National Practitioner Data Bank GUIDEBOOK

National Practitioner Data Bank

GUIDEBOOK

U.S. Department of Health and Human ServicesHealth Resources and Services Administration

Division of Quality Assurance7519 Standish Place

Suite 300Rockville, Maryland 20857

Publication No. HRSA-95-255

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NPDB Guidebook Table of Contents

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A. IntroductionPreface................................................................................................................................... A-1Background........................................................................................................................... A-1

Title IV of Public Law 99-660.......................................................................................... A-2Civil Liability Protection ...................................................................................................... A-2Interpretation of NPDB Information..................................................................................... A-3Confidentiality of NPDB Information .................................................................................. A-3Disclosure of NPDB Information ......................................................................................... A-5Coordination Between the NPDB and the HIPDB ............................................................... A-6Official Language ................................................................................................................. A-6User Fees............................................................................................................................... A-6

B. Eligible EntitiesWhat is an Eligible Entity? ................................................................................................... B-1

Defining Health Care Entities........................................................................................... B-2Hospitals ....................................................................................................................... B-2Other Health Care Entities ............................................................................................ B-2

Defining Professional Societies ........................................................................................ B-3Defining State Licensing Boards ...................................................................................... B-3Defining Medical Malpractice Payers .............................................................................. B-4

Registering with the NPDB .................................................................................................. B-4Certifying Official............................................................................................................. B-4

Entity Recertification............................................................................................................ B-5Data Bank Identification Numbers (DBIDs) ........................................................................ B-5

Deactivate a DBID........................................................................................................ B-5Reactivate a DBID ........................................................................................................ B-6

User IDs ................................................................................................................................ B-6Update Entity Information .................................................................................................... B-6Lost Your DBID?.................................................................................................................. B-6Organizations That May Report and Query on Behalf of Entities ....................................... B-6

Authorized Submitter........................................................................................................ B-7Authorized Agents ............................................................................................................ B-7Designating Authorized Agents........................................................................................ B-8Questions and Answers..................................................................................................... B-9

C. Health Care PractitionersOverview............................................................................................................................... C-1Defining Health Care Practitioners....................................................................................... C-1Practitioner Self-Query ......................................................................................................... C-4Self-Querying on the Internet ............................................................................................... C-4Subject Information in the NPDB......................................................................................... C-4Questions and Answers......................................................................................................... C-5

D. QueriesOverview............................................................................................................................... D-1

Hospitals ........................................................................................................................... D-1

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Residents and Interns ........................................................................................................ D-3Professional Societies ....................................................................................................... D-3State Licensing Boards ..................................................................................................... D-3

Types of Queries ................................................................................................................... D-5Attorney Access .................................................................................................................... D-5Authorized Agents ................................................................................................................ D-6Submitting a Query to the NPDB ......................................................................................... D-6

Equipment Needed to Query Electronically ..................................................................... D-7Querying Through an Authorized Agent .......................................................................... D-7

Query Processing .................................................................................................................. D-7Subject Information .......................................................................................................... D-8Subject Database............................................................................................................... D-8Character Limits ............................................................................................................... D-8Query Responses............................................................................................................... D-8Query Response Availability ............................................................................................ D-9Missing Query Responses................................................................................................. D-9

Correcting Query Information .............................................................................................. D-9Failure to Query .................................................................................................................... D-9Questions and Answers....................................................................................................... D-10

E. ReportsOverview................................................................................................................................E-1

Time Frame for Reporting to the NPDB............................................................................E-1Civil Liability Protection ...................................................................................................E-1Official Language ..............................................................................................................E-1Computation of Time Periods............................................................................................E-1

Submitting Reports to the NPDB...........................................................................................E-2Subject Information ...........................................................................................................E-2When Subject Information Is Unknown ............................................................................E-2Reporting Subject Social Security Numbers .....................................................................E-3Incorrectly Identified Subject ............................................................................................E-3Submitting Reports Via the IQRS .....................................................................................E-3

Draft Capability .............................................................................................................E-4Submitting Reports to the NPDB Via ITP.........................................................................E-4

Types of Reports ....................................................................................................................E-4Initial Report ......................................................................................................................E-4Correction ..........................................................................................................................E-5Void Previous Report.........................................................................................................E-5Revision to Action .............................................................................................................E-5

Report Processing ..................................................................................................................E-6Report Responses...................................................................................................................E-6

Missing Report Verification ..............................................................................................E-7Reporting Medical Malpractice Payments.............................................................................E-8

Trigger Date for Reporting ................................................................................................E-8Interpretation of Medical Malpractice Payment Information ............................................E-8Sample Descriptions (for Illustrative Purposes Only) .......................................................E-9


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Reporting of Payments by Individuals.............................................................................E-10Payments for Corporations and Hospitals .......................................................................E-10Deceased Practitioners .....................................................................................................E-11Identifying Practitioners ..................................................................................................E-11Insurance Policies that Cover More than One Practitioner .............................................E-11One Settlement for More than One Practitioner ..............................................................E-11Residents and Interns .......................................................................................................E-11Students............................................................................................................................E-12Practitioner Fee Refunds..................................................................................................E-12Loss Adjustment Expenses ..............................................................................................E-12Dismissal of a Defendant from a Lawsuit........................................................................E-12High-Low Agreements.....................................................................................................E-13Reporting by Authorized Agents .....................................................................................E-14Payments by Multiple Payers ..........................................................................................E-14Structured Settlements .....................................................................................................E-14Subrogation-Type Payments............................................................................................E-15Offshore Payers................................................................................................................E-15Payments Made Prior to Settlement.................................................................................E-15

Reporting Adverse Clinical Privileges Actions ...................................................................E-17Multiple Adverse Actions................................................................................................E-18Denial of Applications .....................................................................................................E-18Withdrawal of Applications.............................................................................................E-19Investigations ...................................................................................................................E-19

Guidelines for Investigations .......................................................................................E-19Summary Suspension.......................................................................................................E-19Examples of Reportable and Non-Reportable Actions....................................................E-21

Reporting Adverse Licensure Actions.................................................................................E-24Effective Date of Action ..................................................................................................E-24Examples of Reportable Actions .....................................................................................E-24Examples of Non-Reportable Actions .............................................................................E-25

Reporting Adverse Professional Society Membership Actions...........................................E-26Reporting Requirements ..................................................................................................E-26

Sanctions for Failing to Report to the NPDB ......................................................................E-27Medical Malpractice Payers.............................................................................................E-27Hospitals and Other Health Care Entities ........................................................................E-28State Boards .....................................................................................................................E-28Professional Societies ......................................................................................................E-28Questions and Answers....................................................................................................E-29

F. DisputesThe Dispute Process...............................................................................................................F-1

Subject Statements .............................................................................................................F-1Subject Disputes ................................................................................................................F-2

Secretarial Review .................................................................................................................F-3Pertinent Documentation ...................................................................................................F-4

Reporting Medicare/Medicaid Exclusions ..........................................................................E-27

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Secretarial Review Results ................................................................................................F-4Report Accurate as Submitted ...........................................................................................F-4Report Inaccurate as Submitted .........................................................................................F-5Dispute Outside the Scope of Secretarial Review .............................................................F-5

Secretarial Review Overview ........................................................................................F-5Reconsideration of the Secretary’s Decisions on Disputes ...............................................F-6Improper Requests for Secretarial Review ........................................................................F-6

Examples of Disputes ............................................................................................................F-6Due Process - Alleged Denial ............................................................................................F-6Due Process - Legal Action Pending .................................................................................F-6Licensure Completion - Trigger Date ................................................................................F-7Narrative Description - Inaccurate.....................................................................................F-7Narrative Description - Legal Sufficiency.........................................................................F-7Narrative Description - Misleading ...................................................................................F-8Privileges - Resignation and Surrender While Under Investigation..................................F-8

Professional Review - Alternative Employment Termination Procedure .........................F-9Residency Status ................................................................................................................F-9Responsibility for Treatment .............................................................................................F-9Settlement - Subject Disagrees ........................................................................................F-10Settlement - Subject Dismissed from Lawsuit.................................................................F-10Suspension - Indefinite Length ........................................................................................F-10Suspension - Summary ....................................................................................................F-10Questions and Answers....................................................................................................F-11

G. FeesQuery Fees ............................................................................................................................ G-1

Entity Query Fees ............................................................................................................. G-1Self-Query Fees ................................................................................................................ G-1

Methods of Payment ............................................................................................................. G-1Account Discrepancies ......................................................................................................... G-3Credits and Debits................................................................................................................. G-4Bankruptcy............................................................................................................................ G-4Questions and Answers......................................................................................................... G-4

H. Information SourcesNPDB-HIPDB Web Site Assistance..................................................................................... H-1NPDB-HIPDB Customer Service Center ............................................................................. H-1Data Bank Addresses ............................................................................................................ H-2Interpretation of NPDB Statutes and Regulations ................................................................ H-2The Privacy Act and the NPDB............................................................................................ H-2The Freedom of Information Act and the NPDB.................................................................. H-3Federal Employer Identification Number ............................................................................. H-3State Medical and Dental Boards.......................................................................................... H-3

Privileges - Suspension and Hospital Motivation...............................................................F-9


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APPENDIX A: GlossaryAPPENDIX B: Laws and RegulationsAPPENDIX C: Abbreviations

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NPDB Guidebook Chapter A Introduction

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Preface

The National Practitioner Data BankGuidebook is meant to serve as a resourcefor the users of the National PractitionerData Bank (NPDB). It is one of a numberof efforts to inform the United Stateshealth care community about the NPDBand what is required to comply with therequirements established by Title IV ofPublic Law 99-660, the Health CareQuality Improvement Act of 1986, asamended. This Guidebook containsinformation that authorized users need tointeract with the NPDB. Authorized usersinclude State licensing authorities;medical malpractice payers; hospitals andother health care entities; and physicians,dentists, and other licensed health carepractitioners.

Final regulations governing the NPDBwere published in the Federal Register onOctober 17, 1989, and are codified at 45CFR Part 60. The U.S. Department ofHealth and Human Services (HHS) isresponsible for implementing the NPDB.

This Guidebook is divided into broadtopical sections. This introductioncontains general information on theNPDB, which includes its history, the lawsand regulations that govern it, and otherinformation for authorized users. ChapterH, Information Sources, provides a varietyof sources to facilitate user interactionwith the NPDB. The Glossary, includedas Appendix A, defines terms helpful inunderstanding NPDB operations,including querying and reportingrequirements.

This edition of the NPDB Guidebookreflects the entire range of NPDB policiesand operations, including those that havechanged or expanded since the NPDB

opened in September 1990. Thiscomprehensive Guidebook is for both newand experienced entities that are eligible toparticipate in the NPDB; it supersedes allprevious versions.

Background

The legislation that led to the creation ofthe NPDB was enacted because the U.S.Congress perceived that the increasingoccurrence of medical malpracticelitigation and the need to improve thequality of medical care had becomenationwide problems that warrantedgreater efforts than those that could beundertaken by any individual State. Effective professional peer review canrestrict the ability of incompetentpractitioners to move from State to Statewithout disclosure or discovery ofprevious damaging or incompetentperformance. The Congress felt that thethreat of private money damage liabilityunder Federal laws, including trebledamage liability under Federal antitrustlaw, unreasonably discouraged physiciansand dentists from participating in effectiveprofessional peer review. Therefore,Congress sought to provide incentive andprotection for physicians and dentistsengaging in effective professional peerreview.

Hearings were held in the U.S. House ofRepresentatives on the proposedlegislation, the Health Care QualityImprovement Act of 1986, on March 18and July 15, 1986, by the Subcommitteeon Health and the Environment,Committee on Energy and Commerce, andon October 8 and 9, 1986, by theSubcommittee on Civil and ConstitutionalRights, Committee on the Judiciary. Atthese public hearings, testimony was givenby physicians, attorneys, insurance

Chapter A Introduction NPDB Guidebook

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officials, representatives of health careassociations, and others. The Health CareQuality Improvement Act of 1986 wasincorporated as Title IV into legislationrequiring States to develop, establish, andimplement State comprehensive mentalhealth plans. This legislation becamePublic Law 99-660 when it was signed byPresident Ronald Reagan onNovember 14, 1986.

Title IV of Public Law 99-660

The intent of Title IV of Public Law99-660 is to improve the quality of healthcare by encouraging State licensingboards, hospitals and other health careentities, and professional societies toidentify and discipline those who engagein unprofessional behavior; and to restrictthe ability of incompetent physicians,dentists, and other health care practitionersto move from State to State withoutdisclosure or discovery of previousmedical malpractice payment and adverseaction history. Adverse actions caninvolve licensure, clinical privileges, andprofessional society memberships.

Civil Liability Protection

To encourage and support professionalreview activity of physicians and dentists,Part A of Title IV provides that theprofessional review bodies of hospitalsand other health care entities, and personsserving on or otherwise assisting suchbodies, are offered immunity from privatedamages in civil suits under Federal orState law. Immunity provisions applywhen professional review responsibilitiesare conducted with the reasonable belief offurthering the quality of health care andwith proper regard for due process. Thereare exceptions under the law for civil

rights actions and antitrust actions broughtby Federal and State Governments.

In order to receive immunity protection, aprofessional review action regarding theprofessional competence or professionalconduct of a physician or dentist must betaken:

• In the reasonable belief that the actionwas in the furtherance of quality healthcare.

• After a reasonable effort to obtain thefacts of the matter.

• After adequate notice and hearingprocedures are afforded to thephysician or dentist involved or aftersuch other procedures as are fair to thephysician or dentist under thecircumstances.

• In the reasonable belief that the actionwas warranted by the facts known,after such reasonable effort to obtainfacts and after meeting the notice andhearing requirement.

Because the immunity provided by theHealth Care Quality Improvement Act isfrom liability rather than from suit, adisciplined physician or dentist retains theright to sue; however, the court may awardattorneys' fees and court costs to thedefendants if the suit is determined to befrivolous, unreasonable, withoutfoundation, or in bad faith.

Title IV of Public Law 99-660, the HealthCare Quality Improvement Act of 1986,led to the establishment of the NPDB, aninformation clearinghouse, to collect andrelease certain information related to theprofessional competence and conduct ofphysicians, dentists, and, in some cases,


September 2001 A-3

other health care practitioners. Theestablishment of the NPDB represents animportant step by the U.S. Government toenhance professional review efforts bymaking certain information concerningmedical malpractice payments and adverseactions available to eligible entities andindividuals.

A web link to the NPDB Regulationscodified at 45 CFR Part 60 is referenced inAppendix B of this Guidebook.

Interpretation of NPDBInformation

The NPDB is primarily an alert orflagging system. The informationcontained in it is intended to directdiscrete inquiry into and scrutiny ofspecific areas of a practitioner’s licensure,professional society memberships, medicalmalpractice payment history, and record ofclinical privileges. NPDB information isan important supplement to acomprehensive and careful review of apractitioner’s professional credentials. The NPDB is intended to augment, notreplace, traditional forms of credentialsreview. As a nationwide flagging system,it provides another resource to assist Statelicensing boards, hospitals, and otherhealth care entities in conductingextensive, independent investigations ofthe qualifications of the health carepractitioners they seek to license or hire,or to whom they wish to grant clinicalprivileges.

Settlement of a medical malpractice claimmay occur for a variety of reasons that donot necessarily reflect negatively on theprofessional competence or conduct of thephysician, dentist, or other health carepractitioner. Thus, a payment made in

settlement of a medical malpracticeaction or claim shall not be construed asa presumption that medical malpracticehas occurred.

The information in the NPDB should serveonly to alert State licensing authorities andhealth care entities that there may be aproblem with a particular practitioner’sprofessional competence or conduct. NPDB information should be consideredtogether with other relevant data inevaluating a practitioner’s credentials(e.g., evidence of current competencethrough continuous quality improvementstudies, peer recommendations, healthstatus, verification of training andexperience, and relationships with patientsand colleagues).

Confidentiality of NPDBInformation

Information reported to the NPDB isconsidered confidential and shall not bedisclosed except as specified in the NPDBregulations at 45 CFR Part 60. Theconfidential receipt, storage, anddisclosure of information is an essentialingredient of NPDB operations. Acomprehensive security system has beendesigned to prevent manipulation of andaccess to the data by unauthorized staff orexternal sources. The facility in which theNPDB is housed meets HHS securityspecifications, and NPDB staff haveundergone in-depth background securityinvestigations.

The Office of Inspector General (OIG),HHS, has been delegated the authority toimpose civil money penalties on thosewho violate the confidentiality provisionsof Title IV. The civil money penalties forviolating the confidentiality provisions of


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Title IV are to be imposed in the samemanner as other civil money penaltiespursuant to §1128A of the Social SecurityAct, 42 U.S.C. 1320a-7a. Regulationsgoverning civil money penalties under§1128A are set forth at 42 CFR Part 1003.

For each violation of confidentiality, acivil money penalty of up to $11,000 canbe levied. In any case in which it isdetermined that more than one party wasresponsible for improperly disclosingconfidential information, a penalty of upto the maximum $11,000 limit can beimposed against each responsibleindividual, entity, or organization.

Persons or entities who receiveinformation from the NPDB either directlyor indirectly are subject to theconfidentiality provisions and theimposition of a civil money penalty if theyviolate those provisions. When anauthorized agent is designated to handleNPDB queries, both the entity and theagent are required to maintainconfidentiality in accordance with Title IVrequirements.

The Privacy Act, 5 USC §552a, protectsthe contents of Federal systems of recordson individuals, like those contained in theNPDB, from disclosure without theindividual’s consent, unless the disclosureis for a routine use of the system ofrecords as published annually in theFederal Register. The published routineuses of NPDB information, which arebased on the laws and the regulationsunder which the NPDB operates, do notallow disclosure to the general public. The limited access provision of the HealthCare Quality Improvement Act of 1986, asamended, supersedes the disclosurerequirements of the Freedom of

Information Act (FOIA), 5 USC §552, asamended.

The confidentiality provisions of Title IVdo not prohibit an eligible entity receivinginformation from the NPDB to disclosethe information to others who are part ofthe peer review process, as long as theinformation is used for the purpose forwhich it was provided. Examples ofappropriate uses of NPDB informationinclude:

• A hospital may disclose theinformation it receives from the NPDBto hospital officials responsible forreviewing a practitioner's applicationfor a medical staff appointment orclinical privileges. In this case, boththe hospital officials who receive theinformation and the hospital officialswho subsequently review it during theemployment process are subject to theconfidentiality provisions of Title IV.

