Number fields should be leftultimately concedes and pays Insurer Y blank only when there was not a filingthe $500,000 plus defense costs. Insurer with an adjudicative body. See Table E-2X is not required to report its on page E-16 for information onreimbursement of Insurer Y to the NPDB. determining reportable medical malpractice payments.Offshore PayersA medical malpractice payment made byan offshore medical malpractice insurermust be reported to the NPDB. AnSeptember 2001 E-15
    • Chapter E Reports NPDB Guidebook Table E-2. Determining Reportable Medical Malpractice Payments Action NPDB Reporting Responsibility A malpractice settlement or court judgment Must file report. includes stipulation that the terms are kept confidential. Malpractice settlement is structured so that Report the initial payment after NPDB opening; claimant receives an annual sum for each year he identify as multiple payments. or she is alive. Malpractice settlement involves five practitioners. Must file a separate report on each of the five practitioners. Payment is made based only on oral demands. No report is required. Payment made by an individual. A professional corporation or other business entity comprised of sole practitioner must file a report. No report is required for an individual making payment out of personal funds. Payments made for corporations and hospitals. Payments made for the benefit of a corporation such as a clinic group practice or hospital are not currently reportable. Payment is reportable when made for business entities comprised of sole practitioners. Payments made for licensed residents and interns. Must file report. Practitioner fee refund. Must file report if refund is made by an entity (including solo incorporated practitioners). No report is required if refund is made by an individual. Dismissal of defendant from lawsuit. No report required if defendant is dismissed prior to settlement or judgment. Report is required if dismissal results from condition in settlement or release.E-16 September 2001
    • NPDB Guidebook Chapter E Reports REPORTING ADVERSE CLINICAL PRIVILEGES ACTIONS Report Verification Document Entity’s Report Clinical Privileges Subject Notification Document COPY OF REPORT TO STATE BOARDReporting Adverse Clinical • Professional review actions thatPrivileges Actions adversely affect a physician’s or dentist’s clinical privileges for a periodHealth care entities must report adverse of more than 30 days.actions within 15 days from the date the • Acceptance of a physician’s oradverse action was taken or clinical dentist’s surrender or restriction ofprivileges were voluntarily surrendered. clinical privileges while underThe health care entity must print a copy investigation for possible professionalof each report submitted to the NPDB incompetence or improper professionaland mail it to the appropriate State conduct or in return for not conductinglicensing board for its use. The Report an investigation or reportableVerification Document that health care professional review action.entities receive after a report issuccessfully processed by the NPDB Adverse actions taken against ashould be used for submission to the physician’s or dentist’s clinical privilegesappropriate State licensing board. include reducing, restricting, suspending, revoking, or denying privileges, and alsoReportable adverse clinical privileges include a health care entity’s decision notactions are based on a physician’s or to renew a physician’s or dentist’sdentist’s professional competence or privileges if that decision was based on theprofessional conduct that adversely practitioner’s professional competence oraffects, or could adversely affect, the professional conduct. Health carehealth or welfare of a patient. Hospitals entities may report such actions takenand other eligible health care entities must against the clinical privileges of otherreport: health care practitioners.September 2001 E-17
    • Chapter E Reports NPDB GuidebookAdverse actions involving censures, must be submitted when the probationaryreprimands, or admonishments should not period ends.)be reported to the NPDB. Matters notrelated to the professional competence or If an adverse action against the clinicalprofessional conduct of a practitioner privileges of a practitioner is based onshould not be reported to the NPDB. For multiple grounds, only a single reportexample, adverse actions based primarily must be submitted to the NPDB.on a practitioner’s advertising practices, However, all reasons for the action shouldfee structure, salary arrangement, be reported and explained in the narrative.affiliation with other associations or health The reporting entity may select up to fourcare professionals, or other competitive Basis for Action codes to indicate theseacts intended to solicit or retain business multiple reasons. Additional reasonsare excluded from NPDB reporting should be summarized in the narrativerequirements. description.See Table E-3 on page E-21 for more Denial of Applicationsinformation on determining reportableactions for clinical privileges. A restriction or denial of clinical privileges that occurs solely because aHospitals and other health care entities practitioner does not meet a health caremust report revisions to previously institution’s established thresholdreported adverse actions. For more eligibility criteria for that particularinformation on revisions, see page E-5, privilege is not reportable to the NPDB.Revision to Action, in the Types ofReports section. Such restrictions or denials are not deemed the result of a professional review actionMultiple Adverse Actions relating to the practitioner’s professional competence or professional conduct, butIf a single professional review action are considered decisions based onproduces multiple clinical privileges eligibility.actions (for example, a 12-monthsuspension followed by a 5-month For example, if an institution retroactivelyprobation), only one report should be changes the eligibility criteria for asubmitted to the NPDB. The Adverse particular clinical privilege, a physicianAction Classification Code for the that does not meet the new criteria willprincipal action should be submitted on lose previously granted clinical privileges;the AAR, and the narrative description this loss of privileges is not reportable toshould describe the additional adverse the NPDB.actions imposed. Adverse clinical privileges actionsA Revision to Action must be submitted reportable to the NPDB result fromwhen each of the multiple actions is lifted. professional review actions relating to the (Following the previous example, a practitioner’s professional competence orrevision must be submitted when clinical professional conduct.privileges are reinstated with probationafter the suspension, and another revisionE-18 September 2001
    • NPDB Guidebook Chapter E ReportsWithdrawal of Applications Guidelines for InvestigationsVoluntary withdrawal of an initial • An investigation must be carried outapplication for medical staff appointment by the health care entity, not anor clinical privileges prior to a final individual on the staff.professional review action generally is not • The investigation must be focused onreportable to the NPDB. However, if a the practitioner in question.practitioner applies for renewal of medicalstaff appointment or clinical privileges and • The investigation must concern thevoluntarily withdraws that application professional competence and/orwhile under investigation by the health professional conduct of the practitionercare entity for possible professional in question.incompetence or improper professional • A routine or general review of cases isconduct, or in return for not conducting not an investigation.such an investigation or taking aprofessional review action, then the • A routine review of a particularwithdrawal of application for clinical practitioner is not an investigation.privileges is reportable to the NPDB. • An investigation should be the precursor to a professional reviewInvestigations action.Investigations should not be reported to • An investigation is considered ongoingthe NPDB; only the surrender or until the health care entity’s decisionrestriction of clinical privileges while making authority takes a final action orunder investigation or to avoid formally closes the investigation.investigation is reportable. This wouldinclude a failure to renew clinical Summary Suspensionprivileges while under investigation. A summary suspension is reportable if it is:A health care entity that submits an AAR • In effect or imposed for more than 30based on surrender or restriction of a days.physician’s or dentist’s privileges whileunder investigation should have • Based on the professional competencecontemporaneous evidence of an ongoing or professional conduct of theinvestigation at the time of surrender, or physician, dentist, or other health careevidence of a plea bargain. The reporting practitioner that adversely affects, orentity should be able to produce evidence could adversely affect, the health orthat an investigation was initiated prior to welfare of a patient.the surrender of clinical privileges by a • The result of a professional reviewpractitioner. Examples of acceptable action taken by a hospital or otherevidence may include minutes or excerpts health care entity.from committee meetings, orders fromhospital officials directing an A summary suspension is often imposedinvestigation, and notices to practitioners by an individual, for instance, theof an investigation. chairman of a department. Commonly,September 2001 E-19
    • Chapter E Reports NPDB Guidebookthis action is then reviewed and confirmed The basis for this interpretation is that,by a hospital committee, such as a medical pursuant to Part A of the Health Careexecutive committee, as authorized by the Quality Improvement Act (42 U.S.C.medical staff bylaws. The suspension §11112)(c)(2), a summary suspension iswould then be viewed as a professional taken to prevent “imminent danger to thereview action taken by the entity. health of any individual.”If the suspension is modified or revised as The Act itself treats summary suspensionspart of a final decision by the governing differently than other professional reviewboard or similar body, the health care actions: the procedural rights of theentity must then submit a Revision to practitioner are provided for following theAction of the Initial report made to the suspension, rather than preceding it. ThisNPDB. reporting policy for summary suspensions is in keeping with the purpose of the Act,If the physician, dentist, or other health which is to protect the public from thecare practitioner surrenders his or her threat of incompetent practitionersclinical privileges during a summary continuing to practice without disclosuresuspension, that action must be reported to or discovery of previous damaging orthe NPDB. The action is reportable incompetent performance.because the practitioner is surrendering theprivileges either while under investigation In establishing this policy on the reportingconcerning professional conduct or of summary suspensions, HHS assumesprofessional competence that did or could that hospitals use summary suspensionsaffect the health or welfare of a patient or for the purpose stated in Part A of the Act:in order to avoid a professional review to protect patients from imminent danger,action concerning the same. rather than for reasons that warrant routine professional review actions. HHS alsoSummary suspensions are considered to emphasizes that this policy on summarybe final when they become professional suspension is solely for the purpose ofreview actions through action of the reporting to the NPDB, and does not relateauthorized hospital committee or body, to the criteria for immunity under Part Aaccording to the hospital bylaws. of the Act.E-20 September 2001
    • NPDB Guidebook Chapter E Reports Table E-3. Determining Reportable Actions for Clinical Privileges Action Reportable Based on assessment of professional competence, a proctor is assigned to a physician or Yes dentist for a period of more than 30 days. The practitioner must be granted approval before certain medical care is administered. Based on assessment of professional competence, a proctor is assigned to supervise a No physician or dentist, but the proctor does not grant approval before medical care is provided by the practitioner. As a matter of routine hospital policy, a proctor is assigned to a physician or dentist No recently granted clinical privileges. A physician or dentist voluntarily restricts or surrenders clinical privileges for personal No reasons; professional competence or professional conduct is not under investigation. A physician or dentist voluntarily restricts or surrenders clinical privileges; professional Yes competence or professional conduct is under investigation. A physician or dentist voluntarily restricts or surrenders clinical privileges in return for Yes not conducting an investigation of professional competence or professional conduct. A physician’s or dentist’s application for medical staff appointment is denied based on Yes professional competence or professional conduct. A physician or dentist is denied medical staff appointment or clinical privileges because No the health care entity has too many specialists in the practitioner’s discipline. A physician’s or dentist’s clinical privileges are suspended for administrative reasons not No related to professional competence or professional conduct. A physician’s or dentist’s request for clinical privileges is denied or restricted based upon Yes assessment of clinical competence as defined by the hospital.Examples of Reportable and Non- physician’s request for expanded clinicalReportable Actions privileges for reasons relating to professional competence.Example 1: A physician member of ahospital medical staff wishes to perform The action is reportable because the denialseveral clinical tests and procedures, but of privileges adversely affects the clinicaldoes not have the appropriate clinical privileges of the physician for longer thanprivileges. The physician applies for an 30 days.expansion of clinical privileges. Thephysician’s Department Head and the Whether particular actions are reportableMedical Staff Credentials Committee find to the NPDB is often best determined bythat, based on their assessment of the examining a hospital’s medical staffphysician’s demonstrated professional bylaws, rules, and regulations with regardperformance, the physician does not have to provisions defining who is empoweredthe clinical competence to perform the to take a professional review action, whatadditional tests and procedures, and they constitutes a professional review actionrecommend denial of the request for that adversely affects the clinicalexpanded clinical privileges. The privileges of a practitioner, and how thathospital’s governing body reviews the action relates to professional competencecase, affirms the findings and or professional conduct.recommendations, and denies theSeptember 2001 E-21
    • Chapter E Reports NPDB GuidebookExample 2: A 30-day suspension is (3) geographic proximity to the hospital,imposed as a result of a professional and (4) failure to have performed thereview action based on a physician’s minimum number of proceduresprofessional competence. prescribed for a particular clinical privilege.The action is not reportable because theadverse action taken by the professional Example 6: The hospital CEO summarilyreview body did not last for more than 30 suspends a physician’s privileges fordays. failure to respond to an emergency department call.Example 3: A hospital reviews asurgeon’s professional competence and The action is reportable if the suspensionassigns a surgical proctor for 60 days. The continues for longer than 30 days and thesurgeon cannot perform surgery without hospital bylaws state that summarybeing granted approval by the surgical suspension decisions by the medicalproctor. executive committee are considered to be professional review actions. A CEO maySince the surgeon cannot practice surgery be considered a committee assisting thewithout approval from another surgeon, governing body in a professional reviewthis restriction of clinical privileges is activity. If this is the case and thereportable. physician has been summarily suspended, the hospital medical staff bylaws willExample 4: A 31-day suspension is usually provide for an appeal to theimposed on a physician for failure to medical executive committee within a fewcomplete medical records. days of the CEO’s decision.Such a suspension would be reportable to Example 7: A hospital’s professionalthe NPDB if the failure to complete review body terminates a provider-basedmedical records related to the physician’s physician contract for causes relating toprofessional competence or conduct and poor patient care, which in turn results inadversely affects or could adversely affect loss of privileges with no right to a hearinga patient’s health or welfare. as provided in the contract and the medical staff bylaws.Example 5: A physician’s application forsurgical privileges is denied because the The termination of the contract, in itself, isphysician is not board certified in the not reportable to the NPDB. Theparticular clinical specialty or termination of the practitioner’s clinicalsubspecialty. privileges because of the termination of the contract for reasons relating toThe action is not reportable if the professional competence or professionalphysician fails to meet the hospital’s conduct is reportable if it is considered ainitial credentialing criteria applied to all professional review action by the hospital.medical staff or clinical privilegeapplicants. Examples of initial criteria Hospitals are advised to consult with legalmay include: (1) minimum professional counsel to review the State’s case lawliability coverage, (2) board certification, concerning due process.E-22 September 2001
    • NPDB Guidebook Chapter E ReportsExample 8: A physician surrenders Example 10: A physician holdingmedical staff privileges due to personal courtesy privileges in a hospital appliesreasons, infirmity, or retirement. for full staff privileges. The full staff privileges are granted. As a condition ofThe surrender is not reportable. The staff privileges, the physician is requiredreasons for surrender are irrelevant to be on-call in the Emergencyunless the physician surrenders while Department for one weekend a month.under an investigation by a health care Due to personal reasons, the physician isentity relating to possible professional unable to fulfill his Emergencyincompetence or improper professional Department commitment. The hospitalconduct, or in return for not conducting and the physician eventually agree tosuch an investigation. change his clinical privileges from full staff to courtesy.Example 9: A physician was underinvestigation four weeks prior to the The change in clinical privileges is notexpiration of his clinical privileges. The reportable. The change to the physician’sphysician failed to renew his clinical privileges is not the result of aprivileges. professional review action based on the physician’s professional competence orThis event is considered a reportable conduct which affects or could adverselysurrender while under investigation. This affect the health or welfare of a patient.action is reportable regardless of whetherthe physician knew he was underinvestigation at the time he failed to renewhis clinical privileges. A practitioner’sawareness that an investigation is beingconducted is not a requirement forreportability.September 2001 E-23