• A private accreditation entity canreview confidential information that ahealth care entity has obtainedregarding its practitioners only if thepurpose of the disclosure is to carryout peer review activity for that healthcare entity (i.e., the privateaccreditation entity maintains a role inthe decision-making process forpractitioner membership in the healthcare entity, which would make itsactivities part of the peer reviewprocess). If the private accreditationentity’s activities are not consideredpart of the peer review process, theprivate accreditation entity cannotview any documents that the healthcare entity has obtained from theNPDB that show the results of anNPDB query (e.g., match or nomatch), such as an NPDB report or the


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query response document entitled,Response to Information DisclosureRequest. However, the health careentity would not be in violation of theconfidentiality requirements if itdiscloses a copy of the Response toInformation Disclosure Request to theprivate accreditation entity, as long asinformation that discloses the queryresult is removed from the copy, (i.e.,so the document shows only the nameson which queries were submitted). Additionally, if the health care entityobtains a release from a physicianauthorizing it to specifically releaseconfidential information it obtainsfrom the NPDB to the privateaccreditation entity, the health careentity may do so without violating theNPDB’s confidentiality restrictions.

The confidentiality provisions do notapply to the original documents or recordsfrom which the reported information isobtained. The NPDB’s confidentialityprovisions do not impose any newconfidentiality requirements or restrictionson those documents or records. Thus,these confidentiality provisions do not baror restrict the release of the underlyingdocuments, or the information itself, bythe entity taking the adverse action ormaking the payment in settlement of awritten medical malpractice complaint orclaim. For example, if a hospital thatreported an adverse action against aphysician pursuant to the provisions ofTitle IV receives a subpoena for theunderlying records, it may not refuse toprovide the requested documents on thegrounds that Title IV bars the release ofthe records or information.

Individual health care practitioners whoobtain information about themselves from

the NPDB are permitted to share thatinformation with whomever they choose.

Disclosure of NPDB Information

The Health Care Quality Improvement Actof 1986, as amended, and its governingregulations limit the disclosure ofinformation in the NPDB. Information isavailable to:

• Hospitals requesting informationconcerning a practitioner on theirmedical staff or to whom they havegranted clinical privileges, or withrespect to professional review activity.

• Health care entities (includinghospitals) that have entered or may beentering employment or affiliationrelationships with a practitioner or towhich the practitioner has applied forclinical privileges or appointment tothe medical staff, or with respect toprofessional review activity.

• Practitioners requesting informationabout themselves.

• Boards of medical examiners or otherState licensing boards.

• Attorneys or individuals representingthemselves upon submission of proofthat a hospital failed to submit amandatory query.

• Persons or entities requestinginformation in a form which does notidentify any particular entity orpractitioner.

The Privacy Act protects the contents ofFederal systems of records on individuals,like those in the NPDB, from disclosure


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without the individual's consent unless thedisclosure is for a routine use of thesystem of records as published annually in the Federal Register. The publishedroutine uses of NPDB information, whichare consistent with the law and theregulations under which it operates, do notinclude disclosure to the general public.

• The general public may not requestinformation that identifies anyparticular entity or practitioner fromthe NPDB.

• Medical malpractice payers may notrequest information even though theyare required to report.

See §60.11 of the NPDB Regulations. Alink to the NPDB Regulations is includedin Appendix B of this Guidebook.

Coordination Between the NPDBand the HIPDB

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 Reporting

Service (IQRS) is able to sort theappropriate actions into the HIPDB, theNPDB, or both. Similarly, entitiesauthorized to query both Data Banks havethe option of querying both the NPDB andthe HIPDB with a single querysubmission.

Official Language

The official language of the NPDB isEnglish, and all documents submitted tothe NPDB must be written in English. Documents submitted in any otherlanguage are not accepted.

User Fees

User fees are assessed to cover theprocessing costs for all queries for NPDBinformation. Refer to the NPDB-HIPDBweb site at www.npdb-hipdb.com fordetails regarding the payment of NPDBuser fees.

NPDB Guidebook Chapter B Eligible Entities

September 2001 B-1

What is an Eligible Entity?

Entities entitled to participate in theNational Practitioner Data Bank aredefined in the provisions of Title IV ofPublic Law 99-660, the Health CareQuality Improvement Act of 1986, asamended, and in the regulations codifiedat 45 CFR Part 60. Eligible entities areresponsible for meeting Title IV reportingand/or querying requirements, asappropriate. Each eligible entity mustcertify its eligibility in order to report toand/or query the NPDB.

Information from the NPDB is available toState licensing boards, hospitals and otherhealth care entities, professional societies,certain Federal agencies, and others asspecified in the law. The NPDB collectsinformation 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 otherState licensing board.

• A hospital.

• A health care entity that provideshealth care services and follows aformal peer review process to furtherquality health care.

• A professional society that follows aformal peer review process to furtherquality health care.

To be eligible to report to the NPDB, anentity must be one of the following:

• An entity that makes a medicalmalpractice payment.

• A board of medical examiners or aState licensing board taking an adverseaction against a physician or dentist.

• A health care entity that takes anadverse clinical privileging action as aresult of professional review.

• A professional society that takes anadverse membership action as a resultof professional review.

Each entity is responsible for determiningits eligibility to participate in the NPDBand must certify that eligibility to theNPDB in writing.

Chapter B Eligible Entities NPDB Guidebook

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Defining Health Care Entities

Health care entities include hospitals andother organizations that provide healthcare services and follow a formal peerreview process in order to further qualityhealth care. See §60.3 of the NPDBRegulations. A link to the NPDBRegulations is included in Appendix B ofthis Guidebook.

Hospitals

A hospital is defined under Section1861(e)(1) and (7) of the Social SecurityAct as an institution primarily engaged inproviding, by or under the supervision ofphysicians, to inpatients: diagnostic andtherapeutic services; rehabilitationservices for medical diagnosis, treatment,and care; or rehabilitation of injured,disabled, or sick persons.

Hospitals must be licensed or approved asmeeting the standard established forlicensing by the State or applicable locallicensing authorities.

Other Health Care Entities

A health care entity must provide healthcare services and follow a formal peerreview process to further quality healthcare.

The phrase “provides health care services”means the delivery of health care servicesthrough any of a broad array of coveragearrangements or other relationships withpractitioners either by employing themdirectly, or through contractual or otherarrangements. This definition specificallyexcludes indemnity insurers that have nocontractual or other arrangement withphysicians, dentists, or other health carepractitioners.

Examples of other health care entities mayinclude health maintenance organizations(HMOs), preferred provider organizations(PPOs), group practices, nursing homes,rehabilitation centers, hospices, renaldialysis centers, and free-standingambulatory care and surgical servicecenters.

In addition to HMOs and PPOs, othermanaged care organizations mayqualify as health care entities. A healthcare entity must provide health careservices and follow a formal peer reviewprocess to further quality health care tosatisfy the eligibility requirements ofTitle IV.

Examples of hospitals and other healthcare entities are listed in the table thatfollows.


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Examples of Hospitals and Other Health Care EntitiesHospitals Other Health Care Entities

• All Federal and non-Federal short-term caregeneral and specialty hospitals that are licensedor otherwise authorized by the State.

• Ambulatory or outpatient care centers, evenwhen otherwise part of a hospital.

• “One-day surgery” centers, even when• All Federal and non-Federal long-term care

general and specialty hospitals that providediagnostic and/or therapeutic care under thesupervision of a physician and/or psychologist,that are licensed or otherwise authorized by theState.

otherwise part of a hospital.

• Nursing homes that provide skilled nursing carenot under the supervision of a physician orpsychologist.

• Hospices that provide care not under the• A long-term skilled nursing facility that is

licensed as a hospital by the State, as long ascare is provided under the supervision of aphysician or psychologist.

supervision of a physician or psychologist.

• Nursing homes or hospices that provide onlydaily care.

• A hospice that provides skilled nursing andcomfort care under the supervision of aphysician and which is licensed by the State.

Defining Professional Societies

A professional society is a membershipassociation of physicians, dentists, or otherhealth care practitioners that follows aformal peer review process for the purposeof furthering quality health care.

Examples of professional membershipsocieties may include national, State,county, and district medical and dentalsocieties and academies of medicine anddentistry. Examples of professionalorganizations that ordinarily do not meetthe definition of a professional societyinclude medical and surgical specialtycertification boards, independent practiceassociations (IPAs), and PPOs.

Professional societies are notautomatically eligible to query and/orreport to the NPDB. A professional

society must qualify as a “health careentity” as defined in §60.3 of the NPDBregulations. To meet NPDB eligibilityrequirements, a professional society mustfollow a formal peer review process forthe purpose of furthering quality healthcare.

Defining State Licensing Boards

A State licensing board, or board ofmedical examiners, is responsible forlicensing, monitoring, and discipliningphysicians, dentists, or other health carepractitioners. A board of medicalexaminers includes a medical or dentalboard, a board of osteopathic examiners, acomposite board, a subdivision, or anequivalent body as determined by theState.


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Defining Medical Malpractice Payers

A medical malpractice payer is an entitythat makes a medical malpractice paymentfor the benefit of physicians, dentists, orother health care practitioners insettlement of or in satisfaction in whole orin part of, a claim or judgment againstsuch practitioner.

Registering with the NPDB

Eligible entities are responsible formeeting Title IV reporting and/or querying requirements. Entities not currentlyregistered with the NPDB are responsiblefor determining their eligibility andregistering with the NPDB by completingan Entity Registration form. A Data BankIdentification Number (DBID), a user ID,and a password are issued to eachsuccessfully registered entity. An entitythat does not have this information is notregistered with the NPDB and will beunable to submit reports and queries.

The Entity Registration form may bedownloaded from the NPDB-HIPDB website at www.npdb-hipdb.com. The EntityRegistration form allows entities toregister simultaneously for both the NPDBand the Healthcare Integrity andProtection Data Bank (HIPDB). Theinformation requested on this formprovides the NPDB with essentialinformation concerning your entity, suchas your organization's name, address,Federal Taxpayer Identification Number(TIN), and type of ownership; yourorganization’s authority to participate inthe NPDB and the HIPDB under each ofthe statutes governing the Data Banks(Title IV for the NPDB; and Section1128E for the HIPDB); yourorganization’s primary function or service

Certifying Official

A certifying official is the individualselected and empowered by an entity tocertify the legitimacy of registration forparticipation in the NPDB.

The Entity Registration form containscertification information that must becompleted by an entity’s certifyingofficial. The entity’s certifying officialcertifies the legitimacy of the registrationinformation provided to the NPDB. Thecertification section must contain anoriginal ink signature and a signature date.Faxed, stamped, or photocopied signaturesare unacceptable. The title of thecertifying official, a telephone number,and an e-mail address must also beprovided.

Once the completed Entity Registrationform is received and processed, the NPDBassigns a unique, confidential DBID andpassword and sends an Entity RegistrationVerification document to the entity. Thisdocument contains the entity’sconfidential DBID, user ID, and password,as well as the information that wasprovided to the NPDB on the EntityRegistration form. The certifying officialshould read the document carefully and, ifthe document contains any errors, followthe instructions provided on the documentfor correcting the inaccurate information.

(e.g., entity type); and, for those entitiesauthorized by law to query both DataBanks, whether queries are to besubmitted to the NPDB only, to theHIPDB only, or to both Data Banks. Thisinformation allows the NPDB to registeryour entity’s authorization to participate inthe NPDB, and to determine your entity’sreporting and/or querying requirementsand restrictions.


September 2001 B-5

The certifying official may also designatean authorized agent to query and/or reporton behalf of the entity by completing anAuthorized Agent Designation form andsubmitting it to the NPDB. (Specificresponsibilities of authorized agents aredescribed on page B-7.)

Entity Recertification

The NPDB periodically requires entities torecertify their eligibility. At these times,the NPDB sends to each active entity thecurrent identification information on filewith the NPDB. The entity’s certifyingofficial should review the information toensure that it is correct, indicate theentity’s applicable certification statement,sign the document, and return it to theNPDB.

Data Bank IdentificationNumbers (DBIDs)

Each entity that registers with the NPDBis assigned a unique DBID and passwordas well as an initial user ID. DBIDs areused to identify registered entities andauthorized agents, and must be providedon all reports, queries, and correspondencesubmitted to the NPDB.

A DBID is a link into the NPDB computersystem and should be safeguarded toprevent inadvertent disclosure. It isrevealed only to the entity or agent towhich it is assigned. In the event that yourentity’s DBID is compromised, follow theinstructions in the Deactivate a DBIDsection.

The assignment of a DBID is not arepresentation by HHS that an entity meetsthe eligibility criteria for participation inthe NPDB, as specified in the Health CareQuality Improvement Act of 1986, as

amended, and its implementingregulations, 45 CFR Part 60. Each entityis responsible for determining whether itmeets the eligibility criteria and forcertifying its eligibility to the NPDB.

DBIDs are assigned only to entities thatcertify their eligibility to the NPDB and toauthorized agents who act on behalf ofregistered entities. DBIDs are notassigned to certifying officials,authorized submitters or otherindividuals associated with a reportingor querying entity. However, entitiesmay create multiple user accounts (userIDs) for a given DBID (see the User IDsection in this chapter). For each user IDthat an entity establishes, the entity mustalso create a separate password. For moreinformation on establishing multiple userIDs, refer to the NPDB-HIPDB web site.

Deactivate a DBID

An eligible entity may request at any timethat its current DBID be deactivated and anew DBID assigned by selecting theAssign New DBID or Deactivate DBIDboxes on the Entity Registration form andcompleting the required sections. Forinstance, if you believe that your entity’sDBID has been compromised in any way,or if your entity merges with anotherentity, you may wish to deactivate yourDBID and request a new one. You mustprovide your reason for requesting a newDBID on the completed form when it isreturned to the NPDB for processing.

Additionally, if at any time, your entityrelinquishes eligibility to participate in theNPDB, your entity’s certifying officialmust notify the NPDB in writing todeactivate your entity’s DBID. The EntityRegistration form, which can be retrievedfrom the NPDB-HIPDB web site, must be


B-6 September 2001

used to request deactivation. TheDeactivate DBID option must be checkedand the required sections of the formcompleted. The reason for deactivationmust be provided on the completed formwhen it is returned to the NPDB forprocessing.

Reactivate a DBID

If your entity’s DBID is currently inactiveand you determine that it should be active,your entity’s certifying official should complete an Entity Registration form. Select the Reactivate an Entity option onthe form to request that the DBID bereactivated. The reason for reactivationmust be provided on the completed formwhen it is returned to the NPDB forprocessing.

User IDs

Entities can create multiple user accountsso that multiple departments/people canuse the same DBID for querying andreporting. User IDs are created andmaintained through the IQRS. The userID an entity receives when it initiallyregisters with the Data Banks is theadministrator account. The administratoroversees all other user IDs and is the onlyuser that may add, update, and removeother user accounts (user IDs). If an entityhas only one person who uses the IQRS,the entity may choose to use theadministrator account as its regular useraccount. For more information onestablishing multiple users, see theNPDB-HIPDB web site.

Update Entity Information

If your entity’s name, address, statutoryauthority, organization type, certifyingofficial, or any other item of your

You may update selected profileinformation via the IQRS. After loggingin to the IQRS, you will see the EntityRegistration Confirmation screen. Selecta button at the bottom of the screen calledUpdate Entity Profile. You will be able tochange the following information:department name, mailing address, e-mailaddress, and Taxpayer IdentificationNumber (TIN). To update any other entityinformation, complete and mail an EntityRegistration form as described above.

When the NPDB receives updated entityinformation, the updated information isprocessed into the NPDB computer systemand an Entity Registration Verificationdocument, reflecting the changessubmitted, is mailed to the entity’scertifying official. The certifying officialshould read the document carefully. If thedocument contains any errors, follow theinstructions provided on the document forcorrecting the inaccurate information.

Lost Your DBID?

If you cannot remember your DBID,contact the NPDB-HIPDB CustomerService Center for assistance.

Organizations That May Reportand Query on Behalf of Entities

Authorized submitters or authorizedagents may submit queries and reports andretrieve responses from the NPDB onbehalf of registered entities.

registration information changes, yourentity’s certifying official should obtainand complete an Entity Registration formfrom the website, and select the ChangeEntity Information option.


September 2001 B-7

Authorized Submitter

An authorized submitter is the individualselected and empowered by a registeredentity to certify the legitimacy ofinformation provided in a query or reportto the NPDB. In most cases, theauthorized submitter is an employee of theorganization submitting the report orquery, such as an administrator, a riskmanager, or medical staff servicespersonnel. The NPDB does not assignDBIDs to authorized submitters.

Entities are responsible for selecting theirauthorized submitter, and the submittermay change at any time. Entities maychoose to have multiple submitters. Forexample, an entity may designate aparticular individual within theorganization to be the authorized submitterfor reporting and another individual to bethe authorized submitter for querying. The authorized submitter is often theindividual designated by the organizationto submit and retrieve report and/or queryresponses from the NPDB. However,personnel may be designated as desired. Entities are not required to register theauthorized submitter or to identify thatperson by name to the NPDB in advance,although the authorized submitter mustprovide his or her name, title and phonenumber at the time a query or report issubmitted.

Authorized Agents

Registered entities may elect to haveoutside organizations query or report tothe NPDB on their behalf. Such anorganization is referred to as an authorizedagent. In most cases, an authorized agentis an independent contractor used forcentralized credentialing, for example, acounty medical society, a State hospitalassociation, a credentials verification

organization (CVO), or organizations thatmay be used for centralized credentialingor professional oversight, such as theNational Council of State Boards ofNursing and the Federation ofChiropractic Licensing Boards.

Entities must ensure that certain guidelinesare followed when designating anauthorized agent to query or report ontheir behalf. The entity should establish awritten agreement with that authorizedagent confirming the following:

• The agent is authorized to conductbusiness in the State.

• The agent’s facilities are secure,ensuring the confidentiality of NPDBresponses.

• The agent is explicitly prohibited fromusing information obtained from theNPDB for any purpose other than thatfor which the disclosure was made. For example, two different health careentities designate the same authorizedagent to query the NPDB on theirbehalf. Both health care entities wishto request information on the samepractitioner. The authorized agentmust query the NPDB separately onbehalf of each health care entity. Theresponse to an NPDB query submittedfor one health care entity cannot beshared with another health care entity.

• The agent is aware of the sanctionsthat can be taken against the agent ifinformation is requested, used, ordisclosed in violation of NPDBprovisions.

• Authorized agents are not eligible toaccess information in the NPDB undertheir own authority. These


B-8 September 2001

organizations and other organizationsthat do not meet the statute’s specificquery eligibility criteria may onlyinteract with the NPDB as authorizedagents. Authorized agents may onlyquery the NPDB with the authorizationof an eligible entity (i.e., the eligibleentity must designate the authorizedagent to act on its behalf bycompleting the Authorized AgentDesignation form) for specificallydesignated and limited purposes.

The authorized agent must have a copy ofthe most recent Guidebook (whichincludes the regulations and the civilmoney penalty regulations of the Office ofInspector General (OIG), HHS, at 42 CFRPart 1003) and should be aware of thesanctions that can be taken if informationis requested, used, or disclosed inviolation of NPDB provisions. TheHealth Care Quality Improvement Act andthe OIG’s civil money penalty regulationauthorizes a penalty of up to $11,000 foreach violation.

Designating Authorized Agents

Before an authorized agent may act onbehalf of an entity, the entity mustdesignate the agent to interact with theNPDB on its behalf. Registered entitiesthat want to designate an authorized agentshould obtain an Authorized AgentDesignation form from the NPDB-HIPDBweb site. The entity must complete theform, providing the authorized agent’sname, DBID (if known), address, andtelephone number; and the entity’sresponse routing and fee paymentpreferences, and return it to the NPDB.

Authorized agents must be registered withthe NPDB before they can be designatedto report and/or query on behalf of eligibleentities. If the agent is not registered with

the NPDB, the agent must obtain anAuthorized Agent Registration form fromthe NPDB-HIPDB web site. Once theagent is registered, a DBID and apassword is assigned to that agent, and theentity can designate that agent to reportand query on its behalf.

NPDB responses to reports and queriessubmitted by an authorized agent will berouted to either the eligible entity or itsauthorized agent, as indicated by the entityon the Authorized Agent Designationform. If the entity wishes to retrieveresponses itself from the IntegratedQuerying and Reporting Service, the entitymust have access to the Internet (i.e., anInternet Service Provider) and anappropriate web browser. Requirementsfor using the Integrated Querying andReporting Service can be found on theNPDB-HIPDB web site.

In addition, a plug-in or stand-aloneprogram that can read files in PortableDocument Format (PDF) is required, suchas Adobe Acrobat Reader 4.0.

An authorized agent should have only oneDBID, even though more than one entitymay designate the agent to query andreport to the NPDB. If an authorizedagent has been issued more than oneDBID, the authorized agent should obtainan Authorized Agent Registration formfrom the NPDB-HIPDB web site, indicatewhich DBID it intends to use, and requestthat any other DBIDs be deactivated.

Any changes to an authorized agentdesignation, such as a change to responserouting or termination of an authorizedagent’s authorization to query and reporton an entity’s behalf, must be submittedby the entity. If changes in an authorizedagent designation are required, the entityshould obtain an Authorized Agent


September 2001 B-9

Designation form from the NPDB-HIPDBweb site, select the Update Previous AgentDesignation option on the form, completethe form as directed, and return it to theNPDB.

All forms should be mailed to the NPDB:

NPDB-HIPDBP.O. Box 10832Chantilly, VA 20153-0832

Questions and Answers

1. How do I know if my organization isan eligible entity?

See §60.3, Definitions, of the NPDBRegulations. A link to the NPDBRegulations is included in Appendix Bof this Guidebook.

2. Can the NPDB certify or verify thatmy organization is eligible to reportor query?

Each entity must determine its owneligibility to participate in the NPDB. The assignment of a DBID is not arepresentation by HHS that yourorganization meets the eligibilitycriteria for participation in the NPDB,as specified in the Health Care QualityImprovement Act of 1986, as amended,and its implementing regulations, 45CFR Part 60. The NPDB Regulations,included as Appendix B, describe thecriteria for eligibility. Otherinformational materials designed tohelp you determine yourorganization’s eligibility can beobtained from the NPDB-HIPDB website.

3. Does my organization have to notifythe NPDB when we have a newcertifying official?

Yes. The eligible entity gives thecertifying official authority to certifythe legitimacy of registrationinformation provided to the NPDB. The person authorized by the entity toact as the certifying official maychange at any time at the discretion ofthe entity. However, the NPDB makesa record of the staff title and name ofthe individual assigned as thecertifying official and should benotified when changes occur.

4. My hospital merged with anotherhospital, and both have medical staffoffices. Should we continue to queryseparately using two differentDBIDs?

If the hospitals maintain separatemedical staff credentialing, thehospitals should query separately. If by applying to one hospital apractitioner is granted privileges topractice at both institutions, onehospital should query on behalf ofboth institutions. However, bothhospitals should be aware that if oneDBID is deactivated, the NPDB willmaintain only one hospital address andonly one “electronic address.” Formore information on query responses,see Chapter D, Queries.


B-10 September 2001

5. My organization provides a resourcethat identifies practitioners whomeet minimum standards asestablished by the organization. Does producing this list make myorganization eligible to participatein the NPDB?

In order to be eligible to participate inthe NPDB, an organization must meetthe definition of a State licensingboard, a hospital, or other health careentity, including a professional society,as defined in this Guidebook. If yourorganization does not confer rights orresponsibilities of membership on apractitioner and conduct formal peerreview, it does not meet the definitionof a professional society as describedin the NPDB Regulations and is noteligible to participate in the NPDB.

6. If my organization queries theNPDB, is it also required to report? Conversely, if my organizationreports to the NPDB, is itautomatically eligible to query?

Not necessarily. See Chapters D andE, Queries and Reports, respectively,for discussions on querying andreporting eligibility criteria.

7. Are PPOs eligible to participate inthe NPDB?

PPOs would normally be considered as“providing” health care services. If aPPO conducts formal peer review tofurther quality health care, it would beeligible to participate in the NPDB.

8. Can my organization have morethan one DBID?

If you have multiple departments orpeople who handle NPDB queryingand/or reporting, you may registereach department or person separatelyand receive separate DBIDs for eachone. However, departments or peoplewith different DBID cannot assist oneanother other (i.e., one departmentcannot download a response from aquery entered by another departmentwith a different DBID). Also, specialcare must be taken to be sure that thesame query or report is not submittedtwice.

Rather than registering for multipleDBIDs, an entity may choose insteadto simply create multiple user accounts(i.e., user IDs) under the organization’sDBID. Using the IQRS, an entity canestablish as many user accounts asnecessary, and can deactivate thoseaccounts itself when needed withoutdeactivating its DBID.

NPDB Guidebook Chapter C Health Care Practitioners

September 2001 C-1

Overview

NPDB querying and reportingrequirements apply to physicians, dentists,and other licensed health carepractitioners. The NPDB acts as aclearinghouse of information relating tomedical malpractice payments, certainadverse actions taken againstpractitioners’ licenses, clinical privileges,and professional society memberships, andeligibility to participate inMedicare/Medicaid. NPDB information isintended to be used in combination withinformation from other sources in makingdeterminations on granting clinicalprivileges or in employment, affiliation, orlicensure decisions. Table C-1, NPDBRequirements Affecting Physicians,Dentists, and Other Health CarePractitioners, summarizes Title IVrequirements affecting physicians,dentists, and other health carepractitioners.

Defining Health CarePractitioners

A physician is defined as a doctor ofmedicine or osteopathy who is legallyauthorized by a State to practice medicineor surgery. A dentist is defined as adoctor of dental surgery, doctor of dental medicine, or the equivalent, who is legallyauthorized by a State to practice dentistry.

Any individual who, without authority,holds himself or herself out to be anauthorized physician or dentist isconsidered a physician or dentist.

Other health care practitioners aredefined as individuals other thanphysicians or dentists who are licensedor otherwise authorized (certified orregistered) by a State to provide healthcare services; or individuals who, withoutauthority, hold themselves out to be solicensed or authorized. For examples, seethe list on page C-3 entitled Examples ofOther Health Care Practitioners.

The licensing or authorization of otherhealth care practitioners to provide healthcare services varies from State to State. Each entity that reports to or queries theNPDB is responsible for determiningwhich categories of health carepractitioners are licensed or otherwiseauthorized by their State to provide healthcare services.

Currently, there is no NPDB requirementto query or report on other health carepractitioners who are not licensed orotherwise authorized by a State to providehealth care services, unless the individualholds himself or herself to be soauthorized.

Chapter C Health Care Practitioners NPDB Guidebook

C-2 September 2001

Table C-1. NPDB Requirements AffectingPhysicians, Dentists, and Other Health Care Practitioners

Entity Reporting to the NPDB Querying the NPDBState Medical and Dental Boards

Must report certain adverse licensure actionsrelated to professional competence orprofessional conduct and revisions to suchactions for physicians and dentists.

May query at any time.

Other State LicensingBoards

Do not report. May query at any time.

Hospitals and OtherHealth Care Entities

Must report (1) professional review actionsrelated to professional competence orprofessional conduct that adversely affectclinical privileges of a physician or dentistfor more than 30 days; (2) a physician’s ordentist’s voluntary surrender or restriction ofclinical privileges while under investigationfor professional competence or professionalconduct or in return for not conducting aninvestigation; and (3) revisions to suchactions. May report on other health carepractitioners.

Hospitals must query when screeningapplicants for a medical staff appointmentor granting/adding to/expanding clinicalprivileges, and every 2 years on health carepractitioners on the medical staff or whohave clinical privileges. Hospitals mayquery at other times, as they deemnecessary. Other health care entities mayquery when screening applicants for amedical staff appointment or grantingaffiliation, clinical privileges, and insupport of professional review activity.

Professional Societies Must report professional review actions,based on reasons relating to professionalcompetence or conduct, that adversely affectprofessional society memberships andrevisions to such actions for physicians anddentists. May report on other health carepractitioners.

May query when screening an applicant formembership or affiliation, and in support ofprofessional review activity.

Medical MalpracticePayers

Must report payments made for the benefit ofphysicians, dentists, and other health carepractitioners in settlement of or insatisfaction in whole or in part of a claim orjudgment against such practitioner.

May not query the NPDB.

Health CarePractitioners

Do not report on their own behalf. May self-query the NPDB at any time.

Office of InspectorGeneral (OIG), HHS

Reports exclusions from theMedicare/Medicaid programs againstphysicians, dentists, and other health carepractitioners.

May not query the NPDB.


September 2001 C-3

Examples of Other Health Care Practitioners

The 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

CounselorCounselor, Mental HealthProfessional CounselorProfessional Counselor, AlcoholProfessional Counselor, Family/MarriageProfessional Counselor, Substance Abuse

Dental Service ProviderDental AssistantDental HygienistDenturist

Dietician/NutritionistDieticianNutritionist

Emergency Medical Technician (EMT)EMT, BasicEMT, Cardiac/Critical CareEMT, Intermediate EMT, Paramedic

Nurse/Advanced Practice NurseRegistered (Professional) NurseNurse AnesthetistNurse MidwifeNurse PractitionerLicensed Practical or Vocational Nurse

Nurses Aide/Home Health AideNurses AideHome Health Aide (Homemaker)

Eye and Vision Service ProviderOcularistOpticianOptometrist

Pharmacy Service ProviderPharmacistPharmacist, NuclearPharmacy Assistant

Physician AssistantPhysician Assistant, AllopathicPhysician Assistant, Osteopathic

Podiatric Service ProviderPodiatristPodiatric Assistant

Psychologist, Clinical

Rehabilitative, Respiratory, and RestorativeService ProviderArt/Recreation TherapistMassage TherapistOccupational TherapistOccupational Therapy AssistantPhysical TherapistPhysical Therapy AssistantRehabilitation TherapistRespiratory TherapistRespiratory Therapy Technician

Social Worker

Speech, Language, and Hearing ServiceProviderAudiologistSpeech/Language Pathologist

TechnologistMedical TechnologistCytotechnologist Nuclear Medicine TechnologistRadiation Therapy TechnologistRadiologic Technologist

Other Health Care PractitionerAcupuncturistAthletic TrainerHomeopathMedical AssistantMidwife, Lay (Non-nurse)NaturopathOrthotics/Prosthetics FitterPerfusionistPsychiatric Technician

Chapter C Health Care Practitioners NPDB Guidebook

C-4 September 2001

Practitioner Self-Query

A self-query is a practitioner’s request forinformation about himself or herself.Practitioners may self-query the NPDBand the HIPDB at any timeby visiting the NPDB-HIPDB web site atwww.npdb-hipdb.com. All self-queryapplications must be submitted throughthe NPDB-HIPDB web site. Previouspaper versions of the Self-Query formwill be rejected. Practitioners who do nothave access to the Internet may call theNPDB-HIPDB Customer Service Centerfor assistance. For detailed instructionson self-querying, see the Fact Sheet onSelf-Querying, available atwww.npdb-hipdb.com.

A practitioner who submits a self-query tothe Data Banks will receive via U.S. maileither a response notifying them that noinformation exists in the Data Banks, or acopy of all report information submittedby eligible reporting entities. Allpractitioner self-queries will be processedagainst both the NPDB and the HIPDB. As part of their self-query response,subjects of an Adverse Action Report orMedical Malpractice Payment Reportsubmitted to the NPDB will receive a listof all queriers to whom the reportedinformation has been disclosed with theresponse.

All Self-Query forms must be signed andnotarized, and all fields in thenotarization section must be completed. The NPDB-HIPDB will reject any self-query received without signature andnotarization or with an incompletenotarization.

A fee will be charged for each self-querysubmitted. For more information on self-query fees, refer to Chapter G, Fees.

Self-Querying on the Internet

The NPDB-HIPDB employs the latesttechnology, along with variousimplementation measures, to provide asecure environment for querying,reporting, data storage, and retrieval. Security features include firewallprotection from unauthorized access andencryption of transmitted data to preventunauthorized use.

Practitioners complete and transmit theirself-queries to the NPDB-HIPDB on-line;however, a self-query is not officiallysubmitted until a signed and notarizedpaper copy is received by the Data Banks. A formatted copy of the self-query isgenerated immediately after electronictransmission. To complete the self-queryprocess, practitioners must print theformatted copy, sign and date it in thepresence of a notary public, and mail thenotarized self-query to the addressspecified.

Once a properly signed and notarized self-query is received by the Data Banks, ittypically is processed within one businessday and returned to the practitioner viaU.S. mail. The practitioner may view theprocessing status of his or her self-queryrequest via the NPDB-HIPDB web site atwww.npdb-hipdb.com.

Subject Information in the NPDB

The NPDB is committed to maintainingaccurate information and ensuring thatsubjects are informed when medicalmalpractice payments or adverse actionsare reported about them. When the NPDBreceives a report, the information isprocessed by the NPDB computer systemexactly as submitted by the reporting


September 2001 C-5

entity. Reporting entities are responsiblefor the accuracy of the information theyreport.

When the NPDB processes a report, aReport Verification Document is madeavailable to the reporting entity forretrieval from the Integrated Querying andReporting Service (IQRS), and aNotification of a Report in the DataBank(s) is sent to the subject. The subjectshould review the report for accuracy,including current address, telephonenumber, and place of employment.

Subjects may not submit changes toreports. If any information in a report isinaccurate, the subject must contact thereporting entity to request that it file acorrection to the report.

If the reporting entity refuses to correct thereport, the subject of a report may:

• Add a statement to the report.• Initiate a dispute of the report.• Add a statement and initiate a dispute.

For more information about the NPDBdispute process, see Chapter F, Disputes.


1. How do I correct my address if it iswrong in a report?

You must contact the reporting entity(identified in both the Notification ofa Report in the NPDB and Self-QueryResponse document) and request thatthe entity correct the address on thereport. If the entity does not honoryour request to correct the inaccurateaddress, you can dispute the report.

2. I am a practitioner who personallyrefunded a fee to a patient. Is thisrefund reportable to the NPDB?

No. A refund from a practitioner’spersonal funds is not reportable. However, if the refund is paid by aninsurer or any entity other than anindividual practitioner (including aprofessional services corporationcomprised of a sole practitioner), therefund is reportable. For moreinformation concerning NPDBreporting requirements, seeChapter E, Reports.

3. Can a hospital, State licensingboard, or medical malpracticeinsurer require that I give themthe results of a self-query?

The response you receive to a self-query is yours to do with as you wish.Various licensing, credentialing, andinsuring entities may require a copyof your query before you mayparticipate in their programs. Anyarrangement between you and one ofthese entities is voluntary. HHS doesnot regulate such arrangements. However, a copy of a subject self-query does not satisfy a hospital'slegal requirement to query.

warnerc


NPDB Guidebook Chapter D Queries

September 2001 D-1

Overview

The NPDB is a resource to assist Statelicensing boards, hospitals, and otherhealth care entities in investigating thequalifications of the health carepractitioners they seek to license or hire,or to whom they wish to grant membershipor clinical privileges. The NPDBdisseminates certain information toeligible entities on medical malpracticepayments, Medicare/Medicaid exclusions,adverse licensure actions, adverse clinicalprivileges actions, and adverseprofessional society membership actionsfor physicians, dentists, and other healthcare practitioners who are licensed orotherwise authorized by a State to providehealth care services.

• Hospitals must query when apractitioner applies for privileges ormedical staff membership and every 2years on practitioners on the medicalstaff or holding privileges.

• Other health care entities, includingprofessional societies, may querywhen entering an employment oraffiliation relationship with apractitioner or in conjunction withprofessional review activities.

• State licensing boards may query atany time.

• Health care practitioners may self-query at any time.

• Plaintiff’s attorneys may query undercertain limited circumstances. SeeNPDB Regulations §60.11(a)(5) orTable D-1, Title IV QueryingRequirements, on page D-4.

• Medical malpractice payers may notquery at any time.

Hospitals

Hospitals are the only health care entitieswith mandatory requirements for queryingthe NPDB. Each hospital must requestinformation from the NPDB as follows:

• When a physician, dentist, or otherhealth care practitioner applies for medical staff appointment (courtesy orotherwise) or for clinical privileges atthe hospital.

• Every 2 years (biennially) on allphysicians, dentists, and other healthcare practitioners who are on itsmedical staff (courtesy or otherwise)or who hold clinical privileges at thehospital.

Chapter D Queries NPDB Guidebook

D-2 September 2001

The biennial query may be done inaccordance with regular medical staffreappointment and clinical privilegeredelineation. Hospitals are not requiredto query more than once every 2 yearson a practitioner who is continuously onstaff. Hospitals with annualreappointment are not required toquery annually. Hospitals may query theNPDB at any time they wish with respectto professional review activity.

Hospitals are also required to query theNPDB when a practitioner wishes toadd to or expand existing privileges andwhen a practitioner submits anapplication for temporary privileges. For example, if a practitioner applies fortemporary clinical privileges four times inone year, the hospital must query theNPDB on each of those four occasions. A hospital is required to query the NPDB

each time a locum tenens practitionermakes an application for temporaryprivileges, not each time the practitionercomes to the facility. To reduce the queryburden, hospitals that frequently useparticular locum tenens practitioners maychoose to appoint such practitioners totheir consultant staff or other appropriatestaff category in accordance with theirbylaws and then query on them when theyquery on their full staff biennially.

Hospitals are required to query oncourtesy staff considered part of themedical staff, even if afforded only non-clinical professional courtesies such as useof the medical library and continuingeducation facilities. If a hospital extendsnon-clinical practice courtesies withoutfirst appointing practitioners to a medicalstaff category, querying is not required onthose practitioners.

Applicationto medicalstaff or for

clinicalprivileges

Every 2 years forthose on medicalstaff or withclinical privileges

Hospitals

MANDATORY QUERYING


September 2001

Residents and Interns

Health care entities are not required toquery the NPDB on medical and dentalresidents, interns, or staff fellows(housestaff), even though they are oftenlicensed, because they are trainees instructured programs of supervisedgraduate medical education, rather thanmembers of the medical staff.