    • Chapter E Reports NPDB Guidebook REPORTING ADVERSE LICENSURE ACTIONS Report Verification Document Entity’s Report Licensure Subject Notification Document COPY OF REPORT TO STATE BOARDReporting Adverse Licensure occur between the formal approval of theActions action and the drafting of the order for publication; however, the trigger date for reporting the adverse action is basedState medical and dental licensing boards on the board’s formal approval of themust report adverse actions against action.physicians and dentists to the NPDBwithin 30 days from the date an adverse Examples of Reportable Actionslicensure action was taken. The following adverse licensure actions,State medical and dental boards must when related to the professionalreport to the NPDB certain disciplinary competence or professional conduct of aactions related to professional competence physician or dentist, must be reported toor professional conduct taken against the the NPDB:licenses of physicians or dentists. Suchlicensure actions include revocation, • Denial of an application for licensesuspension, censure, reprimand, probation, renewal.and surrender. State medical and dental • Withdrawal of an application forboards must also report revisions to license renewal (should be reported asadverse licensure actions, such as a voluntary surrender).reinstatement of a license. • Licensure disciplinary action taken byEffective Date of Action a State board against one of its licensees/applicants for licensureAn Adverse Action Report must be renewal based upon a licensuresubmitted within 30 days of the date of the disciplinary action, related to theformal approval of the licensure action by practitioner’s professional competencethe State medical or dental board or its or professional conduct, taken byauthorized official. Significant delays may another State board.E-24 September 2001
    • NPDB Guidebook Chapter E Reports• Licensure disciplinary action taken by • A settlement agreement which imposes a State board based upon the monitoring of a practitioner for a practitioner’s deliberate failure to specific period of time, unless such report a licensure disciplinary action monitoring constitutes a restriction of taken by another State board, when a the practitioner’s license or is report of such action is requested on a considered to be a reprimand. licensure renewal application. • A licensure disciplinary action which• Fines and other monetary sanctions is imposed with a “stay” pending accompanied by other licensure action, completion of specific programs or such as revocation, suspension, actions. However, if a “stay” of a censure, reprimand, probation, or disciplinary action is accompanied by surrender. probation, the probation is reportable.Examples of Non-Reportable Actions • Voluntary relinquishment of a physician’s license for personalThe following adverse licensure actions reasons not related to his or hershould not be reported to the NPDB: professional competence or professional conduct (for example,• Fines and other monetary sanctions retirement). unaccompanied by other licensure action, such as revocation, suspension, • Licensure actions taken against non- censure, reprimand, probation, or physician, non-dentist, health care surrender. practitioners.• Denial of an initial application for license.September 2001 E-25
    • Chapter E Reports NPDB Guidebook REPORTING ADVERSE PROFESSIONAL SOCIETY MEMBERSHIP ACTIONS Report Verification Document Entity’s Report Professional Society Subject Notification Document COPY OF REPORT TO STATE BOARDReporting Adverse Professional Reportable actions must be based onSociety Membership Actions reasons relating to professional competence or professional conduct whichProfessional societies must report adverse affects or could adversely affect the healthactions within 15 days from the date the or welfare of a patient. Matters not relatedadverse action was taken. A copy of each to the professional competence orreport sent to the NPDB should be printed professional conduct of a physician orand mailed to the appropriate State dentist are not to be reported to the NPDB.licensing board for its use. For example, adverse actions against aThe Report Verification Document that practitioner based primarily on his or herhealth care entities receive after a report is advertising practices, fee structure, salarysuccessfully processed by the NPDB arrangement, affiliation with othershould be used for submission to the associations or health care professionals,appropriate State licensing board. or other competitive acts intended to solicit or retain business are excluded fromReporting Requirements NPDB reporting requirements.Professional societies must report An adverse action taken by a professionalprofessional review actions based on society against the membership of areasons related to professional competence physician or dentist must be reported toor professional conduct that adversely the NPDB when that action constitutes aaffect the membership of a physician or professional review action taken in thedentist. Professional societies may report course of professional review activitysuch adverse membership actions when through a formal peer review process,taken against health care practitioners provided that the action is based on theother than physicians and dentists. member’s professional competence orE-26 September 2001
    • NPDB Guidebook Chapter E Reportsprofessional conduct. Adverse (5 U.S.C. 522a(b)(3)). CMS retains fullmembership actions involving censures, responsibility for the content and accuracyreprimands, or admonishments should not of CMS exclusion reports; the NPDB onlybe reported. acts as a disclosure service. Notification of exclusion from CMS programs is madeReporting Medicare/Medicaid by CMS. Inquiries on the appropriatenessExclusions or content of CMS exclusion reports must be referred to CMS for response.In 1997, reports of exclusions from the *The NPDB contains Medicare/MedicaidMedicare and Medicaid programs against exclusions against health carehealth care practitioners* were added to practitioners (i.e., physicians, dentists,the NPDB through a collective effort and a chiropractors, psychologists, etc.).Memorandum of Understanding between Exclusions against individuals other thanHRSA, the HHS Office of Inspector licensed health care practitioners andGeneral (OIG), and the Centers for entities, in addition to exclusions againstMedicare & Medicaid Services (CMS). health care practitioners, can be found inThe NPDB now includes Medicare/ the Healthcare Integrity and ProtectionMedicaid exclusions from May 1979 to Data Bank (HIPDB).the present.NPDB Medicare/Medicaid exclusions Sanctions for Failing to Report toidentify practitioners who have been the NPDBdeclared ineligible for Medicare andMedicaid payments. Hospitals, managed Medical Malpractice Payerscare organizations, and other providers areprohibited from billing the Medicare and The HHS Office of Inspector General hasMedicaid programs for any services that the authority to impose civil moneymight be rendered by these providers. penalties in accordance with SectionsInformation from the Medicare/Medicaid 421(c) and 427(b) of Title IV of Publicexclusions is released in accordance with Law 99-660, the Health Care Qualitythe Social Security Act. Improvement Act of 1986, as amended. Under the statute, any malpractice payerThe HHS Office of Inspector General has that fails to report medical malpracticethe authority to exclude individuals and payments in accordance withorganizations from participating in the Section 421(c) is subject to a civil moneyMedicare and/or certain State health care penalty of up to $11,000 for each suchplans under sections 1128(a), 1128(b), payment involved.1892, or 1156 of the Social Security Act.The exclusion also applies to all other The civil money penalties provided forExecutive Branch procurement and non- under Sections 421(c) and 427(b) are to beprocurement programs and activities. imposed in the same manner as other civilDisclosure of the Office of Inspector money penalties imposed pursuant toGeneral Exclusion List to HRSA is under Section 1128A of the Social Security Act,authority of section 1106(a) of the Social 42 U.S.C. 1320a-7a. Regulations governingSecurity Act, 42 CFR 401.105, and the civil money penalties under Section 1128Aroutine use exception of the Privacy Act are set forth at 42 CFR Part 1003.September 2001 E-27
    • Chapter E Reports NPDB GuidebookHospitals and Other Health Care State BoardsEntities State medical and dental boards that fail toThe Secretary of HHS will conduct an comply with NPDB reportinginvestigation if there is reason to believe requirements can have the responsibility tothat a health care entity has substantially report removed from them by thefailed to report required adverse actions. Secretary of HHS. In such instances, theIf the investigation reveals that the health Secretary will designate another qualifiedcare entity has not complied with NPDB entity to report NPDB information.regulations, the Secretary will provide the State medical or dental boards do not meetentity with written notice describing the Title IV requirements when they fail tononcompliance. This written notice report licensure disciplinary actionsprovides the entity with the opportunity to required to be reported to the NPDB or failcorrect the noncompliance, as well as to notify HHS when they are aware anotifies it of its right to request a hearing. health care entity is failing to report adverse actions it has taken againstA request for a hearing must contain a physicians and dentists.statement of the material factual issues indispute to demonstrate cause for a hearing When an HHS investigation substantiatesand must be submitted to HHS within 30 such reporting failures, a written notice ofdays of receipt of notice of noncompliance is sent to the State medicalnoncompliance. An example of a material or dental board. This notice allows Statefactual issue in dispute is a health care medical and dental boards an opportunityentity refuting HHS’s claim that the health to correct the situation. If the Statecare entity failed to meet reporting medical or dental board fails to complyrequirements. with the HHS notice, then HHS will designate another qualified entity forA request for a hearing will be denied if it reporting to the NPDB.is untimely, lacks a statement of materialfactual issues in dispute, or if the Professional Societiesstatement is frivolous or inconsequential.Hearings are held in the Washington, DC, A professional society that hasmetropolitan area. substantially failed to report adverse membership actions can lose, for 3 years,If HHS determines that a health care entity the immunity protections provided underhas substantially failed to report Title IV for professional review actions itinformation in accordance with Title IV takes against physicians and dentists basedrequirements, the name of the entity will on their professional competence andbe published in the Federal Register, and professional conduct.the entity will lose the immunityprovisions of Title IV with respect to The Secretary of HHS will conduct anprofessional review activities for a period investigation if there is reason to believeof 3 years commencing 30 days from the that a professional society hasdate of publication in the Federal substantially failed to report adverseRegister. membership actions taken as result of professional review activity.E-28 September 2001
    • NPDB Guidebook Chapter E ReportsIf the investigation reveals that the Questions and Answersprofessional society has not compliedwith Title IV reporting requirements, 1. How long are reports held in theHHS will inform the professional society NPDB?of its noncompliance in writing. Thiswritten notice provides the professional Information reported to the NPDB issociety with the opportunity to correct maintained permanently unless it isthe noncompliance, as well as notifies it corrected or voided from the system.of its right to request a hearing. A Correction or Void may only be submitted by the reporting entity orA request for a hearing must contain a directed by the Secretary of HHS.statement of the material factual issues indispute to demonstrate cause for a hearing 2. Can my organization provide a copyand must be submitted to HHS within 30 of an NPDB report to the subjectdays of receipt of notice of practitioner?noncompliance. An example of a materialfactual issue in dispute is a professional The NPDB appreciates entities thatsociety refuting HHS’s claim that the attempt to maintain an open exchangehealth care entity failed to meet reporting with subjects. However, if yourequirements. provide a copy of the report to the subject, be sure to remove or obliterateA request for a hearing is denied if it is your organization’s DBID. The DBIDuntimely, lacks a statement of material should remain confidential to thefactual issues in dispute, or if the organization to which it is assigned.statement is frivolous or inconsequential.Hearings are held in the Washington, DC, 3. Where can I find lists of Adversemetropolitan area. Action Classification Codes, Basis for Actions Codes, and MalpracticeIf HHS determines that a professional Act(s) or Omission(s) codes?society has substantially failed to reportinformation in accordance with Title IV Adverse action classification codesrequirements, the name of the entity will and medical malpractice act(s) orbe published in the Federal Register, and omission(s) codes are provided inthe professional society will lose the pop-up lists in the respective IQRSimmunity provisions of Title IV with web input screens. These codes alsorespect to professional review activities are found in the applicable Interfacefor a period of 3 years commencing 30 Control Document (ICD) that isdays from the date of publication in the available on the NPDB-HIPDBFederal Register. website.September 2001 E-29
    • Chapter E Reports NPDB GuidebookReporting Medical Malpractice Payments complaint with, for example, a State board, and a medical malpractice4. I am the new authorized submitter payment results, the payment must be for a medical malpractice payer. I reported to the NPDB. found some documentation of payments that were not reported to 7. How does a medical malpractice the NPDB. What should I do? payer report a payment if a total amount has not been determined If the payments were made on or after and the payer is making an initial September 1, 1990 (when the NPDB partial payment? opened), submit reports on those payments to the NPDB. The Complete the MMPR screens regulations prescribe that any entity according to the instructions on the that fails to report a payment required IQRS. Note the amount of the first to be reported is subject to a civil payment and, in the narrative section, money penalty of up to $11,000 for explain that the total amount has not each such payment. Submit the report been determined and the first payment through the IQRS and then send a is a partial payment. When the final letter to the NPDB that explains the amount is determined, submit a circumstance of the report being Correction to the Initial report, and submitted late. The NPDB will note the final amount in the narrative maintain this information for audit section. purposes. 8. Should payment exclusively for the5. As a medical malpractice payer, do benefit of a clinic or hospital be I have to report payments made for reported? a deceased subject? Medical malpractice payments made Yes. One of the principal objectives solely for the benefit of a clinic or of the NPDB is to restrict the ability hospital are not currently reportable to of incompetent practitioners to move the NPDB. from State to State without disclosure of their previous damaging or 9. Our insurance company reimbursed incompetent performance. Fraudulent a practitioner for a medical practitioners may seek to assume the malpractice payment the identity of a deceased practitioner. practitioner made to a patient. Is this reportable?6. Must a written complaint be directed to the subject cited in the Yes. An insurance company that claim? reimburses a practitioner for such a payment (makes a payment in No. The definition of a medical response to the medical malpractice malpractice complaint includes claim or judgment) must report that complaints “brought in any State or payment to the NPDB, as long as the Federal court or other adjudicative patient submitted the demand in body.” If a patient files a written writing.E-30 September 2001
    • NPDB Guidebook Chapter E Reports10. If a patient makes an oral demand 13. What are the reporting for a refund for services, is the requirements for self-insured em- resulting payment reportable to the ployers who provide professional NPDB? liability coverage for their employed practitioners? No. Only payments resulting from written demands are reportable to the Employers who insure their NPDB. Even if the practitioner employees must report medical transmits the demand in writing to the malpractice payments they make for medical malpractice payer, the the benefit of their employees. payment is not reportable if the patient’s only demand was oral. 14. If a stipulation of settlement or However, if a subsequent written court order requires that its terms claim or demand is received from the remain confidential, how does a patient and results in a payment, that medical malpractice insurer report payment is reportable. the payment to the NPDB without violating the settlement agreement11. If an individual practitioner is not or court order? named in a medical malpractice claim or complaint, but the facility Confidential terms of a settlement or or practitioner group is named, judgment do not excuse an entity from should the payment be reported? the statutory requirement to report the payment to the NPDB. The reporting No, with one exception. If the named entity should explain in the narrative defendant is a sole practitioner section of the MMPR that the identified as a “professional settlement or court order stipulates corporation,” a payment made for the that the terms of the settlement are professional corporation must be confidential. reported for the practitioner. 15. If there is no medical malpractice12. A supervisory practitioner is named payment and Loss Adjustment in an action based on the services of Expenses (LAEs) are paid in order a subordinate practitioner. How do to release or dismiss a healthcare I report the supervisory practitioner from a medical practitioner? malpractice suit, should the LAE be reported? The report on the supervisory practitioner should be submitted using No. If LAEs are not included in the the same malpractice claim descrip- medical malpractice payment, then tion code used for the subordinate. they should not be reported to the The reporting entity may provide an NPDB. explanation that the supervisory practitioner was named based on the subordinate practitioner’s services in the narrative description.September 2001 E-31