There is no difference between thehousestaff of the clinical facility belongingto the formal education program and thehousestaff rotating to a clinical facilityproviding a clinical training site for theformal educational program. Hospitalsare not required to query the NPDB onhousestaff providing services as part oftheir formal clinical education. However,hospitals are required to query on

residents or interns when such individualsare appointed to the medical staff orgranted clinical privileges to practiceoutside the parameters of the formalmedical education program (for example,moonlighting in the intensive care unit orEmergency Department of that hospital).

Professional Societies

Professional societies that meet Title IVeligibility requirements may requestinformation from the NPDB whenscreening applicants for membership oraffiliation and in support of professionalreview activities.

State Licensing Boards

State licensing boards may requestinformation from the NPDB at any time.

D-3

OPTIONAL QUERYING

STATE LICENSING BOARDS

PROFESSIONAL SOCIETIES(with formal peer review)

OTHER HEALTH CAREENTITIES(with formal peer review)

PRACTIONERS(on own files)

HOSPITALS(as needed, in addition tomandatory queries)

PLAINTIFF’S ATTORNEY(with HHS authorization)


D-4 September 2001

Table D-1. Title IV Querying Requirements

ENTITY REQUIREMENT

Hospitals

Screening applicants for medical staff appointment or granting of clinicalprivileges; every 2 years for physicians, dentists or other health carepractitioners on the medical staff or granted clinical privileges.

Must query

At other times as they deem necessary. May query

State Licensing Boards (including Medical and Dental)

When they deem necessary.May query

Other Health Care Entities

Screening applicants for medical staff appointment, membership oraffiliation, or granting of clinical privileges; supporting professionalreview activities.

May query


Screening applicants for membership or affiliation; supportingprofessional review activities.

May query

Plaintiff’s Attorneys

Plaintiff’s attorney or plaintiff representing himself or herself who hasfiled 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.

May query

Physicians, Dentists, and Other Health Care Practitioners

Regarding their own files. May query

Medical Malpractice Payers May not query


September 2001 D-5

Types of Queries

Title IV of Public Law 99-660, the HealthCare Quality Improvement Act of 1986, asamended, prescribes the following types ofqueries:

• Privileging or Employment: for useby a hospital or other health careentity, including a professional society,when screening applicants for medicalstaff appointment, granting of clinicalprivileges, membership, orprofessional affiliation.

• Professional Review Activity: for useby a hospital or other health careentity, including a professional society,when conducting professional reviewactivity.

• Mandatory 2-Year: for use by ahospital when submitting biennialqueries on physicians, dentists, orother health care practitioners on theirmedical staff or to whom clinicalprivileges have been granted.

• State Licensing Board: for use byState boards of medical examiners,State boards of dentistry, or other Statelicensing bodies.

• Self-Query: for use by a physician,dentist, or other health carepractitioner.

• Other: for use by a plaintiff’s attorneyor the Secretary of HHS, as authorizedby Title IV.

Attorney Access

A plaintiff’s attorney or a plaintiffrepresenting himself or herself ispermitted to obtain information from theNPDB under the following limitedconditions:

• A medical malpractice action or claimmust have been filed by the plaintiffagainst a hospital in a State or Federalcourt or other adjudicative body, and

• The subject on whom the informationis requested must be named in theaction or claim.

Obtaining NPDB information on thespecified subject is permitted only afterevidence is submitted to HHSdemonstrating that the hospital failed tosubmit a mandatory query to the NPDBregarding the subject named by theplaintiff in the action. This evidence is notavailable to the plaintiff through theNPDB. Evidence that the hospital failedto request information from the NPDBmust be obtained by the plaintiff from thehospital through discovery in the litigationprocess.

A plaintiff’s attorney must submit all ofthe following to the NPDB:

• A letter requesting authorization toobtain information.

• Supporting evidence that the hospitaldid not make a mandatory query to theNPDB regarding the subject named bythe plaintiff in the action or claim.

• Identifying information about thesubject on whom the attorney wishesto query.


D-6 September 2001

Examples of evidence may include adeposition, a response to aninterrogatory, and admission or otherevidence of the failure of a hospital torequest information. The plaintiff’sattorney must submit a separate request forinformation disclosure for each subjectnamed in the action or claim.

The approval of a plaintiff’s attorneyquery is limited to a one-time-onlydisclosure; the approval of such a requestdoes not allow a plaintiff’s attorney toobtain NPDB information on a continuingbasis. Subsequent disclosures of NPDBinformation require the plaintiff’s attorneyto initiate a new request. A fee is assessedwhen the NPDB discloses suchinformation.

An approved query request entitles theplaintiff’s attorney to receive only thatinformation available in the NPDB at thetime the hospital was required to query butdid not. It also includes information onany reports that were subsequently voided.

There are limitations on the use ofinformation obtained by the plaintiff in ajudicial proceeding. Specifically, theinformation obtained from the NPDB onthe subject can only be used with respectto a legal action or claim against thehospital, not against the subject. Anyfurther disclosure or use violates theconfidentiality provisions of Title IV, andsubjects the plaintiff’s attorney and/orplaintiff to a civil money penalty of up to$11,000.

Defense attorneys are not permitted accessto the NPDB under Title IV because thedefendant subject is permitted to self-query the NPDB.

Authorized Agents

Eligible entities may elect to have anauthorized agent query the NPDB on theirbehalf. Authorized agents must query theNPDB separately on behalf of eacheligible entity. The response to an NPDBquery submitted for one entity cannot bedisclosed to another entity. For moreinformation on authorized agents, see pageB-7.

Submitting a Query to the NPDB

Eligible entities prepare and submitqueries using the Integrated Querying andReporting Service (IQRS) atwww.npdb-hipdb.com. A DBID, a userID, and a unique password are used byeligible entities and their authorized agentsto report and retrieve query responses viathe World Wide Web. Internet accesswith a web browser is required for usingthe IQRS.

The IQRS does not accept an incompletequery (one that is missing requiredinformation or is improperly completed). Such queries are rejected. Entities areencouraged to gather as much informationas possible as part of the applicationprocess, to make the completion of thequery easier.

Entities may submit queries usingelectronic transaction file submission, alsoknown as the ICD Transfer Program (ITP).The ITP is a program that transmitsInterface Control Document (ICD) querysubmission files and receives queryresponse files from the NPDB-HIPDB. All data are transmitted over an InternetSecure Socket Layer (SSL) connection.Submitting queries using the ITP is analternative for those entities that generate


September 2001 D-7

queries from custom (third-party) or otherspecial purpose software. Entities thatchoose to query via the ITP must providedata in the format specified in the NPDB-HIPDB Interface Control Document (ICD)for Query Transactions. Informationabout querying via the ITP is available atwww.npdb-hipdb.com.

Entities that are authorized and registeredto query both the NPDB and theHealthcare Integrity and Protection DataBank (HIPDB) may elect to query bothData Banks simultaneously with a singlequery submission. Entities that wish toquery both Data Banks should indicate thispreference on their Entity Registrationform.

Equipment Needed to QueryElectronically

Requirements for using the IQRS can befound on the NPDB-HIPDB web site.Entities must use the appropriate versionof either Internet Explorer or NetscapeCommunicator to query the NPDB. Entities can determine their browser’sversion number by starting their browser,selecting Help from the main menu, thenselecting About Communicator or AboutInternet Explorer, as appropriate.

You also need a program that can readfiles in Portable Document Format (PDF)(i.e., files with a .pdf extension), such asAdobe Acrobat Reader 4.0 (or higher). Download the latest version of the freeAcrobat Reader at http://www.adobe.com.These guidelines explain the minimumrequirements necessary to access theIQRS. To improve reliability, the NPDBrecommends that you use the most recentversion of each browser available for youroperating system.

Querying Through an AuthorizedAgent

The NPDB’s response to a querysubmitted by an authorized agent onbehalf of an entity is based upon twoeligibility standards: (1) the entity must beentitled to receive the information, and (2)the agent must be authorized to receivethat information on behalf of that entity. Both the entity and the agent must beproperly registered with the NPDB prior tothe authorized agent’s query submission.

Authorized agents cannot use a queryresponse on behalf of more than oneentity. NPDB regulations specify thatinformation received from the NPDB mustbe used solely for the purpose for which itwas provided. If two different entitiesdesignate the same authorized agent toquery the NPDB on their behalf, and bothentities wish to request information on thesame subject, the authorized agent mustquery the NPDB separately on behalf ofeach entity. The response to a querysubmitted for one entity cannot bedisclosed to another entity.

Query Processing

When the NPDB receives a properlycompleted query, the information isentered into the NPDB computer system. The computer system performs avalidation process that matches subject(i.e., practitioner) identifying informationsubmitted in the query with informationpreviously reported to the NPDB. Information reported about a specificsubject is released to an eligible querieronly if the identifying informationprovided in the query matches theinformation in a report.


D-8 September 2001

Each query processed by the NPDBcomputer system is assigned a unique DataBank Control Number (DCN). The DCNis used by the NPDB to locate the querywithin the computer system and isprominently displayed on an electronicresponse. If a question arises concerning aparticular query, the entity must referencethe DCN in any correspondence to theNPDB.

Subject Information

When submitting a query, the entity isrequired to provide certain subjectinformation. The NPDB computersystem does not allow entities to submitqueries that do not include informationin all mandatory fields. An entity’s lackof mandatory information does notrelieve it of querying requirements forthe purposes of Title IV.

A subject’s Social Security Number (SSN)should be provided if known, but only if itwas obtained in accordance with Section 7 of the Privacy Act of 1974, which statesthat disclosure of an individual’s SSN isvoluntary unless otherwise provided bylaw. Disclosure of an individual’s SSNfor the purposes of this program isvoluntary. The NPDB uses SSNs only toverify the identity of individuals, andSSNs will be disclosed only as authorizedby the Health Care Quality ImprovementAct of 1986, as amended. The inclusion ofthis information helps to ensure theaccurate identification of the subject of thereport.

Subject Database

You may establish a subject database tocomplete your querying and reportingobligations more efficiently. The subject

Character Limits

Each field in a query (such as SubjectName, Work Address, and LicenseNumber) is limited to a certain number ofcharacters, including spaces andpunctuation. The IQRS software does notallow the entity to use more than theallotted number of characters. The NPDBdoes not change any informationsubmitted in a query.

Query Responses

In general, query responses are availableelectronically within an average of 4 to 6hours of receipt by the NPDB. Undercertain circumstances, additionalprocessing may be required. Entities thatsubmit queries using the IQRS shouldretrieve their query responses from theIQRS. Queries marked Completed havebeen processed and are available forretrieval. Queries marked Pending havenot yet been processed. Queries markedPartially Completed require additionalprocessing time. Queries marked Rejectedhave one or more errors; they have beenprocessed and a document describing theerror(s) is available for retrieval.

database is a feature of the IQRS thatoffers an easy method for maintaininginformation about the subjects on whomyou routinely query or report, (e.g., SocialSecurity Numbers, dates of birth, licensenumbers).

You may import a pre-existing QPRAC subject database into the IQRS, eliminating the need to retype subject data. For information, see the Fact Sheet on Creating and Maintaining a Subject Database, available at www.npdb-hipdb.com.


September 2001 D-9

Entities that submit queries via the ITPmust retrieve their query responses usingthe file transfer program specified in theITP instructions. ITP responses areformatted in the Interface ControlDocument (ICD) for Query Transactionsaccording to the specifications of theappropriate ICD. Subjects who self-querywill receive paper responses sent by FirstClass U.S. Mail.

When there is no information in the NPDBabout a subject, the entity receives inresponse to a query only the identifyingsubject information provided in the queryand a notification that no informationabout the subject is contained in theNPDB. Query information submitted bythe entity is not retained on subjects forwhom there is no record in the NPDB.

Entities that submit 10 or fewer subjectnames receive separate response files foreach query. When the number of subjectnames submitted is 11 or more, batchdownloading consolidates query files sothat a single file can contain multipleresponses and hold up to 1 megabyte ofdata. Along with the query response files,entities also receive a list of all the subjectnames queried and the file number whereeach response is located. This list helps toquickly identify the location of a specificsubject query response.

Query Response Availability

Query responses are available via theIQRS or ITP 4 to 6 hours after the query isprocessed. Entities must retrieveresponses within 30 days of processing, orthey will be forced to re-submit theirqueries. Entities that wish to save queryresponses should download themimmediately and save them to their harddrives.

Ideally, information from the NPDB willbe considered during the credentialingprocess. However, the NPDB law doesnot require querying entities to receivequery responses from the NPDB beforeproceeding with the granting of clinicalprivileges, hiring, appointment to themedical staff, issuance of licenses, orapproval of memberships. Because theNPDB is one of several resources for thecredentials review process, entities mayact on applications according to theirestablished criteria and informationobtained from other sources.

Missing Query Responses

If you do not receive a query responsewithin 2 to 3 business days of submission,please contact the NPDB-HIPDBCustomer Service Center to request aquery status. Please do not resubmit aquery on the subject in question, as thiswill result in duplicate transactions andduplicate query fees.

Correcting Query Information

If the information you submitted in aquery does not accurately identify thesubject on whom you intended to query,your query will not match NPDB reportssubmitted with correct identifyinginformation. To query the NPDB with the proper identifying information onthe subject, submit a new, correctlycompleted query to the NPDB.

Failure to Query

Any hospital that does not query on apractitioner (1) at the time the practitionerapplies for a position on its medical staffor for clinical privileges (initial orexpanded) at the hospital, and (2) every 2


D-10 September 2001

years concerning any practitioner who ison its medical staff or has clinicalprivileges at the hospital, is presumed tohave knowledge of any informationreported to the NPDB concerning thepractitioner. A hospital’s failure to queryon a practitioner may give a plaintiff’sattorney or plaintiff representing himselfor herself access to NPDB information onthat practitioner for use in litigationagainst the hospital.


1. Should I query on the members ofmy hospital’s Allied HealthPractitioner Staff?

If the Allied Health Practitioners aregranted clinical privileges or medicalstaff membership, yes. For example,if your hospital grants clinicalprivileges to nurse practitioners, youmust query on them. Each hospitalmust determine, based on State lawand on its own by-laws, whichpractitioners are licensed by its Stateand credentialed as part of the medicalstaff or granted clinical privileges. The intent of the statute is to requirequerying on medical staff members orprivilege holders who are individuallycredentialed by the hospital.

2. Are hospitals required to query theNPDB on medical and dental internsand residents?

No. Since interns and residents aretrainees in structured programs ofsupervised graduate medical educationand are not (generally) members of themedical staff in a formal sense, there isno requirement to query on them. Hospitals may choose to query onresidents and interns if they desire.

However, if the resident or intern isbeing considered for clinical privilegesoutside of his or her structuredprogram, the hospital must query. Note that medical malpracticepayments made on behalf of andadverse licensure actions taken againstresidents and interns must be reported.

3. Is my hospital required to query onall of our nurses?

If an individual belongs to the medicalstaff or has clinical privileges at yourhospital and if that individual islicensed or otherwise authorized(either registered or certified) by aState to provide health care services,the hospital is required to query onthat individual. Examples of nursingstaff who frequently are grantedindividual privileges and meet thisdefinition may include certified nurseanesthetists and nurse practitioners.

4. Are hospitals required to documentand maintain records of theirrequests for information?

Hospitals are not specifically requiredby the NPDB’s implementingregulations to do so.

5. How long should my organizationkeep query responses on file?

While the NPDB regulations requirehospitals to query the NPDB, they donot specify that query responses bekept on file by requesting entities. Please note, however, that your queryresponse may be used as proof thatyour organization queried the NPDBon the practitioners.


September 2001 D-11

6. If I cannot find or did not receive aresponse to a query, may I request acopy from the NPDB?

No. The NPDB currently does nothave the capability to produceduplicate responses. If you did notreceive a response to a query and werenot charged for the query, the queryhas not been processed by the NPDBand should be resubmitted. Onceprocessed by the NPDB, queryresponses will be maintained in theIQRS for 30 days. After 30 days, theresponses will be deleted from theIQRS and the entity will have toresubmit the query to receive aresponse. If you did not receive aresponse to a query but were chargedfor it, see the Missing QueryResponses section in this chapter ofthe Guidebook.

7. May self-queries be used to satisfyrequirements for peer review andemployment?

Subjects may share the informationcontained in their own self-queryresponses with whomever they choose; however, such sharedinformation does not satisfy ahospital’s legal requirement to querythe NPDB whenever a physician,dentist, or other health carepractitioner applies for clinicalprivileges or a medical staffappointment.

8. My hospital is in Chapter 7bankruptcy. Can it continue toquery the NPDB?

If your hospital still has ongoingbusiness and is functioning as ahospital while concluding its

liquidation, even under a debtor-in-possession, it must continue to querythe NPDB. If it is in liquidationsolely for the purpose of sale of assetsand there is no ongoing business as ahospital, there is no reason to queryand your DBID will be deactivated. Your organization is responsible fornotifying the NPDB of your status. Ifthe hospital comes under newownership, the new owner mustregister with the NPDB and isresponsible for fulfilling its reportingand querying obligations.


Yes. Your hospital will be chargedfor any queries submitted after theNPDB receives notice of the filing ofthe Petition for Bankruptcy. Organizations that have an obligationto query (i.e., hospitals) must stillmeet their querying obligations.


Yes. Your organization will becharged for any queries submittedafter the NPDB receives notice of thefiling of the Petition for Bankruptcy. Organizations that have an obligationto query (i.e., hospitals) must stillmeet their querying obligations.


D-12 September 2001

11. My hospital has been liquidated bythe State. Can it continue to querythe NPDB?

If your hospital still has ongoingbusiness and is functioning as ahospital while concluding itsliquidation, it must continue to querythe NPDB. Once the liquidationprocess is concluded or yourorganization has no ongoing businessas a hospital, there is no reason toquery and your DBID will bedeactivated. Your organization isresponsible for notifying the NPDB ofits status. If the hospital comes undernew ownership, the new owner mustregister with the NPDB and isresponsible for fulfilling its reportingand querying obligations.

12. Can I designate more than oneauthorized agent to query for myhospital?

Yes. The NPDB computer system cannow accommodate multipleauthorized agents for each queryingentity.

13. If I decide to designate anauthorized agent or change fromone agent to another, how long willit take before the authorized agentcan query for my hospital?

If the authorized agent is alreadyregistered with the NPDB and hasbeen assigned a DBID, the NPDB willsend notification documents to yourorganization and the authorized agent.You should check the documents toensure that all information is correct. Your authorized agent will be able toquery on your organization’s behalfimmediately upon receipt of thenotification documents.

NPDB Guidebook Chapter E Reports

September 2001 E-1

Overview

The NPDB acts primarily as a flaggingsystem; its principal purpose is to facilitatea comprehensive review of professionalcredentials. Information on medicalmalpractice payments, certain adverselicensure actions, adverse clinicalprivilege actions, adverse professionalsociety membership actions and Medicare/Medicaid exclusions is collected from anddisseminated to eligible entities. NPDBinformation should be considered withother relevant information in evaluating apractitioner’s credentials.

Eligible entities are responsible formeeting specific querying and/or reportingrequirements and must register with theNPDB in order to query or report to theNPDB.

The information required to be reported tothe NPDB is applicable to physicians,dentists, and, in some cases, other healthcare practitioners who are licensed orotherwise authorized by a State to providehealth care services.

Time Frame for Reporting to the NPDB

Mandated NPDB reporters must reportmedical malpractice payments andadverse actions taken on or after September 1, 1990. This is the date that the NPDB commenced operation. With the exception of reports on Medicare/Medicaid Exclusions, the NPDBcannot accept any report with a date of payment or a date of action prior to

Civil Liability Protection

The immunity provisions in theHealthcare Quality and Improvement Actof 1986 protect individuals, entities, andtheir authorized agents from being heldliable in civil actions for reports made tothe NPDB unless they have actualknowledge of falsity of the information. The statute provides the same immunity toHHS in maintaining the NPDB. For moreinformation on civil liability protection,refer to page A-2.

Official Language

The NPDB’s official language is English. All reports must be submitted in English. Files submitted in any other language orcontaining non-alphanumeric characters(e.g., tildes, accents, umlauts) are notaccepted.

Computation of Time Periods

In computing any period of timeprescribed or allowed by the NPDB statuteor regulations, the date of the act or eventin question shall not be included. The dayfollowing the date of the act or event isDay 1 for purposes of computation. Thelast day of the period so computed shall beincluded. Saturdays, Sundays, and Federalholidays are to be included in thecalculation of time periods. However, ifthe end date for submitting a report fallson a Saturday, Sunday, or Federal holiday,the due date is the next Federal work day. This method of computation of timeperiods is consistent with Federal Rule ofCivil Procedure 6.September 1, 1990.

Chapter E Reports NPDB Guidebook

E-2 September 2001

Table E-1. NPDB Reporting RequirementsEntity Physicians and

DentistsOther Health Care

PractitionersMedical Malpractice PayersPayment resulting from written claim or judgment. Reports must be submitted to the NPDB and appropriateState licensing board within 30 days of a payment.

Must report Must report

State Licensing BoardsLicensure disciplinary action based on reasons related toprofessional competence or conduct. Reports must besubmitted to the NPDB within 30 days of the action.

Must report Currently no reportingrequirements

Hospitals and Other Health Care EntitiesProfessional 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.

Must report May report

Professional SocietiesProfessional 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.

Must report May report

HHS Office of Inspector GeneralExclusions from Medicaid/Medicare and other Federalprograms. Exclusions are reported monthly.

Must report Must report

Submitting Reports to the NPDB

Subject Information

When submitting a report to the NPDB,the reporting entity is required to providecertain subject information. The NPDBcomputer system does not allow entitiesto submit reports that do not includeinformation in all mandatory fields. Anentity’s lack of mandatory informationdoes not relieve the entity of reportingrequirements for the purposes of TitleIV. All required fields in a subject’srecord must be completed before a reportcan be generated. Entities should provideas much information as possible, even inthe fields that are not required.

When Subject Information Is Unknown

As indicated previously, the NPDBcomputer system does not allow reports tobe submitted without all mandatorysubject information. The NPDB suggeststhat each reporting entity review themandatory fields information and make aneffort to collect this information for eachpractitioner before there is a cause to filea report (i.e., during the applicationprocess). An incomplete report (one thatis missing required information or isimproperly completed) is not accepted. Ifyou are having trouble filing yourelectronic report, please contact theNPDB-HIPDB Customer Service Center.


September 2001 E-3

Reporting Subject Social SecurityNumbers

Under Title IV, a subject’s Social SecurityNumber (SSN) should be provided ifknown when reporting medicalmalpractice payments, adverse clinicalprivileges and professional society actions,but only if obtained in accordance withSection 7 of the Privacy Act of 1974,which provides that disclosure of anindividual’s SSN is voluntary unlessotherwise provided by law. Disclosure ofan individual’s SSN for the purposes ofthe NPDB is voluntary.

The NPDB will use SSNs only to verifythe identity of individuals, and SSNs aredisclosed only as authorized by the HealthCare Quality Improvement Act of 1986, asamended. The inclusion of this informa-tion, wherever possible, is encouragedbecause it helps to ensure the accurateidentification of the subject of the report.

An SSN is required for adverselicensure actions, as these reports arealso mandated for inclusion in theHIPDB under Section 1128E of theSocial Security Act. Section 1128Erequires that SSNs be provided as partof the reporting process.

Incorrectly Identified Subject

If an entity reports information for thewrong subject, the reporting entity mustsubmit a Void of the incorrect report andsubmit a new Initial report for the correctsubject. See page E-5 for moreinformation on Void reports.

Submitting Reports Via the IQRS

Eligible entities may prepare and submitreports using the IQRS at

www.npdb-hipdb.com. Once logged ontothe site, the entity may enter and submitreport information to the NPDB.

Medical malpractice payments aresubmitted using the Medical MalpracticePayment Report (MMPR) format. Clinicalprivileges, professional society andlicensure actions, as well asMedicare/Medicaid exclusions aresubmitted using the Adverse ActionReport (AAR) format.

Both the MMPR and the AAR formats inthe IQRS capture all the necessaryinformation for report submission. Sufficient space is provided in the fields toallow entry of multiple practitioner licensenumbers, Federal Drug EnforcementAdministration (DEA) numbers,professional schools, and hospitalaffiliations. The IQRS allows for a 2,000-character description of the acts oromissions and, in the case of MMPRs, adescription of the judgment or settlementstatements.

Subject information does not need to bereentered into a report format if an entitymaintains a subject database on the IQRS.The IQRS retrieves all pertinentinformation from the entity’s subjectdatabase into the appropriate reportscreens; however, if a record in the subjectdatabase is incomplete (i.e., information ismissing in required fields), the IQRS doesnot allow a report to be generated for thatsubject until the missing information isadded. For more information on subjectdatabases, see the Fact Sheet on Creatingand Maintaining a Subject Database,available at www.npdb-hipdb.com.

Each data field on the report input screensis limited to a certain number ofcharacters, including spaces and


E-4 September 2001

punctuation. For example, the narrativedescription fields allow 2,000 characters,including spaces and punctuation. Anycharacters over 2,000 are truncated. Drafting your narrative in accordance withthe character limits will avoid the need tocorrect a truncated narrative once thereport is accepted by the NPDB.

Upon submitting the report to the NPDB,the entity will receive a Temporary Recordof Submission document with aconfirmation number. The confirmationnumber can be used to verify that theentity submitted the report. Within 4 to 6hours of receipt, the NPDB will makeavailable to the reporting entity an officialReport Verification Document. Thereporting entity must verify the report dataon the Report Verification Document andcorrect any erroneous information on-line.The subject of the report will receive acopy of the submitted report by mail fromthe NPDB. Each NPDB reporter mustmail a copy of the paper report to theappropriate State licensing board.

Draft Capability

The IQRS includes a Draft report featurefor entering report data into input screens,then saving the document in draft status. The draft version of a report can bemodified later. Draft reports may be savedon the IQRS server for a maximum of 30days before they are automatically deleted.Reports saved as drafts are not consideredofficial report submissions. Draft reportsmust be completed, submitted, andsuccessfully processed by the NPDB tofulfill Title IV reporting requirements.

Submitting Reports to the NPDB ViaITP

If a reporting entity does not have accessto the IQRS, or prefers to generate reportsusing custom software, the entity maychoose to submit reports via an electronictransaction file submission (known as ICDTransfer Program [ITP]). This method ofreporting requires the entity to submit datausing a format specified by the NPDB. Interface Control Documents (ICDs)specify the format for ITP reportsubmissions of MMPRs and AARs. Thesedocuments are available at www.npdb-hipdb.com. See page D-6 for anexplanation of ITP.

Types of Reports

Initial Report

The first record of a medical malpracticepayment or adverse action submitted toand processed by the NPDB is consideredthe Initial report. An Initial report is thecurrent version of the report until aCorrection, Void, or Revision to Action issubmitted.

When the NPDB processes an Initialreport, a Temporary Record of Submissiondocument is available to print or save untilthe official Report Verification Documentis retrieved by the reporting entity fromthe IQRS. A Notification of a Report inthe NPDB-HIPDB is mailed to the subject.The reporting entity and the subjectshould review the report information toensure that it is correct. The reportingentity should also print and mail a copy ofthe Initial report to the appropriate Statelicensing board.


September 2001 E-5

Correction

A Correction is a change intended tosupersede the contents of the currentversion of a report. The reporting entitymust submit a Correction as soon aspossible after the discovery of an error oromission in a report. A Correction may besubmitted to replace the current version ofa report as often as necessary.

When the NPDB processes a Correction, aTemporary Record of Submissiondocument is available to print or save untilthe official Report Verification Documentis retrieved from the IQRS. A ReportRevised, Voided, or Status Changeddocument is mailed to the subject and allqueriers who received the previous versionof the report within the past 3 years. Thereporting entity and the subject shouldreview the information to ensure that it iscorrect, and queriers should note thechanged report. The reporting entityshould also print and mail a copy of theCorrection to the appropriate Statelicensing board.

Example: A hospital submits a clinicalprivileges action to the NPDB. Uponreceiving the Report VerificationDocument, the hospital identifies an errorin the subject’s address. The hospitalsubmits a Correction to the Initial Report,including the correct address.

Void Previous Report

A Void is the retraction of a report in itsentirety. An example of a Void is thereversal of a professional review action. The report is removed from the subject’sdisclosable record. A Void may besubmitted by the reporting entity at anytime.

When the NPDB processes a Void, aTemporary Record of Submission isavailable to print or save until the officialvoid verification is retrieved from theIQRS. A Report Revised, Voided, orStatus Changed document is mailed to thesubject and all queriers who received theprevious version of the report within thepast 3 years. The reporting entity and thepractitioner should review the informationto ensure that the correct report wasvoided, and queriers should note that thereport was voided. The reporting entityshould also print and mail a copy of theVoid to the appropriate State licensingboard.

Example: A State Medical Board submitsan AAR when it revokes a physician’slicense. Six months later, the revocation isoverturned by a State court. The StateMedical Board should submit a Void ofthe Initial Report.

Revision to Action

A Revision to Action reports an action thatrelates to and/or modifies an adverseaction previously reported to the NPDB. It is treated as a second and separateaction by the NPDB, but it does not negatethe original action that was taken. Theentity that reports an initial adverse actionmust also report any revision to thataction.

A Revision to Action report should besubmitted for the following reasons:

• Additional sanctions have been takenagainst the subject based on apreviously reported incident.

• The length of action has been extendedor reduced.


E-6 September 2001

• The original suspension orprobationary period has ended.

• Licensure, clinical privileges,professional society membership, orprogram participation has beenreinstated.

A Revision to Action should not bereported unless the initial action wasreported to the NPDB. When submitting aRevision to Action, the reporter mustreference the Data Bank Control Number(DCN) on the report of the action beingmodified.

A Revision to Action is separate anddistinct from a Correction. For example,if the hospital in the above example entersthe Date of Action incorrectly, aCorrection must be submitted to make thenecessary change, and the Correctionoverwrites the Initial report. A Revisionto Action is treated as an addendum to theInitial report.

When the NPDB processes a Revision toAction, a Temporary Record ofSubmission document is available to printor save until the official ReportVerification Document is retrieved fromthe IQRS. A Notification of a Report inthe NPDB is mailed to the subjectpractitioner. The reporting entity and thepractitioner should review the informationto ensure that it is correct. The reportingentity should also print and mail a copy ofthe Revision to Action to the appropriateState licensing board.

Example: A hospital submits an AARwhen it suspends a practitioner’s clinicalprivileges for 90 days. The suspension islater reduced to 45 days. Since this is anew action that modifies a previously

reported action, the hospital must submit anew report using the Revision to Actionoption in the IQRS. The Initial reportdocuments that the hospital suspended thesubject’s clinical privileges, and theRevision to Action documents that thehospital made a subsequent revision to theaction.

Example: A hospital submits an AARwhen it revokes an oral surgeon’s clinicalprivileges. Two years later, the oralsurgeon’s clinical privileges are reinstated.Since this action modifies the originalaction, the hospital must submit aRevision to Action. The Initial reportdocuments that the hospital revoked theoral surgeon’s clinical privileges, and theRevision to Action documents that thehospital made a revision to the action.

Report Processing

When the NPDB receives a report, theinformation is entered into the NPDBcomputer system. Each version of a reportprocessed by the NPDB computer systemis assigned a unique DCN. This number isused to locate the report within the NPDBcomputer system. The DCN isprominently displayed in the electronicReport Verification Document. The DCNassigned to the most current version of thereport must always be referenced in anysubsequent action involving the report.

Report Responses

Each time a report is successfullysubmitted to the IQRS and processed bythe NPDB, a Report VerificationDocument is stored for the reporting entityto retrieve through the IQRS. Reports aregenerally processed within 4 to 6 hours of


September 2001 E-7

receipt. Once viewed, the report output ismaintained on the server for 30 daysbefore it is automatically deleted.

Entities should print or save the reportoutput before automatic deletion occurs.

Entities that submit reports via the ITPmust retrieve their report responses usingthe file transfer program specified in theITP instructions. ITP responses areformatted according to the specificationsof the appropriate ICD. As with responsesdownloaded from the IQRS, entities mustreview their report verifications to ensurethat the information is correct and thatcopies of the reports are mailed to theappropriate State licensing boards.

Missing Report Verification

Reports will be available electronicallywithin an average of 4 to 6 hours ofreceipt by the NPDB. Under certaincircumstances, additional processing maybe required. Entities should not re-submitreports on the subject in question, sincethis will result in duplicate reports. If youdo not receive your response within 2 to 3business days of submission, please callthe NPDB-HIPDB Customer ServiceCenter.

If your original report is not processed, theNPDB will require a new report. TheNPDB will process the report and provideyou with a DCN. If you need to make achange to the report, use the DCN and theappropriate procedures explained in thisGuidebook to submit a Correction or aVoid.


E-8 September 2001

Reporting Medical MalpracticePayments

Each entity that makes a payment for thebenefit of a physician, dentist, or otherhealth care practitioner in settlement of, orin satisfaction in whole or in part of, aclaim or judgment against that practitionermust report the payment information to the NPDB. A payment made as a result of asuit or claim solely against an entity (forexample, a hospital, clinic, or group prac-tice) and that does not identify anindividual practitioner is not reportableunder the NPDB’s current regulations.

Eligible entities must report when a lumpsum payment is made or when the first ofmultiple payments is made. Medicalmalpractice payments are limited toexchanges of money and must be the resultof a written complaint or claim demandingmonetary payment for damages. Thewritten complaint or claim must be basedon a practitioner’s provision of or failureto provide health care services. A writtencomplaint or claim can include, but is not

Trigger Date for Reporting

Reports must be submitted to the NPDBand the appropriate State licensing boardswithin 30 days of the date that a paymentis made (the date of the payment check). The report must be submitted regardless ofhow the matter was settled (for instance,court judgment, out-of-court settlement, orarbitration). The 30-day periodcommences on the day following the dateof payment.

Interpretation of Medical MalpracticePayment Information

As stated in 427(d) of the Health CareQuality Improvement Act of 1986, asamended (Title IV of Public Law 99-660),and in 60.7(d) of the NPDB regulations,“[A] payment in settlement of a medicalmalpractice action or claim shall not beconstrued as creating a presumption thatmedical malpractice has occurred.”

REPORTING MEDICAL MALPRACTICE PAYMENTS

Entity’s ReportMedical Malpractice

Payments

ReportVerificationDocument

COPY OFREPORT

TOSTATEBOARD

SubjectNotificationDocument

based on the law of tort in any State orFederal court or other adjudicative body,such as a claims arbitration board.

limited to, the filing of a cause of action


September 2001 E-9

The Secretary of HHS understands thatsome medical malpractice claims(particularly those referred to as nuisanceclaims) may be settled for convenience,not as a reflection on the professionalcompetence or professional conduct of apractitioner.

Reporting entities should provide adetailed narrative to describe the acts oromissions and injuries or illnesses uponwhich the medical malpractice action orclaim was based. This narrative may be amaximum of 2,000 characters includingspaces and punctuation. Any charactersover 2,000 are truncated.

Narrative descriptions should includeeight general categories of information:age, sex, patient type, initial event(medical condition of the patient),procedure performed, claimant’sallegation, associated legal and otherissues, and outcome. Narratives cannotcontain patient names or names of otherhealth care practitioners, plaintiffs,witnesses, or any other individualsinvolved in the case. Guidelines for thesecategories follow:

• Age – age of claimant at the time ofthe initial event; age is expressed inyears if the claimant is 1 year of age orolder, in months from 1 month through11 months; and in days if the claimantis less than 1 month of age. Unknownmay be used if applicable.

• Sex – male, female, and disputed;disputed may be used in claimsinvolving individuals whose sex hasbeen physically altered or who arephysically one sex but live outwardlyas the other.

• Patient Type – generally an indicationof inpatient or outpatient status;choose inpatient, outpatient, or both.

• Initial Event (Medical Condition ofthe Patient) – choose the words thatbest describe the diagnosis with whichthe claimant presented for treatment. To report the diagnosis, the reportersshould use the actual condition fromwhich the patient suffered. When thepatient has more than one condition,the reporter should use the conditionthat is most applicable to thegeneration of the claim.

• Procedure Performed – the treatmentrendered by the insured to the patientfor the medical condition describedunder “Medical Condition of thePatient.” If more than one procedurewas used, the procedure that is mostsignificant to the claim’s generationshould be used.

• Claimant’s Allegation – theoccurrence that precipitated the claimof medical and/or legal damages; thetime sequence in relation to the initialevent is relevant.

• Associated Legal and Other Issues –any associated issues that have animpact on the claim.

• Outcome – a description of theoutcome resulting from the initialevent and the claimant’s allegation.

Sample Descriptions for IllustrativePurposes Only:

A 65-year-old male outpatient had aprostate exam by Dr. A. Six months later,the patient was diagnosed by Dr. B with


E-10 September 2001

prostate cancer and underwent surgery. One year later, the patient sued Dr. A foralleged failure to diagnose. A settlementwas reached in the amount of $250,000.

A 57-year-old female outpatient had amammogram. One year later, the patientwas diagnosed with breast cancer and sheunderwent chemotherapy and radiation. The patient sues the physician for allegedfailure to diagnose and treat. A settlementwas reached in the amount of $100,000.

A 45-year-old male came to theemergency department with complaints ofshoulder and chest pain, and he wasdischarged after evaluation. Six hourslater, he had a cardiac arrest and could notbe resuscitated. The estate sued thetreating emergency room physician foralleged failure to diagnose and treat. Thecase went to trial and resulted in a verdictin favor of the plaintiff for $1,000,000.