    • Chapter E Reports NPDB Guidebook16. When reporting a medical when the lesser sanction or action is malpractice payment, should loss implemented since it was included in adjustment expenses be included in the description in the Initial Report. the payment amount? 19. How should a State medical or LAEs should be reported only if they dental board report actions when are part of the medical malpractice they are changed by court order? payment. Reporting requirements include the total amount of the The board should report the initial payment and a description and amount adverse action as usual; the judicial of the judgment or settlement and any decision is reported as a Revision to conditions, including terms of Action. For example, if a board payment. LAEs should be itemized in revoked a physician’s license and a the description section of the report. judicial appeal resulted in the court LAEs refer to expenses other than modifying the discipline to probation those in compensation of injuries, for 1 year, then the board would be such as attorney’s fees, billable hours, required to report both its initial expert witness fees, deposition, and revocation action and the court- transcript costs. If LAEs are not ordered revision to a 1-year probation. included in the payment amount, they When a court stays a board’s order, need not be reported. this action may be reported as a Revision to Action, using the Adverse17. Are payments made for the benefit Action Classification Code for of residents, interns, and students Reduction of Previous Action (1295). reportable? When a court overturns a Board’s order, the Board should void the Payments made for the benefit of Initial Report. licensed residents and interns are reportable to the NPDB; payments 20. When reporting a reprimand by a made for the benefit of unlicensed State licensing board, what Length medical or dental students are not of Action should be entered on the reportable to the NPDB. report form?Reporting Adverse Licensure Actions The indefinite block should be marked on the appropriate report screen in the18. How should a State board report an IQRS for reprimands reported to the action with several levels or NPDB. components, for instance, a 6-month license suspension followed by a 2- year probation? The board should report the code of the principal sanction or action and describe its full order, including lesser actions, in the narrative of the AAR. An additional report is not necessaryE-32 September 2001
    • NPDB Guidebook Chapter E ReportsReporting Adverse Clinical Privileges If the reported suspension isActions subsequently altered following a hearing or other procedures, the entity21. If we revoke a practitioner’s clinical must submit a Revision to Action or privileges because the practitioner Void. lost his/her license, do we report the revocation? 23. Are adverse actions on clinical privileges reportable prior to Administrative actions that do not appeals? involve a professional review action are not reportable to the NPDB. Only Adverse actions on clinical privileges actions resulting from professional are not reportable until they are made review and lasting more than 30 days final by the health care entity. If an that are related to the professional internal administrative appeal competence or professional conduct of preceding final action by the entity is a practitioner should be reported to the provided for in the entity’s bylaws, NPDB. Thus, if the revocation of then the action is not reportable until clinical privileges is automatic, the the conclusion of this appeal. action should not be reported to the However, if a previously reported NPDB. adverse action is subsequently modified or vacated after an appeal by22. Are adverse actions on clinical the practitioner, the health care entity privileges reportable prior to is responsible for submitting a hearings? Revision to Action or Void. The action is not reportable until it is 24. A health care entity took an adverse made final by the health care entity. action against a practitioner, but An exception is made if an immediate the action was enjoined before it (that is, summary) suspension or was implemented. Should the restriction subject to subsequent action be reported to the NPDB? notice and hearing is enforced because of imminent danger to an individual’s Adverse actions are reportable only if health and safety. they are in effect for at least 30 days. An adverse action enjoined prior to A summary suspension of clinical implementation should not be privileges is not routinely considered a reported. However, if the adverse reportable event. However, if a action has been in effect for 30 or summary suspension lasts longer than more days and is then enjoined, the 30 days and is considered by the adverse action should be reported and hospital or other health care entity to the enjoinment should be reported as a be a professional review action (which Revision to Action. means that it is so defined in the organization’s bylaws), then the entity must report the summary suspension.September 2001 E-33
    • Chapter E Reports NPDB Guidebook25. Are investigations reportable if they 27. Must a hospital or other health care do not reach a conclusion? entity report adverse actions concerning the clinical privileges of Investigations are not reportable medical and dental residents and events; however, if a practitioner interns? surrenders or fails to renew clinical privileges, or if privileges are Not if the action was taken within the restricted while the practitioner is scope of the training program. Since either under investigation by a health residents and interns are trainees in care entity for possible incompetence graduate health professions education or improper professional conduct, or programs, they are not granted clinical to avoid an investigation, the privileges per se, but are authorized surrender or restriction must be by the sponsoring institution to reported to the NPDB. perform clinical duties and responsibilities within the context of26. A practitioner is under investigation their graduate educational program. relating to possible incompetence or improper professional conduct and However, a resident or intern may resigns from the hospital. If the practice outside the scope of the practitioner did not receive formal graduate education program, notification of the investigation, is for example, moonlighting in the this a reportable event? Intensive Care Unit or Emergency Department. Adverse clinical Under the provisions of the Health privileges actions related to practice Care Quality Improvement Act, the occurring outside the scope of a practitioner is not required to have formal graduate educational program direct knowledge of the investigation. are reportable. Hospitals should be able to produce evidence of an on-going investigation 28. If an initial application for clinical in the event of questioning. See the privileges is denied or the privileges Investigations section of this chapter granted are more limited than those for more information. requested, must this be reported to the NPDB? To be considered reportable, a practitioner’s resignation must be Yes, if the denial or limitation of tendered “in order to prevent a privileges is the result of a professional review action.” A professional review action and is resignation tendered with the related to the practitioner’s understanding that the hospital will professional competence or cease an investigation or professional professional conduct. review action is reportable.E-34 September 2001
    • NPDB Guidebook Chapter E Reports29. If an “impaired practitioner” enters assistance. If an authorized hospital a rehabilitation program, is it official, such as the CEO or reportable? Department Chair, directs the practitioner to give up clinical The voluntary entrance of an privileges and enter a rehabilitation impaired practitioner into a program or face investigation rehabilitation program is not relating to possible professional reportable to the NPDB if no incompetence or improper professional review action was taken professional conduct, is the and the practitioner did not relinquish surrender of clinical privileges clinical privileges. If a practitioner reportable to the NPDB? takes a leave of absence and clinical privileges have not been taken away, Yes. If the hospital CEO directs the then no report to the NPDB is practitioner to surrender his or her required. clinical privileges or face investigation by the hospital for If an impaired practitioner is required possible professional incompetence or by a professional review action to improper professional behavior, the involuntarily enter a rehabilitation surrender is reportable to the NPDB. program, the professional review The surrender of clinical privileges in action is reportable to the NPDB if it exchange for not undergoing an is based on the practitioner’s investigation triggers a report to the professional competence or NPDB, regardless of whether the professional conduct and adversely practitioner is impaired [see §60.9 affects the practitioner’s clinical (a)(ii)(A) and (B) of the NPDB privileges for more than 30 days. regulations].When completing the AAR input 31. Laws related to drug and alcoholscreen, the reporting entity can select treatment programs havean Adverse Action Classification confidentiality provisions. Won’t aCode of “Other” and explain in the report concerning a practitioner innarrative that the practitioner’s a treatment program violate thoseprivileges were restricted or provisions?suspended because of concernsregarding quality of care. Entities No. Only the adverse action affectingmay wish to consult with their legal privileges must be reported; the factcounsel regarding the wording of the that a practitioner entered a treatmentnarrative before it is submitted to the or rehabilitation program should notNPDB. be reported. If only the adverse action is reported as required, there is no30. An “impaired practitioner” violation of laws related to drug or member of a hospital medical staff alcohol treatment (42 USC, §290dd-3 has been repeatedly encouraged to and 290ee-3). enter a rehabilitation program. The practitioner continues to disregard the hospital’s advice and offers ofSeptember 2001 E-35
    • Chapter E Reports NPDB GuidebookReporting Adverse Membership Actions32. If a professional society denies membership to a practitioner, is it reportable to the NPDB? The action must be reported to the NPDB if the denial of membership was based on a professional review action conducted through a formal peer review process and was based on an assessment of the practitioner’s professional competence or professional conduct which affected or could affect the health and welfare of a patient or patients. Denial of membership for reasons not related to professional competence or professional conduct which affects or could adversely affect the health and safety of a patient (advertising practices or fee structures, for example) should not be reported to the NPDB.E-36 September 2001
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    • NPDB Guidebook Chapter F DisputesThe Dispute Process Subjects who wish to add a statement to and/or dispute the factual accuracy of aThe NPDB is committed to maintaining report should follow the instructions onaccurate information and ensuring that the Notification of a Report in the Datahealth care practitioners are informed Bank(s). Subjects who do not have thewhen adverse actions are reported about original Notification of a Report in thethem. When the NPDB receives a report, Data Bank(s) may obtain a Subjectthe IQRS processes the information Statement and Dispute Initiation formexactly as it is submitted by the reporting from the NPDB-HIPDB web site atentity. Reporting entities are responsible www.npdb-hipdb.com.for the accuracy of the information theyreport. Subject StatementsWhen the NPDB processes a report, a The subject of a report may add aReport Verification Document is sent statement to the report at any time. Whenelectronically to the reporting entity via the NPDB processes a statement,the IQRS and can be accessed at the notification of the statement is sent to allReport Status screen. A Notification of a queriers who received the report, and isReport in the Data Bank(s) is mailed to the included with the report when it issubject. The subject should review the released to future queriers. Subjectreport for accuracy, including such Statements are limited to 2,000 characters,information as current address and place including spaces and punctuation.of employment. Drafting a statement in accordance with the character limits ensures that theSubjects may not submit changes to statement contains the information areports. If any information in a report is subject deems most important. Allinaccurate, the subject must request that characters beyond 2,000 are truncated.the reporting entity file a correction to the Subject Statements cannot include anyreport. The NPDB is prohibited by law names, addresses, or phone numbers,from modifying information submitted in including those of patients.reports. A Subject Statement is part of the specificIf the reporting entity declines to change report it is filed for. If the report isthe report, the subject may initiate a changed by the reporting entity, thedispute of the report through the dispute statement attached to the report also isprocess, add a statement to the report, or removed. If a statement is needed with theboth. The dispute process is not an avenue new report, a new statement thatto protest a payment or to appeal the references the Data Bank Control Numberunderlying reasons of an adverse action (DCN) of the new report must beaffecting the subjects license, clinical submitted.privileges, or professional societymembership. Neither the merits of amedical malpractice claim nor theappropriateness of, or basis for, an adverseaction may be disputed.September 2001 F-1
    • Chapter F Disputes NPDB GuidebookSubject Disputes When the NPDB receives a properly completed Subject Statement and DisputeThe subject of a Medical Malpractice Initiation form from the subject initiating aPayment Report (MMPR) or an Adverse dispute, notification of the dispute is sentAction Report (AAR) may dispute either to all queriers who received the report, andthe factual accuracy of the report or is included with the report when it iswhether a report was submitted in released to future queriers.accordance with the NPDB’s reportingrequirements, including the eligibility of A dispute becomes part of the specificthe entity to report the information to the report it is contesting. If the report isNPDB. A subject may not dispute a changed by the reporting entity, thereport in order to protest a decision made dispute notation attached to the reportby an insurer to settle a claim or to appeal is also removed. If the subject believesthe underlying reasons for an adverse that the new version of the report isaction. factually inaccurate, the subject must initiate a new dispute.If a subject believes that information in areport is factually inaccurate (e.g., an There are three possible outcomes for aincorrect adverse action code or payment dispute:amount) or should not have been reported,(e.g., a clinical privileges action that lasts • The reporting entity corrects the report30 days or less), the subject must attempt to the satisfaction of the subject.to resolve the disagreement directly with • The reporting entity voids the report.the reporting entity. Changes to a report • The reporting entity declines to changemay be submitted only by the reporting the report.entity. Dispute Overview (1 of 2) Subject Notified of Receipt of Dispute PRECEDING EVENTS:• Entity Submits Report Reporting• Subject Is Notified Entity• Subject Contacts Reporting Entity Notified of• Subject Notifies NPDB to Dispute Initiate Dispute Historical Queriers Notified of DisputeF-2 September 2001
    • NPDB Guidebook Chapter F Disputes Dispute Overview (2 of 2) Changed Report Verification to Reporting Entity Reporting Entity Resolves Changed Dispute Report to by Correcting or Subject Voiding Report Changed Report to Previous QueriersSecretarial Review report. The dispute and any accompanying documentation must beIf the reporting entity declines to change sent to the NPDB, not directly to thethe disputed Adverse Action Report or Secretary.Medical Malpractice Payment Report ortakes no action, the subject may request The subject also must:that the Secretary of HHS review the • State clearly and briefly in writingdisputed report. The Secretary reviews which facts are in dispute and what thedisputed reports only for accuracy of subject believes are the facts.factual information and to ensure that theinformation was required to be reported. • Submit documentation substantiating that the reporting entity’s informationThe Secretary does not review the merits is inaccurate. Documentation mustof a medical malpractice claim in the case directly relate to the facts in disputeof a payment or the appropriateness of, or and substantially contribute to abasis for, a health care entity’s profes- determination of the factual accuracysional review action or a State licensing of the report. Documentation may notboard’s action. exceed 10 pages, including attachments and exhibits.To request Secretarial Review of adisputed report, the subject must sign and • Submit proof that the subjectreturn to the NPDB the Instructions for attempted to resolve the disagreementReview of the Disputed Report by the with the reporting entity, but wasSecretary of the U.S. Department of unsuccessful. Proof may be a copy ofHealth and Human Services attached to the subject’s correspondence to thethe Report Revised, Voided, or Status reporting entity and the entity’sChanged document related to the disputed response, if any.September 2001 F-3
    • Chapter F Disputes NPDB Guidebook• Wait 30 days from the date of Secretarial Review Results initiating discussions with the reporting entity before requesting When the NPDB receives proper notice of Secretarial Review to give the a request for Secretarial Review, the reporting entity time to respond to the materials are forwarded to the Secretary of dispute. HHS for review. There are three possible outcomes for Secretarial Review of aPertinent Documentation dispute:If the dispute relates to a Medical • The Secretary concludes that the reportMalpractice Payment Report, pertinent is accurate.documentation might include a copy of • The Secretary concludes that the reportthe following: is inaccurate.• Written claim. • The Secretary concludes that the issues• Settlement or release document. in dispute are outside the scope of• Court judgment. Secretarial Review.• Written findings of arbitration or other alternative dispute resolution Report Accurate as Submitted processes. If the Secretary concludes that theIf necessary, the Secretary will ask the information in the report is accurate, thereporting entity to supply additional Secretary sends an explanation of theinformation confirming that the report was decision to the subject. The subject maysubmitted in accordance with NPDB then submit, within 30 days, a statementregulations. Entities must respond to the that is added to the report. The statementSecretary’s request for more information is limited to 2,000 characters, includingwithin 15 days. After reviewing all spaces and punctuation, and is entered intodocumentation related to the dispute, the the NPDB computer system exactly asSecretary will determine whether the submitted. The new Subject Statementinformation in the disputed report is replaces any statement the subjectaccurate and should have been reported to submitted previously. If no new Subjectthe NPDB. Statement is received, any existing statement previously submitted by theIf the dispute relates to an Adverse subject is maintained as part of the reportAction Report, pertinent documentation record.might include a copy of the following: The subject of the report, the reporting• The findings of fact and entity, and all queriers who received recommendations of the health care notice of the disputed report are each sent entity, professional society, or State a Report Revised, Voided, or Status licensing board. Changed document containing the Secretary’s explanation and the subject’s• The final report of the hearing panel or statement. Future queriers will receive the other appellate body upon which the Secretary’s and subject’s statements with description of acts or omissions was the report. based.F-4 September 2001