A 9-month-old girl was seen in a privateoffice with fever and treatedsymptomatically. The next day she wasbrought to the hospital in convulsions. Her parents allege that a delay in thediagnosis of meningitis caused permanentneurological damage. A settlement wasreached in the amount of $2,000,000.

A 31-year-old pregnant woman wasadmitted to the hospital by her physicianin the early stages of labor. After fourhours, the woman began to show signs offetal distress. The hospital staff attemptedto contact the physician but could notlocate her for four hours. The patient suedthe physician, alleging that the physician’sabandonment caused permanentneurological damage to the child. Asettlement was reached in the amount of$2,000,000.

(Portions adopted from the Harvard RiskManagement Foundation Sample ClaimsDescriptions.)

Reporting of Payments by Individuals

Individual subjects are not required toreport payments they make for their ownbenefit to the NPDB. On August 27,1993, the Circuit Court of Appeals for theDistrict of Columbia held that [445 (DCCir. 3 F.3D 1993)] the NPDB regulationrequiring each “person or entity” thatmakes a medical malpractice payment wasinvalid, insofar as it required individualsto report such payments. The NPDBremoved reports previously filed onmedical malpractice payments made byindividuals for their own benefit.

A professional corporation or otherbusiness entity comprised of a solepractitioner that makes a payment for thebenefit of a named practitioner must reportthat payment to the NPDB. However, if apractitioner or other person, rather than aprofessional corporation or other businessentity, makes a medical malpracticepayment out of personal funds, thepayment is not reportable.

Payments for Corporations andHospitals

Medical malpractice payments madesolely for the benefit of a corporation suchas a clinic, group practice, or hospital arecurrently not reportable to the NPDB. Apayment made for the benefit of aprofessional corporation or other businessentity that is comprised of a solepractitioner is reportable if the paymentwas made by the entity rather than by thesole practitioner out of personal funds.


September 2001 E-11

Deceased Practitioners

One of the principal objectives of theNPDB is to restrict the ability ofincompetent physicians to move fromState to State without disclosure ordiscovery of their previous damaging orincompetent performance. The NPDBrequires reporting medical malpracticepayments made for the benefit of deceasedpractitioners (or for their benefit throughtheir estates) because a fraudulentpractitioner could assume the identity of adeceased practitioner.

When submitting an MMPR for adeceased practitioner, check the deceasedblock on the appropriate MMPR screen inthe IQRS. The NPDB makes an electronicreport verification available to thereporting entity via the IQRS.

Identifying Practitioners

In order for a particular physician, dentist,or other health care practitioner to benamed in an MMPR submitted to theNPDB, the practitioner must be named inboth the written complaint or claimdemanding monetary payment fordamages and the settlement release orfinal adjudication, if any. Practitionersnamed in the release, but not in the writtendemand or as defendants in the lawsuit,are not reportable to the NPDB. Apractitioner named in the writtencomplaint or claim who is subsequentlydismissed from the lawsuit and not namedin the settlement release is not reportableto the NPDB. In some States, the givenname of the practitioner does not have toappear in the release or final adjudicationas long as the practitioner is sufficientlydescribed in the settlement or finaladjudication as to be identifiable. In thoseStates, an NPDB report on the practitioner

named in the complaint, but not in therelease or final adjudication, is required aslong as he or she is sufficiently describedas to be individually identifiable.

Insurance Policies that Cover Morethan One Practitioner

A medical malpractice payment madeunder an insurance policy that covers morethan one practitioner should only bereported for the individual subject forwhose benefit the payment was made, notfor every practitioner named on the policy.

One Settlement for More than OnePractitioner

In the case of a payment made for thebenefit of multiple practitioners, wherein itis impossible to determine the amount paidfor the benefit of each individualpractitioner, the insurer must report, foreach practitioner, the total (undivided)amount of the initial payment and the totalnumber of practitioners on whose behalfthe payment was made. In the case of apayment made for the benefit of multiplepractitioners where it is possible toapportion payment amounts to individualpractitioners, the insurer must report, foreach practitioner, the actual amount paidfor the benefit of that practitioner.

Residents and Interns

Reports must be submitted to the NPDBwhen medical malpractice payments aremade for the benefit of licensed residentsor interns. Medical malpractice paymentsmade for the benefit of housestaff insuredby their employers are also reportable tothe NPDB.


E-12 September 2001

Students

Payments made for the benefit of medicalor dental students are not reportable to theNPDB. Unlicensed student providersprovide health care services exclusivelyunder the supervision of licensed healthcare professionals in a trainingenvironment. Students do not fall into the“other health care practitioner category;”other health care practitioners are licensedby a State and/or meet State registration orcertification requirements.

Practitioner Fee Refunds

If a refund of a practitioner’s fee is madeby an entity (including solo incorporatedpractitioners), that payment is reportableto the NPDB. A refund made by anindividual is not reportable to the NPDB.

For purposes of NPDB reporting, medicalmalpractice payments are limited toexchanges of money. A refund of a fee isreportable only if it results from a writtencomplaint or claim demanding monetarypayment for damages. The writtencomplaint or claim must be based on aphysician’s, dentist’s, or other health carepractitioner’s provision of, or failure toprovide, health care services. A writtencomplaint or claim may include, but is notlimited to, the filing of a cause of actionbased on the law of tort in any State orFederal court or other adjudicative body,such as a claims arbitration board.

A waiver of a debt is not considered apayment and should not be reported to theNPDB. For example, if a patient has anadverse reaction to an injection and iswilling to accept a waiver of fee assettlement, that waiver is not reportable tothe NPDB.

Loss Adjustment Expenses

Loss adjustment expenses (LAEs) refer toexpenses other than those in compensationof injuries, such as attorney’s fees, billablehours, copying, expert witness fees, anddeposition and transcript costs. If LAEsare not included in the medicalmalpractice payment amount, they are notrequired to be reported to the NPDB.

LAEs should be reported to the NPDBonly if they are included in a medicalmalpractice payment. Reportingrequirements specify that the total amountof a medical malpractice payment and adescription and amount of the judgment orsettlement and any conditions, includingterms of payment should be reported to theNPDB. LAEs should be itemized in thedescription section of the report form.

Dismissal of a Defendant from aLawsuit

A payment made to settle a medicalmalpractice claim or action is notreportable to the NPDB if the defendanthealth care practitioner is dismissed fromthe lawsuit prior to the settlement orjudgment. However, if the dismissalresults from a condition in thesettlement or release, then the payment isreportable. In the first instance, there is nopayment for the benefit of the health carepractitioner because the individual hasbeen dismissed from the actionindependently of the settlement orrelease. In the latter instance, if thepractitioner is dismissed from the lawsuitin consideration of the payment beingmade in settlement of the lawsuit, thepayment can only be construed as apayment for the benefit of the health care


September 2001 E-13

practitioner and must be reported to theNPDB.

Example: A health care practitioner isnamed in a lawsuit. The practitioneragrees to a payment on the condition thathis or her name does not appear in thesettlement. The payment would bereportable to the NPDB.

High-Low Agreements

A “high-low” agreement, a contractualagreement between a plaintiff and adefendant’s insurer, defines the parametersof a payment the plaintiff may receiveafter a trial or arbitration proceeding. Ifthe finder of fact returns a defense verdict,the defendant’s insurer agrees to pay the“low end” amount to the plaintiff. If thefinder of fact returns a verdict for theplaintiff and against the defendant, thedefendant’s insurer agrees to pay the “highend” amount to the plaintiff.

A payment made at the low end of ahigh/low agreement that is in place priorto a verdict or an arbitration decisionwould not be reportable to the NPDB onlyif the fact-finder rules in favor of thedefendant and assigns no liability to thedefendant practitioner. In this case, thepayment is not being made for the benefitof the practitioner in settlement of amedical malpractice claim. Rather, it isbeing made pursuant to an independentcontract between the defendant’s insurerand the plaintiff. The benefit to theinsurer is the limitation on its liability,even if the plaintiff wins at trial and isawarded a higher amount. The benefit tothe plaintiff is a guaranteed payment, evenif there is no finding of liability against thepractitioner. Note: in order for the low-end payment to be exempted from thereporting requirements, the fact finder

must have made a determinationregarding liability at the trial orarbitration proceeding.

A payment made at the high end of theagreement is one made for the benefit ofthe practitioner and, therefore, must bereported to the NPDB. When adefendant practitioner has been foundto be liable by a fact-finding authority,such as a judge, a jury, or byarbitration, any payment madepursuant to that finding must bereported, regardless of the existence of ahigh-low agreement.

If a high-low agreement is in place, andthe plaintiff and defendant settle the caseprior to trial, the existence of the high-lowagreement does not alter the reportabilityof the settlement payment.

Example 1: A high-low agreement is inplace prior to trial. The parties agree to alow end payment of $25,000 and a highend payment of $100,000. The jury findsthe defendant physician liable and awards$20,000 to the plaintiff in damages. This$20,000 payment is reportable because thejury found the defendant physician liable.

Example 2: A high-low agreement is inplace prior to binding arbitration. Theparties agree to a low end payment of$50,000 and a high end payment of$150,000. The arbitrator finds in favor ofthe defendant practitioner. However, dueto the existence of the high-lowagreement, the defendant’s insurer makesa payment of $50,000 to the plaintiff (thelow end payment). This payment is notreportable since it is being made pursuantto an independent contract between thedefendant’s insurer and the plaintiff.


E-14 September 2001

Example 3: A high-low agreement is inplace prior to trial. The parties agree to alow-end payment of $50,000 and a highend payment of $150,000. Before the factfinder returns a verdict, the parties settlethe case for $50,000. This payment isreportable because it is made in settlementof the claim.

Example 4: A high-low agreement is inplace prior to trial. The parties agree to alow-end payment of $50,000 and a high-end payment of $100,000. Rather than goto trial, the parties agree to bindingarbitration to assess the amount ofdamages the plaintiff will receive. Thearbitrator awards the plaintiff $50,000. Inthis case, the arbitration was conducted todetermine the amount of recovery by theplaintiff, not whether or not the plaintiffwill recover. Because no liability was tobe determined at this arbitrationproceeding, the payment is made insettlement of the claim and is reportable.

Reporting by Authorized Agents

The organization that makes the medicalmalpractice payment is the organizationthat must report medical malpracticepayments to the NPDB.

A medical malpractice payer may chooseto use an adjusting company, claimsservicing company, or law firm, acting asits authorized agent to complete andsubmit NPDB reports. An insurancecompany may also wish to have all of itsNPDB correspondence related to reportshandled by an authorized agent. This isstrictly a matter of administrative policyby the medical malpractice payer. Whenreporting a payment, the reporting entityinformation in the MMPR must becompleted using the name, address, and

DBID of the organization that made thepayment.

For information on registering anauthorized agent or designating one, seepages B-7 and B-8, respectively.

Payments by Multiple Payers

Any medical malpractice payer that makesan indemnity payment for the benefit of apractitioner must submit a report to theNPDB. Generally, primary insurers andexcess insurers are obligated to make anindemnity payment for the benefit of apractitioner and so must submit a report tothe NPDB. Typically, reinsurers areobligated to make an indemnity paymentdirectly to the primary insurer, not for thebenefit of the practitioner, and are notrequired to submit a report to the NPDB.

For example, if three primary insurerscontribute to a payment, all three insurersare required to submit separate MMPRs tothe NPDB. Each insurer should describethe basis for their payment in the narrativedescription of the settlement to avoid theimpression of duplicate reporting.

Structured Settlements

A medical malpractice payer entering intoa structured settlement agreement with alife insurance or annuity company mustsubmit a payment report within 30 daysafter the lump sum payment is made bythe payer to that company.

Payments made after the opening of theNPDB (September 1, 1990) underannuities existing prior to the NPDBopening are not reportable to the NPDB.


September 2001 E-15

Subrogation-Type Payments

Subrogation-type payments made by oneinsurer to another are not required to bereported, provided that the insurerreceiving the payment has previouslyreported the total judgment or settlementto the NPDB. Subrogation often occurswhen there is a dispute between insurancecompanies over whose professionalliability policy ought to respond to alawsuit.

Example: A practitioner is insured in1991 by Insurer X and changes over toInsurer Y in 1992. Both policies provideoccurrence-type coverage. A medicalmalpractice lawsuit is filed in 1992. Thereis a dispute over whether the allegedmedical malpractice occurred in late 1991or early 1992. Under the 1992 policy,Insurer Y agrees to defend the lawsuit butobtains an agreement from the practitionerthat it may pursue the practitioner’s legalright to recover any indemnity and defensepayments that should have been paidunder Insurer X’s policy. This is asubrogation agreement. The jurysubsequently determines that the incidentoccurred in 1991 and awards $500,000 tothe plaintiff. Insurer Y makes the$500,000 payment to the plaintiff andreports it to the NPDB. Insurer Y seekssubrogation of its indemnity and defensepayments from Insurer X. Insurer Xultimately concedes and pays Insurer Ythe $500,000 plus defense costs. InsurerX is not required to report itsreimbursement of Insurer Y to the NPDB.

Offshore Payers

A medical malpractice payment made byan offshore medical malpractice insurermust be reported to the NPDB. An

offshore insurer with an agent in theUnited States is subject to service (whichmeans that it can be served with a Federalcomplaint); therefore, the reportingrequirement can be enforced. It is not theNPDB’s responsibility to identify thesecompanies; rather, it is the responsibilityof these companies to comply with thestatute and register with the NPDB.

Payments Made Prior to Settlement

When a payment is made prior to asettlement or judgment, a report must besubmitted within 30 days from the date thepayment was made. Since the totalamount of the payment is unknown, themedical malpractice payer should statethis in the narrative description section ofthe report. When the settlement orjudgment is finalized, the insurer mustsubmit a Correction to the Initial Report.

When reporting medical malpracticepayment information, please be aware thatleaving the Payment Result reason andDate of Judgment or Settlement fields onthe MMPR format blank indicates that thepayment was made prior to a judgment orsettlement. When a payment is made as aresult of a judgment or settlement, thesefields should be properly completed. Likewise, the Adjudicative Body CaseNumber, Adjudicative Body Name, andCourt File Number fields should be leftblank only when there was not a filingwith an adjudicative body. See Table E-2on page E-16 for information ondetermining reportable medicalmalpractice payments.


E-16 September 2001

Table E-2. Determining Reportable Medical Malpractice PaymentsAction NPDB Reporting Responsibility

A malpractice settlement or court judgmentincludes stipulation that the terms are keptconfidential.

Must file report.

Malpractice settlement is structured so thatclaimant receives an annual sum for each year heor she is alive.

Report the initial payment after NPDB opening;identify as multiple payments.

Malpractice settlement involves five practitioners. Must file a separate report on each of the fivepractitioners.

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 makingpayment out of personal funds.

Payments made for corporations and hospitals. Payments made for the benefit of a corporationsuch as a clinic group practice or hospital are notcurrently reportable. Payment is reportable whenmade for business entities comprised of solepractitioners.

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). Noreport is required if refund is made by anindividual.

Dismissal of defendant from lawsuit. No report required if defendant is dismissed priorto settlement or judgment. Report is required ifdismissal results from condition in settlement orrelease.


September 2001 E-17

Reporting Adverse ClinicalPrivileges Actions

Health care entities must report adverseactions within 15 days from the date theadverse action was taken or clinicalprivileges were voluntarily surrendered. The health care entity must print a copyof each report submitted to the NPDBand mail it to the appropriate Statelicensing board for its use. The ReportVerification Document that health careentities receive after a report issuccessfully processed by the NPDBshould be used for submission to theappropriate State licensing board.

Reportable adverse clinical privilegesactions are based on a physician’s ordentist’s professional competence orprofessional conduct that adverselyaffects, or could adversely affect, thehealth or welfare of a patient. Hospitalsand other eligible health care entities mustreport:

• Professional review actions thatadversely affect a physician’s ordentist’s clinical privileges for a periodof more than 30 days.

• Acceptance of a physician’s ordentist’s surrender or restriction ofclinical privileges while underinvestigation for possible professionalincompetence or improper professionalconduct or in return for not conductingan investigation or reportableprofessional review action.

Adverse actions taken against aphysician’s or dentist’s clinical privilegesinclude reducing, restricting, suspending,revoking, or denying privileges, and alsoinclude a health care entity’s decision notto renew a physician’s or dentist’sprivileges if that decision was based on thepractitioner’s professional competence orprofessional conduct. Health careentities may report such actions takenagainst the clinical privileges of otherhealth care practitioners.

REPORTING ADVERSE CLINICAL PRIVILEGES ACTIONS

Entity’s ReportClinical Privileges


COPY OFREPORT

TOSTATEBOARD



E-18 September 2001

Adverse actions involving censures,reprimands, or admonishments should notbe reported to the NPDB. Matters notrelated to the professional competence orprofessional conduct of a practitionershould not be reported to the NPDB. Forexample, adverse actions based primarilyon a practitioner’s advertising practices,fee structure, salary arrangement,affiliation with other associations or healthcare professionals, or other competitiveacts intended to solicit or retain businessare excluded from NPDB reportingrequirements.

See Table E-3 on page E-21 for moreinformation on determining reportableactions for clinical privileges.

Hospitals and other health care entitiesmust report revisions to previouslyreported adverse actions. For moreinformation on revisions, see page E-5,Revision to Action, in the Types ofReports section.

Multiple Adverse Actions

If a single professional review actionproduces multiple clinical privilegesactions (for example, a 12-monthsuspension followed by a 5-monthprobation), only one report should besubmitted to the NPDB. The AdverseAction Classification Code for theprincipal action should be submitted onthe AAR, and the narrative descriptionshould describe the additional adverseactions imposed.

A Revision to Action must be submittedwhen each of the multiple actions is lifted. (Following the previous example, arevision must be submitted when clinicalprivileges are reinstated with probationafter the suspension, and another revision

must be submitted when the probationaryperiod ends.)

If an adverse action against the clinicalprivileges of a practitioner is based onmultiple grounds, only a single reportmust be submitted to the NPDB. However, all reasons for the action shouldbe reported and explained in the narrative.The reporting entity may select up to fourBasis for Action codes to indicate thesemultiple reasons. Additional reasonsshould be summarized in the narrativedescription.

Denial of Applications

A restriction or denial of clinicalprivileges that occurs solely because apractitioner does not meet a health careinstitution’s established thresholdeligibility criteria for that particularprivilege is not reportable to the NPDB.

Such restrictions or denials are not deemedthe result of a professional review actionrelating to the practitioner’s professionalcompetence or professional conduct, butare considered decisions based oneligibility.

For example, if an institution retroactivelychanges the eligibility criteria for aparticular clinical privilege, a physicianthat does not meet the new criteria willlose previously granted clinical privileges;this loss of privileges is not reportable tothe NPDB.

Adverse clinical privileges actionsreportable to the NPDB result fromprofessional review actions relating to thepractitioner’s professional competence orprofessional conduct.