    • NPDB Guidebook Chapter F Disputes Report Inaccurate as Submitted Dispute Outside the Scope of Secretarial Review If the Secretary concludes that the report is inaccurate, the Secretary directs the NPDB If the Secretary concludes that the issue in to correct the information in the report. dispute is outside the scope of review, the The subject of the report, the reporting Secretary directs the NPDB to add an entity, and all queriers who received entry to that effect to the report and to notice of the disputed report are each sent remove the dispute notation from the a Report Revised, Voided, or Status report. The subject may then submit, Changed document informing them of the within 30 days, a statement that is added correction. to the report. The statement is limited to 2,000 characters, including spaces and If the Secretary concludes that the report punctuation, and is entered into the NPDB was submitted in error, the Secretary computer system exactly as submitted. If directs that the report be voided from the no new Subject Statement is received, any NPDB. The subject of the report, the existing statement previously submitted by reporting entity, and all queriers who the subject is maintained as part of the received notice of the disputed report are report record. each sent a Report Revised, Voided, or Status Changed document informing them The subject of the report, the reporting that the report has been voided. entity, and all queriers who received notice of the disputed report are each sent a Report Revised, Voided, or Status Changed document informing them of the Secretarys decision. Secretarial Review Overview PRECEDING Secretary HHS Subject,• Subject and Reporting Reviews Reporting Entity, Entity Cannot Resolve Dispute• Subject Requests Dispute and Previous Queriers Notified Secretarial Review Documentation of Outcome September 2001 F-5
    • Chapter F Disputes NPDB GuidebookReconsideration of the Secretary’s Examples of DisputesDecisions on Disputes Due Process - Alleged DenialAlthough HHS does not have a formalappeals process for reconsideration of the Example: A practitioner alleged that anSecretarys decisions on disputes, HHS entity, during professional review, denieddoes review such requests. The subject the practitioner due process because themust submit a written request for reviewers ignored the testimony ofreconsideration to the office that issued the medical experts or other witnesses calledSecretarys determination. The subject to prove various points the practitioner feltshould be specific about any new important to the defense.information that was unavailable at thetime of Secretarial Review and which Outcome: The Secretary determined thatissues the practitioner believes were not the dispute request was outside the scopeappropriately considered during the review of review and made an entry to that effectprocess. The Secretary will either affirm in the report. The dispute notation wasthe prior determination or issue a revised removed from the report.finding. HHS, however, gives priority toinitial requests for Secretarial Review. Due Process - Legal Action PendingImproper Requests for Secretarial Example: A practitioner disputed a reportReview on the revocation of his or her clinical privileges by a hospital on the basis thatA request for Secretarial Review is due process was denied duringconsidered improper when the report in professional review. The practitionerquestion has not previously been disputed further stated that since he or she hadby the subject. Before requesting initiated a legal action against the hospitalSecretarial Review, a subject must first regarding the due process, the reportattempt to resolve the disagreement with should be removed from the NPDB untilthe reporting entity and then may dispute legal action is resolved.the report according to the instructionsprovided on the Notification of a Report in Outcome: The Secretary determined thatthe Data Bank(s) document. the dispute request was outside the scope of review. The Secretary additionallyIf a subject submits an improper request stated that if a court action resulted in afor Secretarial Review, the NPDB will reportable change to the action previouslynotify the subject that the report must first reported, a second report must bebe disputed and resolution attempted with submitted by the reporting entity. Thisthe reporting entity. new report could make corrections, be a revision to the action, or be a void of the prior report.F-6 September 2001
    • NPDB Guidebook Chapter F DisputesLicensure Completion - Trigger Date Narrative Description - Legal SufficiencyExample: A pharmacy student committedan act of alleged malpractice while in The purpose of the narrative descriptiontraining in the pharmacy of a retail store. section of the report is to describe the acts,The student had no license at the time of omissions, or reasons for the actionthe alleged act. However, at the time the reported. Section 423(a)(3)(B) of thepayment was made on the student’s behalf, Health Care Quality Assurance Act [42the student had completed training and U.S.C., Section 11133(a)(3)(B)] requiresreceived a license. The practitioner such “description of the acts or omissionsdisputed the report on the basis that a or other reasons for the action.” Thepractitioner must be licensed at the time of legislative history states that the narrativethe alleged incident in order for a report to “... does not necessarily require anbe made to the NPDB. extensive description of the acts or omissions or other reasons for the actionOutcome: The Secretary directed that the or, if known, for the surrender. It does,report be voided from the NPDB since it however, require sufficient specificity tohas been determined that the appropriate enable a knowledgeable observer totrigger date for determining if the determine clearly the circumstances of thepractitioner is licensed is the date on action or surrender.”which the reported incident occurred, notthe date on which the payment was made. A significant number of reports do not meet these legal requirements. TheNarrative Description - Inaccurate following are examples of legally inadequate descriptions found in theExample: A practitioner disputed a report narrative description section of disputedof a licensure disciplinary action taken by reports:a State board of medical examiners statingthat the narrative regarding the act or Example 1: “Dr. X was found to exhibitomission was not accurate. The improper and unprofessional conduct.”practitioner requested that the descriptionbe changed to reflect the findings of the Example 2: “The ABC Hospital Boardboard. took final action on January 2, 1994, instituting a mandatory concurringOutcome: The Secretary reviewed the consultation and monitoring requirementnarrative against the findings reported by for a 6-month period, following an appealthe State board and determined that the by Dr. Y.”report would be accurate if the actuallanguage from the board’s findings were Example 3: “See attached letter.”used. The Secretary directed the NPDB tochange the narrative. The dispute notation Outcomes: The Secretary required thewas removed from the report. reporting entities to correct the reports to include more descriptive/explicative narratives. The contents of attachments are not entered into reports.September 2001 F-7
    • Chapter F Disputes NPDB GuidebookNarrative Description - Misleading Privileges - Resignation and Surrender While Under InvestigationExample: A practitioner disputed ahospital’s report that he resigned while Example: A practitioner disputed a reportunder investigation. The narrative stated that he had resigned privileges during anthat there were no questions of investigation concerning professionalprofessional competence or conduct, but competence. The practitioner disputed thethat the issues that led to the investigation report on the basis that he was unaware ofand the resignation were problems in the any investigation and did not believe onepractitioner’s bedside manner. was ongoing at the time. The practitioner also stated that he did not resign in orderOutcome: The Secretary found that the to avoid a review, but because his contractreport should be voided because the reason was expiring and he had found a new job.for the investigation as shown in thenarrative was unrelated to professional Secretary’s Response: The Secretarycompetence or conduct. The hospital requested that the entity submitchanged the narrative of the report to contemporaneous documentation showingindicate that the investigation was that the entity had undertaken anundertaken as a matter of professional investigation of the physician. Suchcompetence due to a misdiagnosis of a documentation might have includedpatient in the emergency room. The findings of reviewers or directives of thepractitioner disputed this revised report. executive committee or other professionalThe Secretary reviewed the corrected review bodies in the hospital, or minutesreport and the supporting material from a professional review entity. Thesubmitted by the hospital and found that entity was unable or unwilling to providethe corrected report showed a reportable any documentation that an investigationevent. was occurring at the time the practitioner left. Since no contemporaneousIt is unclear why the hospital submitted documentation of an ongoing investigationthe initial report with language in the was provided, the Secretary determinednarrative that made the resignation appear that the report should be voided.unreportable. This case serves toemphasize the importance of providing The Secretary also stated that theaccurate and complete information when practitioner need not be aware of ancomposing the narrative section of a ongoing investigation at the time of thereport. resignation in order for the entity to report the resignation to the NPDB, since many investigations start without any formal allegation being made against the practitioner. The reason the practitioner gives for leaving an entity while under investigation is irrelevant to reportability of the resignation.F-8 September 2001
    • NPDB Guidebook Chapter F DisputesPrivileges - Suspension and Hospital Some hospitals have stated that if theyMotivation follow professional review procedures to remove the practitioner’s privileges, theyExample: A practitioner disputed the must then follow employment terminationreport of a suspension of clinical procedures in order to fire the practitioner.privileges. The practitioner claimed that Hospitals have stated that by followingthe motivation for the action was a the employment termination procedures,personality conflict with the chairman of practitioners’ privileges will automaticallyhis department, a matter unrelated to terminate. One hospital required allprofessional competence. physicians on staff to waive their rights to the professional review process as aOutcome: The Secretary determined that condition of employment. Health carethe dispute request was outside the scope entities are reminded that in order to beof review since the motivation of the reportable to the NPDB, adverse actionshospital or individuals involved in the case must be the result of professional review.is not reviewed by the Secretary and madean entry to that effect in the report. The Residency Statusdispute notation was removed from thereport. Example: A licensed medical resident disputed a Medical Malpractice PaymentProfessional Review - Alternative Report on the basis that she was in trainingEmployment Termination Procedure at the time of the incident.Example: A practitioner disputed a report Outcome: The Secretary determined thatof the revocation of clinical privileges. the dispute request was outside the scopeThe hospital has a system of professional of review and made an entry to that effectreview established under its bylaws and in the report. The payment is reportable ifdelivers health care services. The hospital the practitioner (regardless of residentalso has an “employment termination status) is named in both the claim andprocedure.” The employment termination settlement or judgement and a payment isprocedure was used by the hospital to end made on his or her behalf. The disputea practitioner’s employment without use notation was removed from the report.of the professional review process. Thepractitioner’s privileges were revoked by Responsibility for Treatmentthe employment termination process, butno action was taken through theprofessional review process. Example: A practitioner disputed a Medical Malpractice Payment ReportThe practitioner was given no option in because she saw the patient only once andhow the termination would occur. was not responsible.Outcome: The Secretary directed that the Outcome: The Secretary determined thatreport be voided from the NPDB since the the dispute request was outside the scopeprofessional review process had not been of review and made an entry to that effectfollowed in terminating the practitioner’s in the report. The number of times aprivileges. The termination was not a patient is seen by a practitioner or theprofessional review action. level of responsibility is irrelevant toSeptember 2001 F-9
    • Chapter F Disputes NPDB Guidebookreporting a medical malpractice payment. Suspension - Indefinite LengthThe dispute notation was removed fromthe report. Example: A practitioner disputed a report of a summary suspension of clinicalSettlement - Subject Disagrees privileges on the basis that the suspension was less than 30 days. The hospitalExample: A practitioner disputed a reported the suspension of theMedical Malpractice Payment Report on practitioner’s clinical privileges on thethe basis that he did not concur with the 10th day of an indefinite suspension.settlement. Attendant to the suspension was a requirement that the practitioner completeOutcome: The Secretary determined that a specific course of action (a psychiatricthe dispute request was outside the scope evaluation). When that action wasof review since the practitioner’s completed, the hospital’s professionalagreement to a settlement is irrelevant to review body reinstated the practitioner’sthe reportability of the payment. The clinical privileges. The practitionerSecretary made an entry to that effect in completed the required action on the 20ththe report, and the dispute notation was day of the suspension and clinicalremoved from the report. privileges were immediately restored. The suspension of the practitioner’s clinicalSettlement - Subject Dismissed from privileges did not exceed 30 days, but theLawsuit hospital did not request that the report be voided from the NPDB.Example: A practitioner disputed aMedical Malpractice Payment Report on Outcome: The Secretary directed thethe basis that she was dismissed from the NPDB to void the report since the durationlawsuit by summary judgment before the of the suspension of the practitioner’ssettlement. The order granting summary clinical privileges did not exceed 30 days.judgment provided that the practitioner bedismissed from the lawsuit as having no When a summary suspension isliability, and that the plaintiff make no indefinite in length, it should not berecovery against the practitioner. reported until it has been in effect for more than 30 days.Outcome: The Secretary directed theNPDB to void the report since no claim Suspension - Summaryexisted against the practitioner and nopayment was made on his or her behalf. Example: A report was made to theAlthough the insurance company may NPDB regarding a summary suspensionhave named the practitioner in the release based on a practitioner’s professionalor settlement, any payment made would competence, which did not last more thannot be on behalf of this practitioner due to 30 days. The hospital took no reportablethe summary judgment order. action following the summary suspension. The practitioner disputed the report since the length of the suspension was less than 30 days. The practitioner resigned a year later while still under investigation by theF-10 September 2001
    • NPDB Guidebook Chapter F Disputeshospital for the same type of professional 2. When a subject attempts to resolve acompetency issue. The hospital submitted disagreement with a reportinga report of the practitioner’s resignation entity, must the dispute be resolvedwhile under investigation. The within a certain time frame?practitioner disputed this report on thegrounds that the same issue had previously No. A subject must inform thebeen reported to the NPDB. reporting entity, in writing, of the disagreement with the report and theOutcome: The Secretary directed the basis for that disagreement, but there isNPDB to void the first report since the no requirement that the dispute mustsuspension did not exceed 30 days. The be resolved within a certain amount ofSecretary determined the second report to time.be correct as submitted since theresignation of the practitioner was 3. If a subject wishes to dispute asubmitted while under investigation for report, does the subject have toissues related to professional competence. submit a statement at the time of dispute?The practitioner was correct that thereason for the report was the same; No. The subject may provide ahowever, reportability hinges not upon the statement with the initiation of dispute,nature of the problem or incident, but on but is not required to do so. A Subjectthe circumstances under which the report Statement may be submitted at anywas made (the suspension versus the time.resignation while under investigation). 4. Must a subject initiate a dispute inQuestions and Answers order to add a statement to a report?1. I am the executor of my wife’s estate. I received notification of a No. The subject of a report may add a report about her in the NPDB. Can statement to a report independently of I dispute the report? the dispute process. Yes. To dispute a report on your 5. If the Secretary rules a dispute to be wife’s behalf, you must provide beyond the scope of review and documentation that you have been places a notation to this effect in the appointed the executor or legal NPDB, can the subject also add a representative of her estate. statement? Acceptable documentation can be a photocopy of her will or other legal Yes. Subjects are notified of this documentation showing you as the option by the Secretary. A Subject executor/legal representative. Statement added to the report after dispute resolution replaces any prior Subject Statement.September 2001 F-11
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    • NPDB Guidebook Chapter G FeesQuery Fees Self-Query FeesEntity Query Fees A practitioner may submit a self-query at any time. Self-query requests forFees are charged for all queries submitted individuals are automatically sent to bothto the NPDB. The query fee is based on the NPDB and the HIPDB, and self-the cost of processing requests and pro- queriers are assessed a fee for each Dataviding information to eligible entities. Bank. All self-queries must be submittedThe fee is levied on a per-name basis. through the NPDB-HIPDB web site atWhen multiple-name (i.e., batch) queries www.npdb-hipdb.com. After completingare submitted, the number of names in the the on-line application, a self-querierquery is multiplied by the per-name fee. If should print the formatted copy, sign it (inan eligible entity has registered for both ink) in the presence of a notary public, andthe NPDB and the HIPDB and has mail the notarized form to the NPDB-selected the option to query both Data HIPDB at the address noted on the form.Banks (in Section D of the EntityRegistration form), each query is Methods of Paymentprocessed against both Data Banks andassessed the current fee for each Data The NPDB accepts payment by credit cardBank. (VISA, MasterCard, or Discover) or pre- authorized Electronic Funds TransferThe act of submitting a query to the NPDB (EFT). All self-query fees must be paidis considered an agreement to pay the by credit card. Personal checks, moneyassociated fee. A fee is assessed when a orders, or cash are not accepted.query is: Entities choosing to pay by credit card do• Processed by the NPDB, regardless of not have to make advance arrangements whether there is information on file with the NPDB. The user should enter the regarding a subject. credit card number and expiration date on the appropriate IQRS screen when• Rejected by the NPDB because it is creating a query. (Note: Credit card improperly completed or lacks information must be entered each time a required information. query file is created; the IQRS does not currently store this information.)Even when an entity designates anauthorized agent to query and/or report on Entities choosing to pay by EFT mustbehalf of the entity, the entity is ultimately submit an Electronic Funds Transferresponsible for payment. Contractual Authorization form before EFT paymentsarrangements with authorized agents can be processed. The form is available atshould include procedures for payment of www.npdb-hipdb.com. Entities mustquery fees. provide their Data Bank Identification Number (DBID), bank routing code,Query fees are subject to change. The account number, the type of accountSecretary of HHS announces any changes (checking or savings), attach a voidedin the Federal Register. Query fees are blank check to the form, and sign the formbased on the date of receipt at the NPDB. in ink to establish an EFT. Once theSeptember 2001 G-1