September 2001 E-19

Withdrawal of Applications

Voluntary withdrawal of an initialapplication for medical staff appointmentor clinical privileges prior to a finalprofessional review action generally is notreportable to the NPDB. However, if apractitioner applies for renewal of medicalstaff appointment or clinical privileges andvoluntarily withdraws that applicationwhile under investigation by the healthcare entity for possible professionalincompetence or improper professionalconduct, or in return for not conductingsuch an investigation or taking aprofessional review action, then thewithdrawal of application for clinicalprivileges is reportable to the NPDB.

Investigations

Investigations should not be reported tothe NPDB; only the surrender orrestriction of clinical privileges whileunder investigation or to avoidinvestigation is reportable. This wouldinclude a failure to renew clinicalprivileges while under investigation.

A health care entity that submits an AARbased on surrender or restriction of aphysician’s or dentist’s privileges whileunder investigation should havecontemporaneous evidence of an ongoinginvestigation at the time of surrender, orevidence of a plea bargain. The reportingentity should be able to produce evidencethat an investigation was initiated prior tothe surrender of clinical privileges by apractitioner. Examples of acceptableevidence may include minutes or excerptsfrom committee meetings, orders fromhospital officials directing aninvestigation, and notices to practitionersof an investigation.

Guidelines for Investigations

• An investigation must be carried outby the health care entity, not anindividual on the staff.

• The investigation must be focused onthe practitioner in question.

• The investigation must concern theprofessional competence and/orprofessional conduct of the practitionerin question.

• A routine or general review of cases isnot an investigation.

• A routine review of a particularpractitioner is not an investigation.

• An investigation should be theprecursor to a professional reviewaction.

• An investigation is considered ongoinguntil the health care entity’s decisionmaking authority takes a final action orformally closes the investigation.

Summary Suspension

A summary suspension is reportable if it is:

• In effect or imposed for more than 30days.

• Based on the professional competenceor professional conduct of thephysician, dentist, or other health carepractitioner that adversely affects, orcould adversely affect, the health orwelfare of a patient.

• The result of a professional reviewaction taken by a hospital or otherhealth care entity.

A summary suspension is often imposedby an individual, for instance, thechairman of a department. Commonly,


E-20 September 2001

this action is then reviewed and confirmedby a hospital committee, such as a medicalexecutive committee, as authorized by themedical staff bylaws. The suspensionwould then be viewed as a professionalreview action taken by the entity.

If the suspension is modified or revised aspart of a final decision by the governingboard or similar body, the health careentity must then submit a Revision toAction of the Initial report made to theNPDB.

If the physician, dentist, or other healthcare practitioner surrenders his or herclinical privileges during a summarysuspension, that action must be reported tothe NPDB. The action is reportablebecause the practitioner is surrendering theprivileges either while under investigationconcerning professional conduct orprofessional competence that did or couldaffect the health or welfare of a patient orin order to avoid a professional reviewaction concerning the same.

Summary suspensions are considered tobe final when they become professionalreview actions through action of theauthorized hospital committee or body,according to the hospital bylaws.

The basis for this interpretation is that,pursuant to Part A of the Health CareQuality Improvement Act (42 U.S.C.§11112)(c)(2), a summary suspension istaken to prevent “imminent danger to thehealth of any individual.”

The Act itself treats summary suspensionsdifferently than other professional reviewactions: the procedural rights of thepractitioner are provided for following thesuspension, rather than preceding it. Thisreporting policy for summary suspensionsis in keeping with the purpose of the Act,which is to protect the public from thethreat of incompetent practitionerscontinuing to practice without disclosureor discovery of previous damaging orincompetent performance.

In establishing this policy on the reportingof summary suspensions, HHS assumesthat hospitals use summary suspensionsfor the purpose stated in Part A of the Act:to protect patients from imminent danger,rather than for reasons that warrant routineprofessional review actions. HHS alsoemphasizes that this policy on summarysuspension is solely for the purpose ofreporting to the NPDB, and does not relateto the criteria for immunity under Part Aof the Act.


September 2001 E-21

Table E-3. Determining Reportable Actions for Clinical PrivilegesAction Reportable

Based on assessment of professional competence, a proctor is assigned to a physician ordentist for a period of more than 30 days. The practitioner must be granted approvalbefore certain medical care is administered.

Yes

Based on assessment of professional competence, a proctor is assigned to supervise aphysician or dentist, but the proctor does not grant approval before medical care isprovided by the practitioner.

No

As a matter of routine hospital policy, a proctor is assigned to a physician or dentistrecently granted clinical privileges.

No

A physician or dentist voluntarily restricts or surrenders clinical privileges for personalreasons; professional competence or professional conduct is not under investigation.

No

A physician or dentist voluntarily restricts or surrenders clinical privileges; professionalcompetence or professional conduct is under investigation.

Yes

A physician or dentist voluntarily restricts or surrenders clinical privileges in return fornot conducting an investigation of professional competence or professional conduct.

Yes

A physician’s or dentist’s application for medical staff appointment is denied based onprofessional competence or professional conduct.

Yes

A physician or dentist is denied medical staff appointment or clinical privileges becausethe health care entity has too many specialists in the practitioner’s discipline.

No

A physician’s or dentist’s clinical privileges are suspended for administrative reasons notrelated to professional competence or professional conduct.

No

A physician’s or dentist’s request for clinical privileges is denied or restricted based uponassessment of clinical competence as defined by the hospital.

Yes

Examples of Reportable and Non-Reportable Actions

Example 1: A physician member of ahospital medical staff wishes to performseveral clinical tests and procedures, butdoes not have the appropriate clinicalprivileges. The physician applies for anexpansion of clinical privileges. Thephysician’s Department Head and theMedical Staff Credentials Committee findthat, based on their assessment of thephysician’s demonstrated professionalperformance, the physician does not havethe clinical competence to perform theadditional tests and procedures, and theyrecommend denial of the request forexpanded clinical privileges. Thehospital’s governing body reviews thecase, affirms the findings andrecommendations, and denies the

physician’s request for expanded clinicalprivileges for reasons relating toprofessional competence.

The action is reportable because the denialof privileges adversely affects the clinicalprivileges of the physician for longer than30 days.

Whether particular actions are reportableto the NPDB is often best determined byexamining a hospital’s medical staffbylaws, rules, and regulations with regardto provisions defining who is empoweredto take a professional review action, whatconstitutes a professional review actionthat adversely affects the clinicalprivileges of a practitioner, and how thataction relates to professional competenceor professional conduct.


E-22 September 2001

Example 2: A 30-day suspension isimposed as a result of a professionalreview action based on a physician’sprofessional competence.

The action is not reportable because theadverse action taken by the professionalreview body did not last for more than 30days.

Example 3: A hospital reviews asurgeon’s professional competence andassigns a surgical proctor for 60 days. Thesurgeon cannot perform surgery withoutbeing granted approval by the surgicalproctor.

Since the surgeon cannot practice surgerywithout approval from another surgeon,this restriction of clinical privileges isreportable.

Example 4: A 31-day suspension isimposed on a physician for failure tocomplete medical records.

Such a suspension would be reportable tothe NPDB if the failure to completemedical records related to the physician’sprofessional competence or conduct andadversely affects or could adversely affecta patient’s health or welfare.

Example 5: A physician’s application forsurgical privileges is denied because thephysician is not board certified in theparticular clinical specialty orsubspecialty.

The action is not reportable if thephysician fails to meet the hospital’sinitial credentialing criteria applied to allmedical staff or clinical privilegeapplicants. Examples of initial criteriamay include: (1) minimum professionalliability coverage, (2) board certification,

(3) geographic proximity to the hospital,and (4) failure to have performed theminimum number of proceduresprescribed for a particular clinicalprivilege.

Example 6: The hospital CEO summarilysuspends a physician’s privileges forfailure to respond to an emergencydepartment call.

The action is reportable if the suspensioncontinues for longer than 30 days and thehospital bylaws state that summarysuspension decisions by the medicalexecutive committee are considered to beprofessional review actions. A CEO maybe considered a committee assisting thegoverning body in a professional reviewactivity. If this is the case and thephysician has been summarily suspended,the hospital medical staff bylaws willusually provide for an appeal to themedical executive committee within a fewdays of the CEO’s decision.

Example 7: A hospital’s professionalreview body terminates a provider-basedphysician contract for causes relating topoor patient care, which in turn results inloss of privileges with no right to a hearingas provided in the contract and the medicalstaff bylaws.

The termination of the contract, in itself, isnot reportable to the NPDB. Thetermination of the practitioner’s clinicalprivileges because of the termination ofthe contract for reasons relating toprofessional competence or professionalconduct is reportable if it is considered aprofessional review action by the hospital.

Hospitals are advised to consult with legalcounsel to review the State’s case lawconcerning due process.

Example 8: A physician surrendersmedical staff privileges due to personalreasons, infirmity, or retirement.

The surrender is not reportable. Thereasons for surrender are irrelevantunless the physician surrenders whileunder an investigation by a health careentity relating to possible professionalincompetence or improper professionalconduct, or in return for not conductingsuch an investigation.

Example 9: A physician was underinvestigation four weeks prior to theexpiration of his clinical privileges. Thephysician failed to renew his clinicalprivileges.

This event is considered a reportablesurrender while under investigation. Thisaction is reportable regardless of whetherthe physician knew he was underinvestigation at the time he failed to renewhis clinical privileges. A practitioner’s awareness that an investigation is beingconducted is not a requirement forreportability.

Example 10: A physician holdingcourtesy privileges in a hospital appliesfor full staff privileges. The full staffprivileges are granted. As a condition ofstaff privileges, the physician is requiredto be on-call in the EmergencyDepartment for one weekend a month. Due to personal reasons, the physician isunable to fulfill his EmergencyDepartment commitment. The hospitaland the physician eventually agree tochange his clinical privileges from fullstaff to courtesy.

The change in clinical privileges is notreportable. The change to the physician’sprivileges is not the result of aprofessional review action based on thephysician’s professional competence orconduct which affects or could adverselyaffect the health or welfare of a patient.


September 2001 E-23

Reporting Adverse LicensureActions

State medical and dental licensing boardsmust report adverse actions againstphysicians and dentists to the NPDBwithin 30 days from the date an adverselicensure action was taken.

State medical and dental boards mustreport to the NPDB certain disciplinaryactions related to professional competenceor professional conduct taken against thelicenses of physicians or dentists. Suchlicensure actions include revocation,suspension, censure, reprimand, probation,and surrender. State medical and dentalboards must also report revisions toadverse licensure actions, such asreinstatement of a license.

Effective Date of Action

An Adverse Action Report must besubmitted within 30 days of the date of theformal approval of the licensure action bythe State medical or dental board or itsauthorized official. Significant delays may

occur between the formal approval of theaction and the drafting of the order forpublication; however, the trigger datefor reporting the adverse action is basedon the board’s formal approval of theaction.

Examples of Reportable Actions

The following adverse licensure actions,when related to the professionalcompetence or professional conduct of aphysician or dentist, must be reported tothe NPDB:

• Denial of an application for licenserenewal.

• Withdrawal of an application forlicense renewal (should be reported asa voluntary surrender).

• Licensure disciplinary action taken bya State board against one of itslicensees/applicants for licensurerenewal based upon a licensuredisciplinary action, related to thepractitioner’s professional competenceor professional conduct, taken byanother State board.

REPORTING ADVERSE LICENSURE ACTIONS

Entity’s ReportLicensure


COPY OFREPORT

TOSTATEBOARD


E-24 September 2001


• Licensure disciplinary action taken bya State board based upon thepractitioner’s deliberate failure toreport a licensure disciplinary actiontaken by another State board, when areport of such action is requested on alicensure renewal application.

• Fines and other monetary sanctionsaccompanied by other licensure action,such as revocation, suspension,censure, reprimand, probation, orsurrender.

Examples of Non-Reportable Actions

The following adverse licensure actionsshould not be reported to the NPDB:

• Fines and other monetary sanctionsunaccompanied by other licensureaction, such as revocation, suspension,censure, reprimand, probation, orsurrender.

• Denial of an initial application forlicense.

• A settlement agreement which imposesmonitoring of a practitioner for aspecific period of time, unless suchmonitoring constitutes a restriction ofthe practitioner’s license or isconsidered to be a reprimand.

• A licensure disciplinary action whichis imposed with a “stay” pendingcompletion of specific programs oractions. However, if a “stay” of adisciplinary action is accompanied byprobation, the probation is reportable.

• Voluntary relinquishment of aphysician’s license for personalreasons not related to his or herprofessional competence orprofessional conduct (for example,retirement).

• Licensure actions taken against non-physician, non-dentist, health carepractitioners.

September 2001 E-25


Reporting Adverse ProfessionalSociety Membership Actions

Professional societies must report adverseactions within 15 days from the date theadverse action was taken. A copy of eachreport sent to the NPDB should be printedand mailed to the appropriate Statelicensing board for its use.

The Report Verification Document thathealth care entities receive after a report issuccessfully processed by the NPDBshould be used for submission to theappropriate State licensing board.

Reporting Requirements

Professional societies must reportprofessional review actions based onreasons related to professional competenceor professional conduct that adverselyaffect the membership of a physician ordentist. Professional societies may reportsuch adverse membership actions whentaken against health care practitionersother than physicians and dentists.

Reportable actions must be based onreasons relating to professionalcompetence or professional conduct whichaffects or could adversely affect the healthor welfare of a patient. Matters not related to the professional competence orprofessional conduct of a physician ordentist are not to be reported to the NPDB.

For example, adverse actions against apractitioner based primarily on his or heradvertising practices, fee structure, salaryarrangement, affiliation with otherassociations or health care professionals,or other competitive acts intended tosolicit or retain business are excluded fromNPDB reporting requirements.

An adverse action taken by a professionalsociety against the membership of aphysician or dentist must be reported tothe NPDB when that action constitutes aprofessional review action taken in thecourse of professional review activitythrough a formal peer review process,

Entity’s ReportProfessional

Society

REPORTING ADVERSE PROFESSIONAL SOCIETYMEMBERSHIP ACTIONS



provided that the action is based on themember’s professional competence or

E-26 September 2001

COPY OFREPORT

TOSTATEBOARD


professional conduct. Adverse membership actions involving censures,reprimands, or admonishments should notbe reported.

In 1997, reports of exclusions from theMedicare and Medicaid programs againsthealth care practitioners* were added tothe NPDB through a collective effort and aMemorandum of Understanding betweenHRSA, the HHS Office of InspectorGeneral (OIG), and the Centers forMedicare & Medicaid Services (CMS). The NPDB now includes Medicare/Medicaid exclusions from May 1979 tothe present.

responsibility for the content and accuracyof CMS exclusion reports; the NPDB onlyacts as a disclosure service. Notificationof exclusion from CMS programs is madeby CMS. Inquiries on the appropriatenessor content of CMS exclusion reports mustbe referred to CMS for response.

*The NPDB contains Medicare/Medicaidexclusions against health carepractitioners (i.e., physicians, dentists,chiropractors, psychologists, etc.).Exclusions against individuals other thanlicensed health care practitioners andentities, in addition to exclusions againsthealth care practitioners, can be found inthe Healthcare Integrity and ProtectionData Bank (HIPDB).

Sanctions for Failing to Report tothe NPDB

Medical Malpractice Payers

The HHS Office of Inspector General hasthe authority to impose civil moneypenalties in accordance with Sections421(c) and 427(b) of Title IV of PublicLaw 99-660, the Health Care QualityImprovement Act of 1986, as amended. Under the statute, any malpractice payerthat fails to report medical malpracticepayments in accordance withSection 421(c) is subject to a civil moneypenalty of up to $11,000 for each suchpayment involved.

The civil money penalties provided forunder Sections 421(c) and 427(b) are to beimposed in the same manner as other civilmoney penalties imposed pursuant toSection 1128A of the Social Security Act,42 U.S.C. 1320a-7a. Regulations governingcivil money penalties under Section 1128Aare set forth at 42 CFR Part 1003.

NPDB Medicare/Medicaid exclusionsidentify practitioners who have beendeclared ineligible for Medicare andMedicaid payments. Hospitals, managedcare organizations, and other providers areprohibited from billing the Medicare andMedicaid programs for any services thatmight be rendered by these providers. Information from the Medicare/Medicaidexclusions is released in accordance withthe Social Security Act.


September 2001 E-27

Reporting Medicare/MedicaidExclusions

The HHS Office of Inspector General hasthe authority to exclude individuals andorganizations from participating in theMedicare and/or certain State health careplans under sections 1128(a), 1128(b),1892, or 1156 of the Social Security Act.The exclusion also applies to all otherExecutive Branch procurement and non-procurement programs and activities. Disclosure of the Office of InspectorGeneral Exclusion List to HRSA is underauthority of section 1106(a) of the SocialSecurity Act, 42 CFR 401.105, and theroutine use exception of the Privacy Act

(5 U.S.C. 522a(b)(3)). CMS retains full

Hospitals and Other Health CareEntities

The Secretary of HHS will conduct aninvestigation if there is reason to believethat a health care entity has substantiallyfailed to report required adverse actions. If the investigation reveals that the healthcare entity has not complied with NPDBregulations, the Secretary will provide theentity with written notice describing thenoncompliance. This written noticeprovides the entity with the opportunity tocorrect the noncompliance, as well asnotifies it of its right to request a hearing.

A request for a hearing must contain astatement of the material factual issues indispute to demonstrate cause for a hearingand must be submitted to HHS within 30days of receipt of notice ofnoncompliance. An example of a materialfactual issue in dispute is a health careentity refuting HHS’s claim that the healthcare entity failed to meet reportingrequirements.

A request for a hearing will be denied if itis untimely, lacks a statement of materialfactual issues in dispute, or if thestatement is frivolous or inconsequential. Hearings are held in the Washington, DC,metropolitan area.

If HHS determines that a health care entityhas substantially failed to reportinformation in accordance with Title IVrequirements, the name of the entity willbe published in the Federal Register, andthe entity will lose the immunityprovisions of Title IV with respect toprofessional review activities for a periodof 3 years commencing 30 days from thedate of publication in the FederalRegister.

State Boards

State medical and dental boards that fail tocomply with NPDB reportingrequirements can have the responsibility toreport removed from them by theSecretary of HHS. In such instances, theSecretary will designate another qualifiedentity to report NPDB information.State medical or dental boards do not meetTitle IV requirements when they fail toreport licensure disciplinary actionsrequired to be reported to the NPDB or failto notify HHS when they are aware ahealth care entity is failing to reportadverse actions it has taken againstphysicians and dentists.

When an HHS investigation substantiatessuch reporting failures, a written notice ofnoncompliance is sent to the State medicalor dental board. This notice allows Statemedical and dental boards an opportunityto correct the situation. If the Statemedical or dental board fails to complywith the HHS notice, then HHS willdesignate another qualified entity forreporting to the NPDB.


A professional society that hassubstantially failed to report adversemembership actions can lose, for 3 years,the immunity protections provided underTitle IV for professional review actions ittakes against physicians and dentists basedon their professional competence andprofessional conduct.