    • Chapter G Fees NPDB Guidebookcompleted form has been submitted, the Authorization form before EFT paymentsNPDB-HIPDB will establish electronic can be processed. If the entity intends forcommunications with the entity’s bank. the fees for queries submitted by the agentThis process takes approximately two to be assessed to either the agent’s or theweeks. The entity will receive verification entity’s EFT account, the entity mustby mail that the EFT account has been set indicate this preference on the Authorizedup successfully. Entities should verify the Agent Designation form, available atinformation for accuracy and, if there are www.npdb-hipdb.com.any errors, mark their corrections on thedocument, sign and date it, and return it to Entities and agents may view querythe NPDB-HIPDB. If the information is charges on the Billing History screencorrect, the entity should retain it for within the IQRS. This screen provides thefuture reference. most current information available for entities and agents to better reconcileOnce an entity receives verification, it query charge amounts as they appear onmay begin to pay for query fees using their EFT or credit card statements. ForEFT. Query charges will be deducted each query submission, the Billing Historyautomatically from the entity’s designated screen provides the following information:EFT account. Unlike the process of the Data Bank Control Number (DCN)paying by credit card, the user does not assigned to the query submission, the Dataneed to enter EFT account information Bank(s) queried, the number of querieswhen creating a query. processed and charged compared to the total number of queries in that submission,Entities are responsible for ensuring that the date the credit card or EFT accountadequate funds are present in their account was charged, the amount charged, the typeat the time queries are submitted for of payment used, the last four digits of theprocessing to avoid interruption and account number, and the processing statuspotential termination of services with the of the bill.Data Banks. If an entity’s EFTinformation changes, the entity is Entities also receive a Charge Receipt withresponsible for notifying the Data Banks their query responses. This document,by submitting a new Electronic Funds along with the information on the BillingTransfer Authorization form. History screen, may be used by entities for accounting purposes. The Charge ReceiptEligible entities may elect to have outside provides a list of the queried subjects, theorganizations query and/or report to the search results, and the associated queryData Banks on their behalf. Such an fees.organization is referred to as theauthorized agent (see Chapter D, Queries, An EFT Charge Receipt also contains thefor more information about authorized following information:agents). The entity may choose to havethe query charge assessed to either the • Data Bank Identification Numberagent’s or the entity’s credit card or EFT (DBID)account. Agents that plan to charge query • Entity Namefees to their EFT account must complete • Entity Addressan Electronic Funds Transfer • Payment MethodG-2 September 2001
    • NPDB Guidebook Chapter G Fees• Account Number processed within a query, regardless of the• Transaction Date (Date Queried) date that each per-name fee was charged.• Transaction Number• Current Date Account Discrepancies• Number of Subjects in Query• Number of Subjects Processed With Charge If your EFT account information (e.g.,• Number of Subjects Previously routing number, bank account Processed information) changes, you must submit a• Number of Subjects Not Processed new Electronic Funds Transfer• Fee Per Subject Authorization form that contains the new• Total Charge information. You must ensure that your account information is kept current toA Credit Card Charge Receipt contains the avoid interruption of NPDB services.following information: The NPDB-HIPDB collects outstanding• Data Bank Identification Number query fee balances. The NPDB-HIPDB (DBID) will request the entity to complete an• Entity Name Account Balance Transfer Request form to• Entity Address authorize settlement of an outstanding• Payment Method balance. The form is available at• Account Number www.npdb-hipdb.com. There is no time• Expiration Date limitation associated with the collection of• Transaction Date (Date Queried) an unpaid query charge.• Transaction Number• Date Charged Reconciliation of credit card statements• Number of Subjects in Query must be done through the bank that issued• Number of Subjects Processed With the credit card. If you believe that your Charge credit card or your EFT account should be• Number of Subjects Previously credited or debited, contact the Processed NPDB-HIPDB Customer Service Center• Number of Subjects Not Processed for assistance. The NPDB will research• Fee Per Subject the discrepancy and provide you with a• Total Charge resolution or a request for more information.The Number of Subjects Not Processedfield refers to any query that has a“Pending” status. A status of “Pending” isassigned to any query that requiresadditional research before it can becompleted. Credit cards are billed onlywhen the status for a subject is indicatedas “Complete.” The Charge Receiptincludes the processing and feeinformation for all subject namesSeptember 2001 G-3
    • Chapter G Fees NPDB GuidebookCredits and Debits If your organization is due a credit, the credit must be requested in writing withinThe NPDB issues credits when: the time period set forth by the NPDB- HIPDB. After this period, no refunds will• A fee is incorrectly assessed. be warranted. In the event of a merger or• The NPDB causes a data processing acquisition of another entity, the new error. organization is responsible for payment of any outstanding debt of the priorThe NPDB issues debits when: organization.• A credit is mistakenly applied to an account. Bankruptcy• An original charge is not paid. Entities are responsible for notifying the NPDB of bankruptcy in writing and mustRequests for credits should be made include the following information:within a 60-day period. If you suspect thatyour bill is incorrect, or if you need more • DBIDinformation about a transaction on yourbill, please write us as soon as possible. • Entity NameWe must hear from you no later than 60 • Entity Addressdays after you submitted the query on • Type of Bankruptcy - Chapter 7,which the error or problem appeared. You Chapter 9, Chapter 11, or Statemay call us at 1-800-767-6732 to report Liquidationthe error, but doing so will not preserveyour rights. Your letter must provide the If your organization is undergoingfollowing information: bankruptcy, the outstanding balance is still collectable until final resolution of the• Your name and credit card or EFT bankruptcy. Failure to make payments to account number the Data Bank(s) can result in your• The dollar amount of the suspected organization being terminated from access error to the Data Bank(s).• A description of the error and Questions and Answers explanation of why you believe there is an error 1. How does an entity request a credit• Your entity’s and/or agent’s Data from the NPDB? Bank Identification Number (DBID) The entity may request a credit by• Your telephone number submitting the necessary details and• Your signature supporting documentation (e.g., the• A copy of your bill query Data Bank Control Number, query batch number if part of aThe NPDB has the right to collect all multiple-name submission, and billingoutstanding balances without prior statement) to the NPDB in writing.approval from the customer. Thiscollection authority does not expire.G-4 September 2001
    • NPDB Guidebook Chapter G Fees2. Does the NPDB reconcile credit 5. My hospital is in Chapter 11 card mistakes? bankruptcy. Can it continue to query the NPDB? The NPDB cannot answer questions regarding credit card account Yes. Your organization will be statements sent to you by the bank charged for all queries submitted after that issued your credit card, nor can the NPDB receives notice of the filing the NPDB address or investigate of the Petition for Bankruptcy. unauthorized charges. Please contact Organizations that have an obligation the bank that issued the credit card for to query the NPDB (i.e., hospitals) assistance. must still meet their querying obligations.3. My hospital is in Chapter 7 bankruptcy. Can it continue to 6. My hospital has been liquidated by query the NPDB? the State. Can it continue to query the NPDB? If your hospital has ongoing business and is functioning as a hospital while If your hospital has ongoing business concluding its liquidation, even under and is functioning as a hospital while a debtor-in-possession, it must concluding its liquidation, it must continue to query the NPDB. If it is continue to query the NPDB. Once in liquidation solely for the purpose of the liquidation process has concluded sale of assets and there is no ongoing or your organization has no ongoing business as a hospital, there is no business as a hospital, there is no reason for your organization to query reason for your organization to query and your DBID will be deactivated. and your DBID will be deactivated. Your organization is responsible for Your organization is responsible for notifying the NPDB of its status. If notifying the NPDB of its status. If the hospital comes under new the hospital comes under new ownership, the new owner must ownership, the new owner must register with the NPDB and is register with the NPDB and is responsible for fulfilling its reporting responsible for fulfilling its reporting and querying obligations. and querying obligations.4. My hospital is in Chapter 9 bankruptcy. Can it continue to query the NPDB? Yes. Your hospital will be charged for all queries submitted after the NPDB receives notice of the filing of the Petition for Bankruptcy. Organizations that have an obligation to query the NPDB (i.e., hospitals) must still meet their querying obligations.September 2001 G-5
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    • NPDB Guidebook Chapter H Information SourcesNPDB-HIPDB Web Site • Instructions and requirements forAssistance querying and reporting, including subject self-queries.The National Practitioner Data Bank- • Answers to frequently asked questionsHealthcare Integrity and Protection Data (FAQ).Bank (NPDB-HIPDB) web site, located atwww.npdb-hipdb.com, allows you to • Criteria for entity eligibility.interact with the NPDB-HIPDB moreeasily and quickly. By using your • Information on the dispute process.personal computer and the Internet, you • An archive of NPDB-HIPDBcan instantly access: newsletters and other publications.• The Integrated Querying and Reporting Service (IQRS) where Data The NPDB-HIPDB web site includes Bank querying and reporting occurs. information on how to contact the Data The IQRS contains several security Banks. Please visit the web site to features to prevent unauthorized access instantly access information and find and ensure the confidentiality of answers to your questions. information. NPDB-HIPDB Customer Service• The Self-Query Options screen, where Center you may complete an individual or organization self-query application and For additional assistance, contact the then print a formatted copy for NPDB-HIPDB Customer Service Center notarization before mailing it to the by e-mail at npdb-hipdb@sra.com, or by NPDB-HIPDB. You may also view phone at 1-800-767-6732 (TDD the status of a self-query that was 703-802-9395). previously transmitted to the Data Bank(s). Information specialists are available to• The NPDB and HIPDB Guidebooks. speak with you weekdays from 8:30 a.m. to 6:00 p.m. (5:30 p.m. on Fridays)• Fact Sheets and Forms, including the Eastern Time. The NPDB-HIPDB Entity Registration form, Authorized Customer Service Center is closed on all Agent Registration form, Authorized Federal holidays. Agent Designation form, and Electronic Funds Transfer Authorization form.• A list of authorized agents.• The NPDB and HIPDB governing statutes and regulations.• The NPDB and HIPDB interactive training programs.• General information on the Data Banks.September 2001 H-1
    • Chapter H Information Sources NPDB GuidebookData Bank Addresses Interpretation of NPDB Statutes and RegulationsRequests for general information about theData Banks and requests for Dispute and The Division of Quality Assurance,Secretarial Review materials should be Bureau of Health Professions, Healthaddressed to: Resources and Services Administration, Department of Health and Human National Practitioner Data Bank Services, is the Government agency Healthcare Integrity and Protection Data responsible for administering the NPDB Bank and for interpreting NPDB requirements. P.O. Box 10832 Matters that deal specifically with the Chantilly, VA 20153-0832 legal interpretation of statutory and regulatory authority, should be directed to:Overnight mail delivery address: Associate Director for Policy National Practitioner Data Bank Division of Quality Assurance Healthcare Integrity and Protection Data Policy Branch Bank 7519 Standish Place 4094 Majestic Lane Suite 300 PMB-332 Rockville, MD 20857 Fairfax, VA 22033 The Privacy Act and the NPDBPhone numbers: The Privacy Act (5 USC §552a) protects NPDB-HIPDB Customer Service Center: the contents of Federal systems of records 1-800-767-6732 on individuals, like those in the NPDB Outside the U.S.: 1-703-802-9380 from disclosure without the individual’s Fax: 1-703-502-1222 consent, unless the disclosure is for a TDD 1-703-802-9395 routine use of the system of records as published annually in the FederalRequests for aggregate research data* Register. The published routine use ofmust be addressed to: NPDB information, which are based on the laws and the regulations under which Division of Quality Assurance the NPDB operates, does not include Research and Disputes Branch disclosure to the general public. 7519 Standish Place Suite 300 Write to the address in the Interpretation Rockville, MD 20857 of NPDB Statute and Regulations section, above, for more information. * There may be a charge for some data requests.H-2 September 2001
    • NPDB Guidebook Chapter H Information SourcesThe Freedom of Information Act Federal Employer Identificationand the NPDB NumberThe NPDB, as an agency of the United The Federal Employer IdentificationStates, is required to release records to the Number (FEIN) is used by paying entitiespublic with certain exceptions under the for billing purposes as a vendorprovisions of the Freedom of Information identification number. The vendor name,Act (FOIA), 5 USC §552. The law address, and FEIN for the NPDB are ascreating the NPDB, the Health Care follows:Quality Improvement Act of 1986, asamended, Title IV of P.L. 99-660, HRSA, Department of Health and Humanprovides for limited access to NPDB Servicesinformation by certain authorized 7519 Standish Placeindividuals and entities and, under the Suite 300provisions of the Privacy Act, 5 USC Rockville, MD 20857§552a, protects practitioner informationfrom unauthorized access. The limited FEIN: 52-082-1668access provision of the Health CareQuality Improvement Act of 1986, as State Medical and Dental Boardsamended, may affect the disclosurerequirements of FOIA. The Health Addresses and phone numbers for StateResources and Services Administration of Medical and Dental Boards are listed inthe Department of Health and Human alphabetical order by State. StreetServices processes FOIA requests. For addresses that are different than mailinginformation about the FOIA as it relates to addresses are listed in italics. Thisthe NPDB, please direct your inquiry to: information is current as of the publication date of this Guidebook. HRSA Freedom of Information Officer Health Resources and Services Administration 7519 Standish Place Suite 300 Rockville, MD 20857 (301) 443-2865September 2001 H-3
    • Chapter H Information Sources NPDB GuidebookALABAMA Arizona Board of Osteopathic Examiners in Medicine and SurgeryAlabama State Board of Medical Examiners 9535 E. Doubletree Ranch RoadP.O. Box 946 Scottsdale, AZ 85258Montgomery, AL 36101-0946 Phone: (480) 657-7703848 Washington Avenue Fax: (480) 657-7715Phone: (334) 242-4116 Web Site: http://www.azosteoboard.org/Fax: (334) 242-4155 E-mail: information@azosteoboard.comWeb Site: http://www.albme.org/E-mail: bmedixon@mindspring.com Arizona Board of Dental Examiners 5060 North 19th Avenue, Suite 406Alabama Medical Licensure Commission Phoenix, AZ 85015P.O. Box 887 Phone: (602) 242-1492Montgomery, AL 36101-0887 Fax: (602) 242-1445Phone: (334) 242-4153Fax: (334) 242-4155 ARKANSASWeb Site: http://www.albme.org/E-mail: bmedixon@mindspring.com Arkansas State Medical Board 2100 Riverfront Drive, Suite 200Board of Dental Examiners of Alabama Little Rock, AR 722022327 Pansy Street, Suite B Phone: (501) 296-1802Huntsville, AL 35801 Fax: (501) 296-1805Phone: (205) 533-4638 Web Site: http://www.armedicalboard.org/Fax: (205) 533-4690 E-mail: office@armedicalboard.orgE-mail: bdeaal@compuserve.com Arkansas State Board of Dental ExaminersALASKA 101 East Capitol, Suite 111 Little Rock, AR 72201Alaska State Medical Board Phone: (501) 682-20853601 C Street, Suite 722 Fax: (501) 682-3543Anchorage, AK 99503-5986 Web Site: http://www.asbde.org/Phone: (907) 269-8160 E-mail: asbde@mail.state.ar.usFax: (907) 269-8156Web Site: http://www.dced.state.ak.us/ CALIFORNIAocc/pmed.htm Medical Board of CaliforniaAlaska Board of Dental Examiners 1426 Howe Avenue, Suite 54P.O. Box 110806 Sacramento, CA 95825-3236Juneau, AK 99811-0806 Phone: (916) 263-2466Phone: (907) 465-2542 Toll Free: 800-633-2322Fax: (907) 465-2974 Fax: (916) 263-2387Web Site: http://www.dced.state.ak.us/ Web Site: http://www.medbd.ca.gov/occ/pden.htm Osteopathic Medical Board of CaliforniaARIZONA 2720 Gateway Oaks Drive, Suite 350 Sacramento, CA 95833Arizona Board of Medical Examiners Phone: (916) 263-31009545 E. Doubletree Ranch Road Fax: (916) 263-3117Scottsdale, AZ 85258-5539 Web Site: http://www.docboard.org/cx/Phone: (480) 551-2700 E-mail: ljbombc@inreach.comToll Free: 877-255-2212Fax: (480) 551-2704Web Site:http://www.docboard.org/bomex/index.htmE-mail: questions@bomex.orgH-4 September 2001
    • NPDB Guidebook Chapter H Information SourcesDental Board of California DISTRICT OF COLUMBIA1432 Howe Avenue, Suite 85-BSacramento, CA 95825 District of Columbia Board of MedicinePhone: (916) 263-2300 825 N. Capitol Street, N.E., 2nd FloorFax: (916) 263-2140 Washington, DC 20002Web Site: http://www.dca.ca.gov/r_r/dentalbd.htm Phone: (202) 442-9200 Fax: (202) 442-9431COLORADO Web Site: http://www.dchealth.comColorado State Board of Medical Examiners District of Columbia Board of Dentistry1560 Broadway, Suite 1300 Department of Consumer and Regulatory AffairsDenver, CO 80202-5140 614 H Street, N.W., Room 904Phone: (303) 894-7690 Washington, DC 20001Fax: (303) 894-7692 Phone: (202) 727-7478Web Site: http://www.dora.state.co.us/medicalE-mail: medical@dora.state.co.us FLORIDAColorado State Board of Dental Examiners Florida Board of Medicine1560 Broadway, Suite 1310 4052 Bald Cypress Way, Bin CO3Denver, CO 80202 Tallahassee, FL 32399-3253Phone: (303) 894-7758 Phone: (850) 245-4131Fax: (303) 894-7764 Fax: (850) 922-3040Web Site: http://www.dora.state.co.us/dental Web Site: http://www.doh.state.fl.us/mqa/medical/E-mail: dental@dora.state.co.us mehome.htmCONNECTICUT Florida Board of Osteopathic Medicine 4052 Bald Cypress Way, Bin CO6Connecticut Department of Public Health Tallahassee, FL 32399-3256410 Capitol Avenue Phone: (850) 488-0595P.O. Box 340308 Fax: (850) 921-6184Hartford, CT 06134-0308 Web Site: http://www.doh.state.fl.us/mqa/Phone: (860) 509-8000 osteopath/oshome.htmWeb Site: http://www.state.ct.us/dph/ Florida Board of DentistryDELAWARE 4052 Bald Cypress Way, Bin CO6 Tallahassee, FL 32399-3256Delaware Board of Medical Practice Phone: (850) 488-0595P.O. Box 1401 Fax: (850) 921-6184Dover, DE 19903 Web Site: http://www.doh.state.fl.us/mqa/dentistry/Cannon Building, Suite 203, 861 Silver Lake Blvd., dnhome.htmDover, DE 19904Phone: (302) 739-4522 Ext. 211 GEORGIAFax: (302) 739-2711 Georgia Composite State Board of MedicalDelaware State Board of Dental Examiners ExaminersP.O. Box 1401 2 Peachtree Street, 6th FloorDover, DE 19903 Atlanta, GA 30303-3465Cannon Building, Suite 203, 861 Silver Lake Blvd., Phone: (404) 656-3913Dover, DE 19904 Fax: (404) 656-9723Phone: (302) 739-4522 Ext. 220 Web Site: http://www.sos.state.ga.us/ebd-medical/Fax: (302) 739-2711September 2001 H-5
    • Chapter H Information Sources NPDB GuidebookGeorgia Board of Dentistry Illinois Board of Dentistry237 Coliseum Drive Department of Professional RegulationMacon, GA 31217-3858 320 W. Washington StreetPhone: (478) 207-1680 Springfield, IL 62786Fax: (478) 207-1685 Phone: (217) 785-0800Web Site: http://www.sos.state.ga.us/ebd-dentistry/ Web Site: http://www.dpr.state.il.us/ WHO/dent.cfmHAWAII INDIANAHawaii Board of Medical ExaminersP.O. Box 3469 Indiana Health Professions BureauHonolulu, HI 96801 402 W. Washington Street, Room W0411010 Richards St., Honolulu, HI 96813 Indianapolis, IN 46204Phone: (808) 586-2708 Phone: (317) 232-2960Fax: (808) 586-2689 Fax: (317) 233-4236Licensing: (808) 586-3000 Web Site: http://www.ai.org/hpbFax: (808) 586-3031 Indiana State Board of DentistryHawaii Board of Dental Examiners 402 W. Washington Street, Room W041P.O. Box 3469 Indianapolis, IN 46204Honolulu, HI 96801 Phone: (317) 233-4406Phone: (808) 586-2702 Web Site: http://www.accessindiana.com/Fax: (808) 586-2704 hpb/isbde/Licensing: (808) 586-3000Fax: (586) 586-3031 IOWAIDAHO Iowa Board of Medical Examiners 400 S.W. 8th Street, Suite CIdaho State Board of Medicine Des Moines, IA 50309-4686P.O. Box 83720 Phone: (515) 281-5171Boise, ID 83720-0058 Fax: (515) 242-5908Westgate Office Plaza, 1755 Westgate Drive, Suite Web Site: http://www.docboard.org/ia/140 ia_home.htmPhone: (208) 327-7000 E-mail: ibme@bon.state.ia.usFax: (208) 327-7005 Iowa Board of Dental ExaminersIdaho State Board of Dentistry 400 S.W. 8th Street, Suite DP.O. Box 83720 Des Moines, IA 50309Boise, ID 83720-0021 Phone: (515) 281-5157Phone: (208) 334-2369 Fax: (515) 281-7969Fax: (208) 334-3247 Web Site: http://www.state.ia.us/dentalboard/Web Site: http://www2.state.id.us/isbd KANSASILLINOIS Kansas State Board of Healing ArtsIllinois Department of Professional Regulation 235 S. Topeka Boulevard320 W. Washington Street Topeka, KS 66603-3068Springfield, IL 62786 Phone: (785) 296-7413Phone: (217) 785-0800 Fax: (785) 296-0852Fax: (217) 782-7645 Web Site: http://www.ksbha.org/Web Site: http://www.dpr.state.il.us/ E-mail: Healer3@ink.orgWHO/med.cfmH-6 September 2001
    • NPDB Guidebook Chapter H Information SourcesKansas Dental Board Maine Board of Osteopathic Licensure3601 S.W. 29th Street, Suite 134 142 State House StationTopeka, KS 66614-2062 2 Bangor StreetPhone: (785) 273-0780 Augusta, ME 04333-0142Fax: (785) 273-7545 Phone: (207) 287-2480E-mail: dental@ink.org Fax: (207) 287-3015 Web Site: http://www.docboard.org/me-osteo/KENTUCKY Maine Board of Dental ExaminersKentucky Board of Medical Licensure 143 State House Station310 Whittington Parkway, Suite 1B 2 Bangor StreetLouisville, KY 40222 Augusta, ME 04333-0143Phone: (502) 429-8046 Phone: (207) 287-3333Fax: (502) 429-9923 Fax: (207) 287-8140Web Site: http://www.state.ky.us/agencies/kbml Web Site: http://www.state.me.us/pfr/auxboards/ denhome.htmKentucky Board of Dentistry10101 Linn Station Road MARYLANDLouisville, KY 40223Phone: (502) 423-0573 Maryland Board of Physician Quality AssuranceFax: (502) 423-1239 4201 Patterson Avenue Baltimore, MD 21215-0095LOUISIANA Phone: (410) 764-4777 Toll Free: 1-800-492-6836Louisiana State Board of Medical Examiners Fax: (410) 358-2252P.O. Box 30250 Web Site: http://www.docboard.org/md/default.htmNew Orleans, LA 70190-0250 E-mail: BPQA@erols.com630 Camp Street, New Orleans, LA 70130Phone: (504) 524-6763 Maryland Board of Dental ExaminersFax: (504) 599-0503 Spring Grove Hospital CenterWeb Site: http://www.lsbme.org/ Benjamin Rush BuildingE-mail: Lsbmever@lsbme.org 55 Wade Avenue Baltimore, MD 21228Louisiana State Board of Dentistry Phone: (410) 402-8500365 Canal Street, Suite 2680 Fax: (410) 358-0128New Orleans, LA 70130Phone: (504) 568-8574 MASSACHUSETTSFax: (504) 568-8598Web Site: http://www.lsbd.org Massachusetts Board of Registration in Medicine 10 West StreetMAINE Boston, MA 02111 Phone: (617) 727-3086Maine Board of Licensure in Medicine Fax: (617) 451-9568137 State House Station Web Site: http://www.massmedboard.orgAugusta, ME 04333-0137 E-mail: webmaster@massmedboard.orgPhone: (207) 287-3601Fax: (207) 287-6590 Massachusetts Board of Registration in DentistryWeb Site: http://www.docboard.org/me/ 239 Causeway Street, Suite 500me_home.htm Boston, MA 02114 Phone: (617) 727-9928 Web Site: http://www.state.ma.us/reg/boards/dnSeptember 2001 H-7
    • Chapter H Information Sources NPDB GuidebookMICHIGAN Fax: (601) 944-9624 Web Site: http://www.msbde.state.ms.us/Michigan Board of MedicineP.O. Box 30670 MISSOURILansing, MI 48909-7518611 W Ottawa Street, 1st Floor, Lansing, MI 48933 Missouri State Board of RegistrationPhone: (517) 373-6873 for the Healing ArtsFax: (517) 373-2179 3605 Missouri Blvd.Web Site: http://www.cis.state.mi.us/bhser/ P.O. Box 4 Jefferson City, MO 65102Michigan Board of Osteopathic Medicine and Phone: (573) 751-0098Surgery Fax: (573) 751-3166P.O. Box 30670 Web Site:Lansing, MI 48909-7518 http://www.ecodev.state.mo.us/pr/healarts611 W Ottawa Street, 1st Floor, Lansing, MI 48933 E-mail: healarts@mail.state.mo.usPhone: (517) 373-6873Fax: (517) 373-2179 Missouri State Dental BoardWeb Site: http://www.cis.state.mi.us/bhser/ 3605 Missouri Blvd. P.O. Box 1367Michigan Board of Dentistry Jefferson City, MO 65102P.O. Box 30670-7518 Phone: (573) 751-0040Lansing, MI 48909 Fax: (573) 751-8216611 W Ottawa Street, 1st Floor, Lansing, MI 48933 Web Site: http://www.ecodev.state.mo.us/pr/dental/Phone: (517) 373-9102 E-mail: dental@mail.state.mo.usFax: (517) 373-2179 MONTANAMINNESOTA Montana Board of Medical ExaminersMinnesota Board of Medical Practice 301 South Park, 4th Floor2829 University Avenue S.E., Suite 400 P.O. Box 200513Minneapolis, MN 55414-3246 Helena, MT 59620-0513Phone: (612) 617-2130 Phone: (406) 841-2360Fax: (612) 617-2166 Fax: (406) 841-2363Web Site: http://www.bmp.state.mn.us Web Site: http://www.com.state.mt.us/License/ POL/pol_boards/med_board/board_page.htmMinnesota Board of Dentistry E-mail: compolmed@state.mt.us2829 University Avenue, S.E., Suite 450Minneapolis, MN 55414-3249 Montana Board of DentistryPhone: (612) 617-2250 301 South Park, 4th FloorFax: (612) 617-2260 P.O. Box 200513Web Site: http://www.dentalboard.state.mn.us Helena, MT 59620-0513 Phone: (406) 841-2390MISSISSIPPI Fax: (406) 841-2305 Web Site: http://www.com.state.mt.us/License/Mississippi State Board of Medical Licensure POL/pol_boards/den_board/board_page.htm1867 Crane Ridge Drive, Suite 200-B E-mail: compolden@state.mt.usJackson, MS 39216Phone: (601) 987-3079Fax: (601) 987-4159Web Site: http://www.msbml.state.ms.usMississippi State Board of Dental Examiners600 East Amite Street, Suite 100Jackson, MS 39201-2801Phone: (601) 944-9622H-8 September 2001
    • NPDB Guidebook Chapter H Information SourcesNEBRASKA New Hampshire Board of Dental Examiners 2 Industrial Park DriveNebraska State Board of Examiners Concord, NH 03301-8520in Medicine and Surgery Phone: (603) 271-4561P.O. Box 94986 Fax: (603) 271-6702Lincoln, NE 68509-4986 Web Site: http://webster.state.nh.us/dental/301 Centennial Mall SouthPhone: (402) 471-2118 NEW JERSEYFax: (402) 417-3577Web Site: http://www.hhs.state.ne.us/crl/ New Jersey State Board of Medical Examinerscrlindex.htm P.O. Box 183 Trenton, NJ 08625-0183Nebraska Board of Examiners in Dentistry 140 E. Front Street, 2nd FloorP.O. Box 94986 Phone: (609) 826-7100Lincoln, NE 68509-4986 Fax: (609) 984-3930Phone: (402) 471-2118 Web Site: http://www.state.nj.us/lps/ca/ medical.htmNEVADA New Jersey State Board of DentistryNevada Board of Medical Examiners 124 Halsey StreetP.O. Box 7238 P.O. Box 45005Reno, NV 89510 Newark, NJ 071011105 Terminal Way, Suite 301, Reno, Nevada Phone: (973) 504-640589502 Fax: (973) 273-8075Phone: (775) 688-2559 Web Site: http://www.state.nj.us/lps/ca/Fax: (775) 688-2321 medical.htmToll Free: (888) 890-8210Web Site: http://www.state.nv.us/medical/ NEW MEXICOE-mail: nsbme@govmail.state.nv.us New Mexico State Board of Medical ExaminersNevada State Board of Osteopathic Medicine 491 Old Santa Fe Trail2950 E. Flamingo Road, Suite E-3 Lamy Building, 2nd FloorLas Vegas, NV 89121-5208 Santa Fe, NM 87501Phone: (702) 732-2147 Phone: (505) 827-5022Fax: (702) 732-2079 Toll Free: 1-800-945-5845 Fax: (505) 827-7377Nevada State Board of Dental Examiners Web Site: http://www.nmbme.org2295-B Renaissance Dr.Las Vegas, NV 89119 New Mexico Board of Osteopathic ExaminersPhone: (702) 486-7044 BoardToll Free: 1-800-DDS-EXAM 2055 Pacheco Street, Suite 400Fax: (702) 486-7046 P.O. Box 25101Web Site: http://www.nvdentalboard.org Santa Fe, NM 87505E-mail: nsbde@govmail.state.nv.us Phone: (505) 476-7120 Fax: (505) 827-7095NEW HAMPSHIRE Web Site: http://www.rld.state.nm.us/b&c/ osteopathic_examiners_board.htmState of New Hampshire Board of Medicine E-mail: OsteoBoard@state.nm.us2 Industrial Park Drive, Suite 8Concord, NH 03301-8520Phone: (603) 271-1203Fax: (603) 271-6702Web Site: http://www.state.nh.us/medicineSeptember 2001 H-9
    • Chapter H Information Sources NPDB GuidebookNew Mexico Board of Dental Health Care North Carolina State Board of Dental Examiners2055 Pacheco Street, Suite 400 P.O. Box 32270Santa Fe, NM 87504 Raleigh, NC 27622-2270Phone: (505) 476-7125 3716 National Drive, Raleigh, NC 27612Web Site: Phone: (919) 781-4901http://www.rld.state.nm.us/b&c/dental/index.htm Fax: (919) 571-4197E-mail: DentalBoard@state.nm.us Web Site: http://www.ncdentalboard.org/ E-mail: info@ncdentalboard.orgNEW YORK NORTH DAKOTAOffice of Professional Medical ConductNew York State Department of Health North Dakota State Board of Medical Examiners433 River Street, Suite 303 City Center PlazaTroy, NY 12180 418 E. Broadway, Suite 12Phone: (518) 402-0855 Bismarck, ND 58501Fax: (518) 402-0866 Phone: (701) 328-6500Web Site: http://www.health.state.ny.us/ Fax: (701) 328-6505E-mail: opmc@health.state.ny.us Web Site: http://www.ndbomex.com/New York State Board for Medicine North Dakota State Board of Dental ExaminersCultural Education Center, Room 3023 P.O. Box 7246Empire State Plaza Bismarck, ND 58507-7246Albany, NY 12230 Phone: (701) 258-8600Phone: (518) 474-3841 Fax: (701) 224-9824Fax: (518) 486-4846 Web Site: http://www.nddentalboard.org/Web Site: http://www.op.nysed.gov E-mail: ndsbde@aptnd.comE-mail: medbd@mail.nysed.gov OHIONew York State Board for DentistryCultural Education Center State of Ohio Medical BoardRoom 3035 77 S. High Street, 17th FloorAlbany, NY 12230 Columbus, OH 43266-0315Phone: (518) 474-3838 Phone: (614) 466-3934Fax: (518) 473-6995 Complaint Line: 1-800-554-7717Web Site: http://www.op.nysed.gov Fax: (614) 728-5946E-mail: dentbd@mail.nysed.gov Web Site: http://www.state.oh.us/med/NORTH CAROLINA Ohio State Dental Board 77 S. High Street, 18th FloorNorth Carolina Medical Board Columbus, OH 43266-0306P.O. Box 20007 Phone: (614) 466-2580Raleigh, NC 27619 Fax: (614) 752-89951201 Front Street, Suite 100, Raleigh, NC 27609 Web Site: http://webtest.state.oh.us/den/Phone: (919) 326-1100Fax: (919) 326-1130Web Site: http://www.docboard.org/nc/E-mail: info@ncmedboard.orgH-10 September 2001
    • NPDB Guidebook Chapter H Information SourcesOKLAHOMA PENNSYLVANIAOklahoma Board of Medical Licensure and Pennsylvania State Board of MedicineSupervision P.O. Box 2649P.O. Box 18256 Harrisburg, PA 17105-2649Oklahoma City, OK 73154-0256 Phone: (717) 787-14005104 N. Francis Street, Suite C, Oklahoma City, Fax: (717) 787-7769OK 73118 Web Site: http://www.dos.state.pa.us/bpoa/medbd/Phone: (405) 848-6841 mainpage.htmFax: (405) 848-8240 E-mail: medicine@pados.dos.state.pa.usWeb Site: http://www.osbmls.state.ok.us/E-mail: supportservices@osbmls.state.ok.us Pennsylvania State Board of Osteopathic Medicine P.O. Box 2649Oklahoma Board of Osteopathic Examiners Harrisburg, PA 17105-26494848 N. Lincoln Boulevard, Suite 100 Phone: (717) 783-4858Oklahoma City, OK 73105-3321 Fax: (717) 787-7769Phone: (405) 528-8625 Web Site: http://www.dos.state.pa.us/bpoa/ostbd/Fax: (405) 557-0653 mainpage.htmWeb Site: http://www.docboard.org/ok/ok.htm E-mail: osteopat@pados.dos.state.pa.usOklahoma Board of Dentistry Pennsylvania State Board of Dentistry6501 N. Broadway, Suite 220 P.O. Box 2649Oklahoma City, OK 73116 Harrisburg, PA 17105-2649Phone: (405) 848-1364 Phone: (717) 783-7162Fax: (405) 848-3279 Fax: (717) 787-7769Web Site: http://www.state.ok.us/~dentist/ Web Site: http://www.dos.state.pa.us/bpoa/denbd/E-mail: dentist@oklaosf.state.ok.us mainpage.htm E-mail: dentistr@pados.dos.state.pa.usOREGON RHODE ISLANDOregon Board of Medical Examiners620 Crown Plaza Rhode Island Board of Medical Licensure1500 S.W. First Avenue and DisciplinePortland OR, 97201-5826 Department of HealthPhone: (503) 229-5770 3 Capitol Hill, Room 205Fax: (503) 229-6543 Providence, RI 02908-5097Web Site: http://www.bme.state.or.us/ Phone: (401) 222-3855E-mail: bme.info@state.or.us Fax: (401) 222-2158 Web Site: http://www.docboard.org/ri/main.htmOregon Board of Dentistry1515 S.W. 5th Avenue, Suite 602 Rhode Island Board of Examiners in DentistryPortland, OR 97201-5451 3 Capitol Hill, Room 404Phone: (503) 229-5520 Providence, RI 02908-5097Fax: (503) 229-6606 Phone: (401) 222-2151Web Site: http://www.oregondentistry.org/E-mail: information@oregondentistry.orgSeptember 2001 H-11
    • Chapter H Information Sources NPDB GuidebookSOUTH CAROLINA Tennessee Board of Osteopathic Examiners 1st Floor, Cordell Hull BuildingSouth Carolina Board of Medical Examiners 425 5th Avenue NorthP.O. Box 11289 Nashville, TN 37247-1010Columbia, SC 29211-1289 Phone: (615) 532-4384Koger Office Park, Kingstree Building Fax: (615) 532-5369110 Centerview Drive, Suite 202, Columbia, SC Web Site: http://170.142.76.180/29210 bmf-bin/BMFproflist.plPhone: (803) 896-4500Fax: (803) 896-4515 Tennessee Board of DentistryWeb Site: http://www.llr.state.sc.us./me.htm 1st Floor, Cordell Hull BuildingE-mail: medboard@mail.llr.state.sc.us 425 5th Avenue North Nashville, TN 37247-1010South Carolina Board of Dentistry Phone: (615) 532-3202P.O. Box 11329 Fax: (615) 532-5369Columbia, SC 29211-1329 Web Site: http://170.142.76.180/Koger Office Park, Kingstree Building, bmf-bin/BMFproflist.pl110 Centerview Drive, Columbia, SC 29210Phone: (803) 896-4599 TEXASFax: (803) 896-4596Web Site: http://www.llr.state.sc.us/denlic.htm Texas State Board of Medical Examiners P.O. Box 2018SOUTH DAKOTA Austin, TX 78768-2018 333 Guadalupe, Tower 3, Suite 630,Austin, TXSouth Dakota Board of Medical 78701and Osteopathic Examiners Phone: (512) 305-70101323 S. Minnesota Avenue Fax: (512) 305-7008Sioux Falls, SD 57105 Complaint Line: 1-800-201-9353Phone: (605) 334-8343 Web Site: http://www.tsbme.state.tx.us/Fax: (605) 336-0270Web Site: http://www.state.sd.us/dcr/medical/ Texas State Board of Dental Examinersmed-hom.htm 333 Guadalupe, Tower 3, Suite 800 Austin, TX 78701South Dakota State Board of Dentistry Phone: (512) 463-6400P.O. Box 1037 Fax: (512) 463-7452Pierre, SD 57501 Web Site: http://www.tsbde.state.tx.us/Phone: (605) 224-1282Fax: (605) 224-7426 UTAHWeb Site: http://www.state.sd.us/dcr/dentistry/dent-hom.htm Utah Physicians Licensing BoardE-mail: sdsbd@dtgnet.com Division of Occupational and Professional LicensingTENNESSEE P.O. Box 146741 Salt Lake City, UT 84114-6741Tennessee Board of Medical Examiners 160 East 300 South, 4th Floor, Salt Lake City,1st Floor, Cordell Hull Building UT 84102425 5th Avenue North Phone: (801) 530-6628Nashville, TN 37247-1010 Fax: (801) 530-6511Phone: (615) 532-4384 Web Site: http://www.commerce.state.ut.us/dopl/Fax: (615) 532-5369 dopl1.htmWeb Site: http://170.142.76.180/ E-mail: brdopl.pfairhur@email.state.ut.usbmf-bin/BMFproflist.plH-12 September 2001
    • NPDB Guidebook Chapter H Information SourcesUtah Board of Dentists and Dental Hygienists Virginia Board of DentistryDivision of Occupational and Professional 6606 W. Broad Street, 4th FloorLicensing Richmond, VA 23230-1717P.O. Box 146741 Phone: (804) 662-9906Salt Lake City, UT 84114-6741 Web Site: http://www.dhp.state.va.us/levelone/160 East 300 South, Salt Lake City, UT 84102 den.htmPhone: (801) 530-6740 E-mail: denbd@dhp.state.va.usFax: (801) 530-6511Web Site: http://www.commerce.state.ut.us/dopl/ WASHINGTONdopl1.htmE-mail: brdopl.pfairhur@email.state.ut.us Washington State Department of Health Medical Quality Assurance CommissionVERMONT P.O. Box 47866 Olympia, WA 98504-7866Vermont Board of Medical Practice 1300 Quince Street S.E., Olympia, WA 98501109 State Street Phone: (360) 236-4800Montpelier, VT 05609-1106 Fax: (360) 586-4573Phone: (802) 828-2673 Web Site: http://www.doh.wa.gov/medical/Fax: (802) 828-5450 default.htmWeb Site:http://www.docboard.org/vt/vermont.htm Washington Board of Osteopathic Medicine and SurgeryVermont Board of Osteopathic Physicians P.O. Box 47870and Surgeons Olympia, WA 98504-7870Office of Professional Regulation 1300 Quince Street S.E., Olympia, WA 9850126 Terrace Street, Drawer 09 Phone: (360) 236-4945Montpelier, VT 05609-1101 Fax: (360) 586-0745Phone: (802) 828-2373 Web Site: http://www.doh.wa.gov/hsqa/hpqad/Fax: (802) 828-2465 Osteopath/default.htmWeb Site: http://www.vtprofessionals.org/oprbegin.htm Dental Quality Assurance Commission P.O. Box 47867Vermont Board of Dental Examiners Olympia, WA 98504-786726 Terrace Street, Drawer 09 1300 Quince Street S.E., Olympia, WA 98501Montpelier, VT 05609-1106 Phone: (360) 236-4863Phone: (802) 828-2390 Fax: (360) 664-9077Fax: (802) 828-2465 Web Site: http://www.doh.wa.gov/hsqa/hpqad/Web Site: http://vtprofessionals.org/dentists/ Dental/default.htmVIRGINIA WEST VIRGINIAVirginia Board of Medicine West Virginia Board of Medicine6606 W. Broad Street, 4th Floor 101 Dee DriveRichmond, VA 23230-1717 Charleston, WV 25311Phone: (804) 662-9908 Phone: (304) 558-2921Fax: (804) 662-9943 Fax: (304) 558-2084Web Site: http://www.dhp.state.va.us/levelone/ Web Site: http://www.wvdhhr.org/wvbom/med.htmE-mail: medbd@dhp.state.va.us West Virginia Board of Osteopathy 334 Penco Road Weirton, WV 26062 Phone: (304) 723-4638 Fax: (304) 723-2877 E-mail: bdosteo@mail.wvnet.eduSeptember 2001 H-13
    • Chapter H Information Sources NPDB GuidebookWest Virginia Board of Dental Examiners AMERICAN SAMOAP.O. Drawer 1459Beckley, WV 25802-1459 Department of Medical ServicesPhone: (304) 252-8266 American Samoa GovernmentFax: (304) 252-2779 LBJ Tropical Medical CenterE-mail: apsa@citynet.net Turner Drive Pago Pago, AS 96799WISCONSIN Phone: 011 (684) 633-4590 Fax: 011 (684) 633-1869Wisconsin Medical Examining Board Web Site: http://www.samoanet.com/asg/Department of Regulation and LicensingP.O. Box 8935 GUAMMadison, WI 53708-89351400 E. Washington Avenue, Room 142, Madison, Guam Board of Medical ExaminersWI 53703 Health Professional Licensing OfficePhone: (608) 266-2112 P.O. Box 2816Fax: (608) 267-0644 Hagatna, GU 96932Web Site: http://badger.state.wi.us/agencies/drl/ Phone: 011 (671) 475-0251Regulation/html/dod279.html Fax: 011 (671) 477-4733E-mail: dorl@drl.state.wi.us Web Site: http://www.visitguam.org/GVB/ Govindex.htmlWisconsin Dentistry Examining BoardBureau of Health Professions NORTHERN MARIANASDepartment of Regulation & LicensingP.O. Box 8935 CNMI Board of Professional LicensingMadison, WI 53708 P.O. Box 20781400 E. Washington Avenue Saipan, MP 96950Phone: (608) 266-2811 Phone: (670) 234-5897Web Site: http://www.drl.state.wi.us/agencies/drl/ Fax: (670) 234-6040Regulation/html/dod087.html Web Site: http://www.mariana- islands.gov.mp/contact.htmWYOMING PUERTO RICOWyoming Board of Medicine211 West 19th Street Puerto Rico Board of Medical ExaminersColony Building, 2nd Floor P.O. Box 13969Cheyenne, WY 82002 San Juan, PR 00908Phone: (307) 778-7053 Kennedy Avenue, ILA Bldg., Hogar del Obrero,Fax: (307) 778-2069 Portuario, Piso 8, Puerto Nuevo 00920 Phone: (787) 782-8989Wyoming Board of Dental Examiners Fax: (787) 782-8733P.O. Box 272Kemmerer, WY 83101 Puerto Rico Board of Dental ExaminersPhone: (307) 777-6529 P.O. Box 10200 San Juan, PR 00908U.S. TERRITORIES Phone: (787) 725-8161The following U.S Territories are defined as States VIRGIN ISLANDSin §60.3 of the Data Bank Regulations. Virgin Islands Board of Medical Examiners Department of Health 48 Sugar Estate St. Thomas, VI 00802 Phone: (340) 774-0117 Fax: (340) 777-4001H-14 September 2001
    • NPDB Guidebook Index INDEXA Account Discrepancies ......................................................................................................................................................... G-3 Outstanding Balances ...................................................................................................................................................... G-3 Reconciliation of Credit Card Statements ................................................................................................................... G-3–5 Addresses............................................................................................................................................See Data Bank Addresses Adverse Clinical Privileges Action Reports ....................................................................................................................... E-17 Adverse Licensure Reports ................................................................................................................................................. E-24 Adverse Professional Society Membership Action Reports ............................................................................................... E-26 Attorney Access.................................................................................................................................................................... D-5 Authorized Agents ................................................................................................................................................................ B-7 Designating Authorized Agents....................................................................................................................................... B-8 Authorized Submitter............................................................................................................................................................ B-7B Background Final Regulations............................................................................................................................................................. A-1 Health Care Quality Improvement Act of 1986............................................................................................................... A-1 Hearings....................................................................................................................................................................... A-1–2 Public Law 99-660 .......................................................................................................................................................... A-2 Bankruptcy........................................................................................................................................................ D-11–12, G-4–5C Civil Liability Protection ...................................................................................................................................................... A-2 Confidentiality Provisions ................................................................................................................................................ A-3–5 Appropriate Uses of NPDB Information ..................................................................................................................... A-4–5 Authorized Agents’ Responsiblities ................................................................................................................................ A-4 The Privacy Act.......................................................................................................................................................A-4, A-6 Coordination Between the NPDB and the HIPDB................................................................................................................ A-6 Correction ..........................................................................................................................................See Reporting: Correction Credits and Debits................................................................................................................................................................. G-4 Customer Service Center ...................................................................................................................................................... H-1D Data Bank Addresses ............................................................................................................................................................ H-2 Data Bank Identification Number ......................................................................................................................................... B-5 Deactivate a DBID .......................................................................................................................................................... B-5 Lost Your DBID? ............................................................................................................................................................ B-6 Reactivate a DBID........................................................................................................................................................... B-6 DBID ...............................................................................................................................See Data Bank Identification Number Defining Health Care Practitioners ....................................................................................................................................... H-1 Disclosure of NPDB Information Eligible Entities ............................................................................................................................................................... A-5 Dispute Process......................................................................................................................................................................F-1 Examples of Disputes .......................................................................................................................................................F-6 Secretarial Review............................................................................................................................................................F-3 Subject Disputes ...............................................................................................................................................................F-2 Subject Statements............................................................................................................................................................F-1E Eligible Entities .............................................................................................................................................................. B-1–10 September 2001 Index-1
    • Index NPDB Guidebook For Querying ................................................................................................................................................................... D-1 For Reporting ...................................................................................................................................................................E-1F Federal Employer Identification Number ............................................................................................................................. H-3 Fees................................................................................................................................................................................... G-1–2 Entity Query Fees............................................................................................................................................................ G-1 Payment Methods ............................................................................................................................................................ G-1 Self-Query Fees............................................................................................................................................................... G-1 FEIN .................................................................................................................... See Federal Employer Identification Number FOIA........................................................................................................................................See Freedom of Information Act Freedom of Information Act ................................................................................................................................................. H-3H Health Care Entities Hospitals.......................................................................................................................................................................... B-2 Other Health Care Entities............................................................................................................................................... B-2 Healthcare Integrity and Protection Data Bank .................................................................................................................... A-6 High-Low Agreements ........................................................................................................................................................E-13 HIPDB ........................................................................................................ See Healthcare Integrity and Protection Data BankI ICD .......................................................................................................................................... See Interface Control Document ICD Transfer Program .................................................................................................................................................. D-6, E-4 Immunity Protection .....................................................................................................................See Civil Liability Protection Initial Report..................................................................................................................................See Reporting: Initial Report Integrated Querying and Reporting Service.................................................................................................................. D-6, E-3 Interface Control Document ......................................................................................................................................... D-6, E-4 Interpretation of NPDB Information..................................................................................................................................... A-3 IQRS ................................................................................................................ See Integrated Querying and Reporting Service ITP .................................................................................................................................................... See ICD Transfer ProgramL Liquidation ........................................................................................................................................................................... G-5 Loss Adjustment Expenses ..................................................................................................................................................E-12M Medical Malpractice Payers ................................................................................................................................................. B-4 Medical Malpractice Payment Reports..................................................................................................................................E-8N National Practitioner Data Bank ........................................................................................................................................... A-1 NPDB ................................................................................................................................See National Practitioner Data BankO Official Language ................................................................................................................................................................. A-6P Payment Methods ............................................................................................................................................................. G-1–2 Credit Card ...................................................................................................................................................................... G-1 Electronic Funds Transfer ............................................................................................................................................... G-1 Privacy Act ........................................................................................................................................................................... H-4 Index-2 September 2001
    • NPDB Guidebook Index Professional Societies ........................................................................................................................................................... B-3Q Querying ............................................................................................................................................................................... D-1 Correcting Querying Information .................................................................................................................................... D-9 Equipment Needed to Query Electronically .................................................................................................................... D-7 Failure to Query............................................................................................................................................................... D-9 Hospitals.......................................................................................................................................................................... D-1 Mandatory Querying Requirements ................................................................................................................................ D-1 Professional Societies ...................................................................................................................................................... D-3 Query Processing............................................................................................................................................................. D-7 Query Responses ............................................................................................................................................................. D-8 Querying Through an Authorized Agent ......................................................................................................................... D-7 Residents and Interns....................................................................................................................................................... D-3 State Licensing Boards .................................................................................................................................................... D-3 Submitting a Query to the NPDB .................................................................................................................................... D-6 Types of Queries ............................................................................................................................................................. D-5R Registering with the NPDB .................................................................................................................................................. B-4 Certifying Official ........................................................................................................................................................... B-4 Entity Recertification ...................................................................................................................................................... B-5 Entity Registration Form ................................................................................................................................................. B-4 Registration Verification ................................................................................................................................................. B-4 Reporting .........................................................................................................................................................................E-1–36 Adverse Clinical Privileges Actions ........................................................... See Adverse Clinical Privileges Action Reports Adverse Licensure Actions.......................................................................................See Adverse Licensure Action Reports Adverse Professional Society Membership Actions ........... See Adverse Professional Society Membership Action Reports Correction........................................................................................................................................................................ E-5 Draft Capability ............................................................................................................................................................... E-4 Initial Report.................................................................................................................................................................... E-4 Medical Malpractice Payments ..........................................................................See Medical Malpractice Payment Reports Report Processing ............................................................................................................................................................ E-6 Report Responses ............................................................................................................................................................ E-6 Reporting by Authorized Agents ................................................................................................................................... E-14 Residents and Interns..................................................................................................................................................... E-11 Revision to Action........................................................................................................................................................... E-5 Sanctions for Failing to Report to the NPDB ................................................................................................................ E-27 Students ......................................................................................................................................................................... E-12 Submitting Reports to the NPDB Via ITP or Diskette .................................................................................................... E-4 Submitting Reports Via the IQRS ................................................................................................................................... E-3 Time Frame for Reporting to the NPDB.......................................................................................................................... E-1 Void Previous Report ...................................................................................................................................................... E-5 Revision to Action ................................................................................................................See Reporting: Revision to ActionS Secretarial Review ...................................................................................................... See Dispute Process: Secretarial Review Self-Query ............................................................................................................................................................................ C-4 State Licensing Boards ......................................................................................................................................................... B-3 State Medical and Dental Boards.................................................................................................................................... H-3–14 Subject Database................................................................................................................................................................... D-8 Subject Information in the NPDB......................................................................................................................... C-4, D-8, E-2T Title IV of Public Law 99-660.......................................................................................... See Background: Public Law 99-660 September 2001 Index-3
    • Index NPDB GuidebookU User IDs................................................................................................................................................................................ B-6V Void ................................................................................................................................. See Reporting: Void Previous Report Index-4 September 2001
    • NPDB Guidebook Appendix A Glossary APPENDIX A: GlossaryThis glossary contains terms that relate to the National Practitioner Data Bank (NPDB), andthe definitions apply only to their usage in conjunction with the NPDB and its policies andprocedures.adverse action — (1) an action taken against a practitioner’s clinical privileges or medicalstaff membership in a health care entity, or (2) a licensure disciplinary action.Adverse Action Codes — a list of adverse actions and the codes used to identify them whensubmitting reports to the NPDB.Adverse Action Report (AAR)— the format used by health care entities and StateLicensing Boards to report an adverse action taken against a physician, dentist, or otherhealth care practitioner.adversely affects — reduces, restricts, suspends, revokes, or denies clinical privileges ormembership in a health care entity.authorized agent — an individual or organization that an eligible entity designates to querythe NPDB on its behalf. In most cases, an authorized agent is an independent contractor tothe requesting entity (for instance, a county medical society or state hospital association)used for centralized credentialing. An authorized agent cannot query the NPDB withoutdesignation from an eligible entity.authorized submitter — an individual empowered by an eligible entity to submit reports orqueries to the NPDB. The authorized submitter certifies the legitimacy of information in aquery or report submitted to the NPDB. In most cases, the authorized submitter is anemployee of the eligible entity (such as an Administrator or Medical Staff Director).board of medical examiners — a body or subdivision of such body that is designated by aState for licensing, monitoring, and disciplining physicians or dentists. This term includesboards of allopathic or osteopathic examiners, a composite board, a subdivision, or anequivalent 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 carepractitioner is permitted to furnish medical care by a health care entity.Correction — a change intended to supersede a report in the NPDB.Data Bank Identification Number (DBID) — a unique, 15-digit, identification numberassigned 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. TheDBID must be included on all correspondence to the NPDB.September 2001 Appendix A-1
    • Appendix A Glossary NPDB Guidebookdentist — a doctor of dental surgery, a doctor of dental medicine, or the equivalent who islegally authorized to practice dentistry by a State, or who, without authority, holds himself orherself out to be so authorized.Department of Health and Human Services (HHS)— the Government agency responsiblefor administration of the NPDB.dispute — a formal, written objection of the accuracy of a report or the fact that a specificevent was reported to the NPDB. Disputes may be made only by the subject of a report.Data Bank Control Number (DCN) — the identification number assigned by the NPDBthat is used to identify each query and report. Eligible entities use the DCN when submittinga Correction or a Void to the NPDB.draft—a report that is temporarily stored without being submitted to the NPDB-HIPDB forprocessing. Reporters may create drafts of any type of report and store them for futureretrieval for up to 30 days. Draft reports are not required to have all mandatory dataelements completed and are not considered valid submissions to the NPDB-HIPDB.Drug Enforcement Administration (DEA) — the Government agency that registerspractitioners to dispense controlled substances and assigns practitioners Federal DEANumbers.Electronic Funds Transfer (EFT) — a method of electronic payment for NPDB queries.Entities may authorize their banks to directly debit their accounts in order to pay for queriesprocessed by the NPDB. To use the Electronic Funds Transfer payment method, entitiesmust provide to the NPDB the account number, routing code, and type of account (checkingor savings) for the bank account from which fee payment is authorized.eligible entity — an entity that is entitled to query and/or report to the NPDB under theprovisions of Title IV of Public Law 99-660, as specified in 45 CFR Part 60. Eligibleentities must certify their eligibility to the NPDB in order to query and/or report.Entity Primary Function Codes — two-digit code that best describes the primary functionyour entity performs. The code is used on the Entity Registration form.formal peer review process — the conduct of professional review activities throughformally adopted written procedures that provide for adequate notice and an opportunity fora hearing.Freedom of Information Act (FOIA) — the law that provides public access to FederalGovernmental records. See the Information Sources chapter of this Guidebook.Health Care Quality Improvement Act of 1986, as amended — Title IV of Public Law99-660; legislation intended to improve the quality of medical care by encouraging hospitals,State Licensing Boards, and other health care entities, including professional societies, toAppendix A-2 September 2001
    • NPDB Guidebook Appendix A Glossaryidentify and discipline those who engage in unprofessional behavior; and to restrict theability of incompetent practitioners to move from State to State without disclosure ordiscovery of the practitioners’ previous damaging or incompetent performance.health care entity — (1) a hospital; (2) an entity that provides health care services andfollows 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 formalpeer review process for the purpose of furthering quality health care.health care practitioner — an individual other than a physician or dentist (1) who islicensed 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 careservices.hospital [as described in Section 1861(e)(1) and (7) of the Social Security Act] — aninstitution primarily engaged in providing, by or under the supervision of physicians, toinpatients (1) diagnostic services and therapeutic services for medical diagnosis, treatment,and care of injured, disabled, or sick persons; or (2) rehabilitation services for therehabilitation of injured, disabled, or sick persons, and, if required by State or local law, islicensed or is approved by the agency of the State or locality responsible for licensinghospitals as meeting the standards established for such licensing.ICD Transfer Program (ITP) — a program that transmits Interface Control Document(ICD) report and query files to and from the NPDB-HIPDB. This option is used by entitiesthat do not have access to the IQRS, or prefer to generate reports and queries using customsoftware.Initial Report — the original record of a medical malpractice payment or adverse actionsubmitted by a reporting entity. An eligible entity references an Initial Report (using theDCN) when submitting a Correction, Void, or Revision to Action.Integrated Querying and Reporting Service (IQRS) — an electronic, Internet-basedsystem for querying and reporting to the NPDB and the HIPDB.Interface Control Document (ICD) — a file format for the NPDB-HIPDB that representsall components of reports and queries. Entities who do not have access to the Internet mayftp their queries and reports in ICD format.licensure disciplinary action — (1) revocation, suspension, restriction, or acceptance ofsurrender of a license; and (2) censure, reprimand, or probation of a licensed physician ordentist based on professional competence or professional conduct.medical malpractice payer — an entity that makes a medical malpractice payment throughan insurance policy or otherwise for the benefit of a practitioner.September 2001 Appendix A-3
    • Appendix A Glossary NPDB Guidebookmedical malpractice payment — a monetary exchange as a result of a settlement orjudgment 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 healthcare services, and may include, but is not limited to, the filing of a cause of action, based onthe 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 toreport a medical malpractice payment made for the benefit of a physician, dentist, or otherhealth care practitioner.NPDB-HIPDB Customer Service Center — The Customer Service Center encompasses allthe tools and services that the Data Banks use to support customers. Questions may bedirected to Information Specialists at the Customer Service Center by e-mail at npdb-hipdb@sra.com or by phone at 1-800-767-6732 (TDD 1-703-802-9395).Occupation/Field of Licensure Codes — a list of occupational activities/licensurecategories for health care practitioners, providers, and suppliers, and the codes used toidentify them.physician — a doctor of medicine or osteopathy who is legally authorized to practicemedicine or surgery by a State, or who, without authority, holds himself or herself out to beso authorized.Portable Document Format (PDF) — files with a .pdf extension, such as Adobe AcrobatReader files. Format used for NPDB query and report responses and other forms accessedvia the IQRS.practitioner — a physician, dentist, or other licensed health care practitioner.Privacy Act — the law that establishes safeguards for the protection of Federal systems ofrecords the Government collects and keeps on individual persons. See the InformationSources chapter of this Guidebook.professional review action — an action or recommendation of a health care entity:(1) taken in the course of professional review activity;(2) based on the professional competence or professional conduct of an individual physician, dentist, or other health care practitioner which affects or could affect adversely the health or welfare of a patient or patients; and(3) which adversely affects or may adversely affect the clinical privileges of the physician, dentist, or other health care practitioner.(4) This term excludes actions which are primarily based on: (a) the physician’s, dentist’s, or other health care practitioner’s association, or lack of association, with a professionalAppendix A-4 September 2001
    • NPDB Guidebook Appendix A Glossary society or association; (b) the physician’s, dentist’s, or other health care practitioner’s fees or the physician’s, dentist’s, or other health care practitioner’s advertising or engaging in other competitive acts intended to solicit or retain business; (c) the physician’s, dentist’s, or other health care practitioner’s participation in prepaid group health plans, salaried employment, or any other manner of delivering health services whether on a fee-for-service or other basis; (d) a physician’s, dentist’s, or other health care practitioner’s association with, supervision of, delegation of authority to, support for, training of, or participation in a private group practice with, a member or members of a particular class of health care practitioner or professional; or (e) any other matter that does not relate to the professional competence or professional conduct of a physician, dentist, or other health care practitioner.professional review activity — an activity of a health care entity with respect to anindividual physician, dentist, or other health care practitioner: (1) to determine whether thephysician, dentist, or other health care practitioner may have clinical privileges with respectto, or membership in, the entity; (2) to determine the scope or conditions of such privilegesor membership; or (3) to change or modify such privileges or membership.professional society — an association of physicians or dentists that follows a formal peerreview process for the purpose of furthering quality health care.QPRAC — software previously available from the NPDB that allowed eligible entities toquery and report electronically either via network telecommunication using a modem or ondiskettes submitted by mail. QPRAC has been replaced by the IQRS.query — a request for information submitted to the NPDB by an eligible entity or authorizedagent via the IQRS or ICD format.report — record of a medical malpractice payment or adverse action submitted to the NPDBby an eligible entity. Reports may be submitted via the IQRS or by ITP using the appropriateICD format.Revision to Action — an action relating to and modifying an adverse action previouslyreported to the NPDB. A Revision to Action does not supersede a previously reportedadverse action. An entity that reports an Initial adverse action must also report any revisionto that action.Secretary — the Secretary of Health and Human Services.Secretarial Review — the recourse provided a practitioner in the event that he or shedisputes a report to the NPDB and the reporting entity (1) declines to change the report or(2) does not respond. The Secretary of HHS will review the case and determine whether thereport is factually accurate or should have been reported to the NPDB.self-query — a subject’s request for information contained in the NPDB-HIPDB abouthimself or herself. All self-query requests are automatically submitted to both the NPDB andthe HIPDB. A self-query may not be sent to only one Data Bank.September 2001 Appendix A-5
    • Appendix A Glossary NPDB GuidebookState — the 50 States, the District of Columbia, Puerto Rico, the Virgin Islands, Guam,American Samoa, and the Northern Mariana Islands.State licensing board — a generic term used to refer to State medical and dental boards, aswell as those bodies responsible for licensing other heath care practitioners.State medical or dental board — a board of medical examiners.subject statement — a statement of up to 2,000 characters (including spaces andpunctuation) or less submitted by a subject practitioner regarding a report contained in theNPDB.Void — a retraction of a report in its entirety. Voided reports are not disclosed in responseto queries, including self-queries by practitioners. Reports may be voided only by thereporting entity or the Secretary of HHS through Secretarial Review.45 Code of Federal Regulations Part 60 (45 CFR 60) — Federal regulations that governthe NPDB. See Appendix B.Appendix A-6 September 2001
    • NPDB Guidebook Appendix B Laws and Regulations APPENDIX B: Laws and RegulationsThe following laws and regulations apply to the National Practitioner Data Bank. The fulltext can be accessed by clicking the web site link next to each.Title IV of Public Law 99-660, complete text of the Health Care Quality Improvement Act of1986, as amended. http://www.npdb-hipdb.com/info/legislation/title4.htmlTitle IV Regulations, complete text of the 45 CFR Part 60, October 17, 1989.http://www.npdb-hipdb.com/info/legislation/45cfr60.htmlCivil Money Penalties, 42 CFR Part 1003.http://www.npdb-hipdb.com/info/legislation/42cfr.htmlFreedom of Information Act (FOIA). The provisions of FOIA, 5 USC §552, affect thedissemination of information contained in the NPDB.http://www.npdb-hipdb.com/info/legislation/foia.htmlPrivacy Act of 1974; Alteration of System of Records - The Privacy Act affects thedissemination of information contained in the NPDB. Please reference the Privacy Act,5 USC §552a. http://www.npdb-hipdb.com/info/legislation/privacy.htmlFinal rule in the Federal Register on March 1, 1999, that removes the prohibition against theNPDB charging for self-queries, and therefore, allows the NPDB to assess costs in anequitable manner. http://www.npdb-hipdb.com/pubs/fedreg3-1-99.pdfNotice in the Federal Register on March 1, 1999, announcing a $10 fee for health carepractitioners who request information about themselves (self-query) from the NPDB,effective March 31, 1999. http://www.npdb-hipdb.com/pubs/fedreg3-1-99.pdfSeptember 2001 Appendix B-1
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    • NPDB Guidebook Appendix C Abbreviations APPENDIX C: AbbreviationsAAR Adverse Action ReportBHPr Bureau of Health ProfessionsCFR Code of Federal RegulationsCMS Centers for Medicare & Medicaid Services (formerly the Health Care Financing Administration)DBID Data Bank Identification NumberDCN Data Bank Control NumberDEA Drug Enforcement AdministrationDQA Division of Quality AssuranceEFT Electronic Funds TransferFOIA Freedom of Information ActHHS U.S. Department of Health and Human ServicesHIPDB Healthcare Integrity and Protection Data BankHMO Health Maintenance OrganizationHRSA Health Resources and Services AdministrationICD Interface Control DocumentITP (ICD) Transfer ProtocolIQRS Integrated Querying and Reporting ServiceLAE Loss Adjustment ExpenseMCO Managed Care OrganizationMMER Medicare/Medicaid Exclusion ReportMMPR Medical Malpractice Payment ReportNPDB National Practitioner Data BankOIG Office of Inspector General/HHSPDF Portable Document FilePPO Preferred Provider OrganizationQPRAC Query on PractitionersRVD Report Verification DocumentSND Subject Notification DocumentSSN Social Security NumberTDD Telecommunications Device for the DeafTIN Taxpayer Identification NumberSeptember 2001 Appendix C-1