The Secretary of HHS will conduct aninvestigation if there is reason to believethat a professional society hassubstantially failed to report adverse membership actions taken as result ofprofessional review activity.

E-28 September 2001


If the investigation reveals that theprofessional society has not compliedwith Title IV reporting requirements,HHS will inform the professional societyof its noncompliance in writing. Thiswritten notice provides the professionalsociety with the opportunity to correctthe noncompliance, as well as notifies itof its right to request a hearing.

A request for a hearing must contain astatement of the material factual issues indispute to demonstrate cause for a hearingand must be submitted to HHS within 30days of receipt of notice ofnoncompliance. An example of a materialfactual issue in dispute is a professionalsociety refuting HHS’s claim that thehealth care entity failed to meet reportingrequirements.

A request for a hearing is denied if it isuntimely, lacks a statement of materialfactual issues in dispute, or if thestatement is frivolous or inconsequential. Hearings are held in the Washington, DC,metropolitan area.

If HHS determines that a professionalsociety has substantially failed to reportinformation in accordance with Title IVrequirements, the name of the entity willbe published in the Federal Register, andthe professional society will lose theimmunity provisions of Title IV withrespect to professional review activitiesfor a period of 3 years commencing 30days from the date of publication in theFederal Register.

1. How long are reports held in theNPDB?

Information reported to the NPDB ismaintained permanently unless it iscorrected or voided from the system. A Correction or Void may only besubmitted by the reporting entity ordirected by the Secretary of HHS.

2. Can my organization provide a copyof an NPDB report to the subjectpractitioner?

The NPDB appreciates entities thatattempt to maintain an open exchangewith subjects. However, if youprovide a copy of the report to thesubject, be sure to remove or obliterateyour organization’s DBID. The DBIDshould remain confidential to theorganization to which it is assigned.

3. Where can I find lists of AdverseAction Classification Codes, Basisfor Actions Codes, and MalpracticeAct(s) or Omission(s) codes?

Adverse action classification codesand medical malpractice act(s) oromission(s) codes are provided inpop-up lists in the respective IQRSweb input screens. These codes alsoare found in the applicable InterfaceControl Document (ICD) that isavailable on the NPDB-HIPDBwebsite.


September 2001 E-29


Reporting Medical Malpractice Payments

4. I am the new authorized submitterfor a medical malpractice payer. Ifound some documentation ofpayments that were not reported tothe NPDB. What should I do?

If the payments were made on or afterSeptember 1, 1990 (when the NPDBopened), submit reports on thosepayments to the NPDB. Theregulations prescribe that any entitythat fails to report a payment requiredto be reported is subject to a civilmoney penalty of up to $11,000 foreach such payment. Submit the reportthrough the IQRS and then send aletter to the NPDB that explains thecircumstance of the report beingsubmitted late. The NPDB willmaintain this information for auditpurposes.

5. As a medical malpractice payer, doI have to report payments made fora deceased subject?

Yes. One of the principal objectivesof the NPDB is to restrict the abilityof incompetent practitioners to movefrom State to State without disclosureof their previous damaging orincompetent performance. Fraudulentpractitioners may seek to assume theidentity of a deceased practitioner.

6. Must a written complaint bedirected to the subject cited in theclaim?

No. The definition of a medicalmalpractice complaint includescomplaints “brought in any State orFederal court or other adjudicativebody.” If a patient files a written

complaint with, for example, a Stateboard, and a medical malpracticepayment results, the payment must bereported to the NPDB.

7. How does a medical malpracticepayer report a payment if a totalamount has not been determinedand the payer is making an initialpartial payment?

Complete the MMPR screensaccording to the instructions on theIQRS. Note the amount of the firstpayment and, in the narrative section,explain that the total amount has notbeen determined and the first paymentis a partial payment. When the finalamount is determined, submit aCorrection to the Initial report, andnote the final amount in the narrativesection.

8. Should payment exclusively for thebenefit of a clinic or hospital bereported?

Medical malpractice payments madesolely for the benefit of a clinic orhospital are not currently reportable tothe NPDB.

9. Our insurance company reimburseda practitioner for a medicalmalpractice payment thepractitioner made to a patient. Isthis reportable?

Yes. An insurance company thatreimburses a practitioner for such apayment (makes a payment inresponse to the medical malpracticeclaim or judgment) must report thatpayment to the NPDB, as long as thepatient submitted the demand inwriting.

E-30 September 2001


10. If a patient makes an oral demandfor a refund for services, is theresulting payment reportable to theNPDB?

No. Only payments resulting fromwritten demands are reportable to theNPDB. Even if the practitionertransmits the demand in writing to themedical malpractice payer, thepayment is not reportable if thepatient’s only demand was oral. However, if a subsequent writtenclaim or demand is received from thepatient and results in a payment, thatpayment is reportable.

11. If an individual practitioner is notnamed in a medical malpracticeclaim or complaint, but the facilityor practitioner group is named,should the payment be reported?

No, with one exception. If the nameddefendant is a sole practitioneridentified as a “professionalcorporation,” a payment made for theprofessional corporation must bereported for the practitioner.

12. A supervisory practitioner is namedin an action based on the services ofa subordinate practitioner. How doI report the supervisorypractitioner?

The report on the supervisorypractitioner should be submitted usingthe same malpractice claim descrip-tion code used for the subordinate. The reporting entity may provide anexplanation that the supervisorypractitioner was named based on thesubordinate practitioner’s services inthe narrative description.

13. What are the reportingrequirements for self-insured em-ployers who provide professionalliability coverage for their employedpractitioners?

Employers who insure theiremployees must report medicalmalpractice payments they make forthe benefit of their employees.

14. If a stipulation of settlement orcourt order requires that its termsremain confidential, how does amedical malpractice insurer reportthe payment to the NPDB withoutviolating the settlement agreementor court order?

Confidential terms of a settlement orjudgment do not excuse an entity fromthe statutory requirement to report thepayment to the NPDB. The reportingentity should explain in the narrativesection of the MMPR that thesettlement or court order stipulatesthat the terms of the settlement areconfidential.

15. If there is no medical malpracticepayment and Loss AdjustmentExpenses (LAEs) are paid in orderto release or dismiss a healthcarepractitioner from a medicalmalpractice suit, should the LAE bereported?

No. If LAEs are not included in themedical malpractice payment, thenthey should not be reported to theNPDB.


September 2001 E-31

16. When reporting a medicalmalpractice payment, should lossadjustment expenses be included inthe payment amount?

LAEs should be reported only if theyare part of the medical malpracticepayment. Reporting requirementsinclude the total amount of thepayment and a description and amountof the judgment or settlement and anyconditions, including terms ofpayment. LAEs should be itemized inthe description section of the report. LAEs refer to expenses other thanthose in compensation of injuries,such as attorney’s fees, billable hours,expert witness fees, deposition, andtranscript costs. If LAEs are notincluded in the payment amount, theyneed not be reported.

17. Are payments made for the benefitof residents, interns, and studentsreportable?

Payments made for the benefit oflicensed residents and interns arereportable to the NPDB; paymentsmade for the benefit of unlicensedmedical or dental students are notreportable to the NPDB.

Reporting Adverse Licensure Actions

18. How should a State board report anaction with several levels orcomponents, for instance, a 6-monthlicense suspension followed by a 2-year probation?

The board should report the code ofthe principal sanction or action anddescribe its full order, including lesseractions, in the narrative of the AAR. An additional report is not necessary

when the lesser sanction or action isimplemented since it was included inthe description in the Initial Report.

19. How should a State medical ordental board report actions whenthey are changed by court order?

The board should report the initialadverse action as usual; the judicialdecision is reported as a Revision toAction. For example, if a boardrevoked a physician’s license and ajudicial appeal resulted in the courtmodifying the discipline to probationfor 1 year, then the board would berequired to report both its initialrevocation action and the court-ordered revision to a 1-year probation.When a court stays a board’s order,this action may be reported as aRevision to Action, using the AdverseAction Classification Code forReduction of Previous Action (1295).When a court overturns a Board’sorder, the Board should void theInitial Report.

20. When reporting a reprimand by aState licensing board, what Lengthof Action should be entered on thereport form?

The indefinite block should be markedon the appropriate report screen in theIQRS for reprimands reported to theNPDB.

E-32 September 2001


Reporting Adverse Clinical PrivilegesActions

21. If we revoke a practitioner’s clinicalprivileges because the practitionerlost his/her license, do we report therevocation?

Administrative actions that do notinvolve a professional review actionare not reportable to the NPDB. Onlyactions resulting from professionalreview and lasting more than 30 daysthat are related to the professionalcompetence or professional conduct ofa practitioner should be reported to theNPDB. Thus, if the revocation ofclinical privileges is automatic, theaction should not be reported to theNPDB.

22. Are adverse actions on clinicalprivileges reportable prior tohearings?

The action is not reportable until it ismade final by the health care entity. An exception is made if an immediate(that is, summary) suspension orrestriction subject to subsequentnotice and hearing is enforced becauseof imminent danger to an individual’shealth and safety.

A summary suspension of clinicalprivileges is not routinely considered areportable event. However, if asummary suspension lasts longer than30 days and is considered by thehospital or other health care entity tobe a professional review action (whichmeans that it is so defined in theorganization’s bylaws), then the entitymust report the summary suspension.

If the reported suspension issubsequently altered following ahearing or other procedures, the entitymust submit a Revision to Action orVoid.

23. Are adverse actions on clinicalprivileges reportable prior toappeals?

Adverse actions on clinical privilegesare not reportable until they are madefinal by the health care entity. If aninternal administrative appealpreceding final action by the entity isprovided for in the entity’s bylaws,then the action is not reportable untilthe conclusion of this appeal. However, if a previously reportedadverse action is subsequentlymodified or vacated after an appeal bythe practitioner, the health care entityis responsible for submitting aRevision to Action or Void.

24. A health care entity took an adverseaction against a practitioner, butthe action was enjoined before itwas implemented. Should theaction be reported to the NPDB?

Adverse actions are reportable only ifthey are in effect for at least 30 days. An adverse action enjoined prior toimplementation should not bereported. However, if the adverseaction has been in effect for 30 ormore days and is then enjoined, theadverse action should be reported andthe enjoinment should be reported as aRevision to Action.


September 2001 E-33

25. Are investigations reportable if theydo not reach a conclusion?

Investigations are not reportableevents; however, if a practitionersurrenders or fails to renew clinicalprivileges, or if privileges arerestricted while the practitioner iseither under investigation by a healthcare entity for possible incompetenceor improper professional conduct, orto avoid an investigation, thesurrender or restriction must bereported to the NPDB.

26. A practitioner is under investigationrelating to possible incompetence orimproper professional conduct andresigns from the hospital. If thepractitioner did not receivenotification of the investigation, isthis a reportable event?

Under the provisions of the HealthCare Quality Improvement Act, thepractitioner is not required to havedirect knowledge of the investigation. Hospitals should be able to produceevidence of an on-going investigationin the event of questioning. See theInvestigations section of this chapterfor more information.

To be considered reportable, apractitioner’s resignation must betendered “in order to prevent aprofessional review action.” Aresignation tendered with theunderstanding that the hospital willcease an investigation or professionalreview action is reportable.

27. Must a hospital or other health careentity report adverse actionsconcerning the clinical privileges ofmedical and dental residents andinterns?

Not if the action was taken within thescope of the training program. Sinceresidents and interns are trainees ingraduate health professions educationprograms, they are not granted clinicalprivileges per se, but are authorizedby the sponsoring institution toperform clinical duties andresponsibilities within the context oftheir graduate educational program.

However, a resident or intern maypractice outside the scope of theformal graduate education program,for example, moonlighting in theIntensive Care Unit or EmergencyDepartment. Adverse clinicalprivileges actions related to practiceoccurring outside the scope of aformal graduate educational programare reportable.

28. If an initial application for clinicalprivileges is denied or the privilegesgranted are more limited than thoserequested, must this be reported tothe NPDB?

Yes, if the denial or limitation ofprivileges is the result of aprofessional review action and isrelated to the practitioner’sprofessional competence orprofessional conduct.

E-34 September 2001


29. If an “impaired practitioner” entersa rehabilitation program, is itreportable?

The voluntary entrance of animpaired practitioner into arehabilitation program is notreportable to the NPDB if noprofessional review action was takenand the practitioner did not relinquishclinical privileges. If a practitionertakes a leave of absence and clinicalprivileges have not been taken away,then no report to the NPDB isrequired.

If an impaired practitioner is requiredby a professional review action toinvoluntarily enter a rehabilitationprogram, the professional reviewaction is reportable to the NPDB if itis based on the practitioner’sprofessional competence orprofessional conduct and adverselyaffects the practitioner’s clinicalprivileges for more than 30 days.

When completing the AAR inputscreen, the reporting entity can selectan Adverse Action ClassificationCode of “Other” and explain in thenarrative that the practitioner’sprivileges were restricted orsuspended because of concernsregarding quality of care. Entitiesmay wish to consult with their legalcounsel regarding the wording of thenarrative before it is submitted to theNPDB.

30. An “impaired practitioner”member of a hospital medical staffhas been repeatedly encouraged toenter a rehabilitation program. Thepractitioner continues to disregardthe hospital’s advice and offers of

assistance. If an authorized hospitalofficial, such as the CEO orDepartment Chair, directs thepractitioner to give up clinicalprivileges and enter a rehabilitationprogram or face investigationrelating to possible professionalincompetence or improperprofessional conduct, is thesurrender of clinical privilegesreportable to the NPDB?

Yes. If the hospital CEO directs thepractitioner to surrender his or herclinical privileges or faceinvestigation by the hospital forpossible professional incompetence orimproper professional behavior, thesurrender is reportable to the NPDB. The surrender of clinical privileges inexchange for not undergoing aninvestigation triggers a report to theNPDB, regardless of whether thepractitioner is impaired [see §60.9(a)(ii)(A) and (B) of the NPDBregulations].

31. Laws related to drug and alcoholtreatment programs haveconfidentiality provisions. Won’t areport concerning a practitioner ina treatment program violate thoseprovisions?

No. Only the adverse action affectingprivileges must be reported; the factthat a practitioner entered a treatmentor rehabilitation program should notbe reported. If only the adverse actionis reported as required, there is noviolation of laws related to drug oralcohol treatment (42 USC, §290dd-3and 290ee-3).


September 2001 E-35

Reporting Adverse Membership Actions

32. If a professional society deniesmembership to a practitioner, is itreportable to the NPDB?

The action must be reported to theNPDB if the denial of membershipwas based on a professional reviewaction conducted through a formalpeer review process and was based onan assessment of the practitioner’sprofessional competence orprofessional conduct which affected orcould affect the health and welfare ofa patient or patients. Denial ofmembership for reasons not related toprofessional competence orprofessional conduct which affects orcould adversely affect the health andsafety of a patient (advertisingpractices or fee structures, forexample) should not be reported to theNPDB.

E-36 September 2001


warnerc


NPDB Guidebook Chapter F Disputes

September 2001 F-1

The Dispute Process

The NPDB is committed to maintainingaccurate information and ensuring thathealth care practitioners are informedwhen adverse actions are reported aboutthem. When the NPDB receives a report,the IQRS processes the informationexactly as it is submitted by the reportingentity. Reporting entities are responsiblefor the accuracy of the information theyreport.

When the NPDB processes a report, aReport Verification Document is sentelectronically to the reporting entity viathe IQRS and can be accessed at theReport Status screen. A Notification of aReport in the Data Bank(s) is mailed to thesubject. The subject should review thereport for accuracy, including suchinformation as current address and placeof employment.

Subjects may not submit changes toreports. If any information in a report isinaccurate, the subject must request thatthe reporting entity file a correction to thereport. The NPDB is prohibited by lawfrom modifying information submitted inreports.

If the reporting entity declines to changethe report, the subject may initiate adispute of the report through the disputeprocess, add a statement to the report, orboth. The dispute process is not an avenueto protest a payment or to appeal theunderlying reasons of an adverse actionaffecting the subject's license, clinicalprivileges, or professional societymembership. Neither the merits of amedical malpractice claim nor theappropriateness of, or basis for, an adverseaction may be disputed.

Subjects who wish to add a statement toand/or dispute the factual accuracy of areport should follow the instructions onthe Notification of a Report in the DataBank(s). Subjects who do not have theoriginal Notification of a Report in theData Bank(s) may obtain a SubjectStatement and Dispute Initiation formfrom the NPDB-HIPDB web site atwww.npdb-hipdb.com.

Subject Statements

The subject of a report may add astatement to the report at any time. Whenthe NPDB processes a statement,notification of the statement is sent to allqueriers who received the report, and isincluded with the report when it isreleased to future queriers. SubjectStatements are limited to 2,000 characters,including spaces and punctuation. Drafting a statement in accordance withthe character limits ensures that thestatement contains the information asubject deems most important. Allcharacters beyond 2,000 are truncated. Subject Statements cannot include anynames, addresses, or phone numbers,including those of patients.

A Subject Statement is part of the specificreport it is filed for. If the report ischanged by the reporting entity, thestatement attached to the report also isremoved. If a statement is needed with thenew report, a new statement thatreferences the Data Bank Control Number(DCN) of the new report must besubmitted.

Chapter F Disputes NPDB Guidebook

F-2 September 2001

Subject Disputes

The subject of a Medical MalpracticePayment Report (MMPR) or an AdverseAction Report (AAR) may dispute eitherthe factual accuracy of the report orwhether a report was submitted inaccordance with the NPDB’s reportingrequirements, including the eligibility ofthe entity to report the information to theNPDB. A subject may not dispute areport in order to protest a decision madeby an insurer to settle a claim or to appealthe underlying reasons for an adverseaction.

If a subject believes that information in areport is factually inaccurate (e.g., anincorrect adverse action code or paymentamount) or should not have been reported,(e.g., a clinical privileges action that lasts30 days or less), the subject must attemptto resolve the disagreement directly withthe reporting entity. Changes to a reportmay be submitted only by the reportingentity.

When the NPDB receives a properlycompleted Subject Statement and DisputeInitiation form from the subject initiating adispute, notification of the dispute is sentto all queriers who received the report, andis included with the report when it isreleased to future queriers.

A dispute becomes part of the specificreport it is contesting. If the report ischanged by the reporting entity, thedispute notation attached to the reportis also removed. If the subject believesthat the new version of the report isfactually inaccurate, the subject mustinitiate a new dispute.

There are three possible outcomes for adispute:

• The reporting entity corrects the reportto the satisfaction of the subject.

• The reporting entity voids the report.• The reporting entity declines to change

the report.

ReportingEntity

Notified ofDispute

SubjectNotified ofReceipt of

Dispute

HistoricalQueriers

Notified ofDispute

PRECEDING EVENTS:

Dispute Overview (1 of 2)

• Entity Submits Report• Subject Is Notified• Subject Contacts Reporting Entity• Subject Notifies NPDB to

Initiate Dispute


September 2001 F-3

Secretarial Review

If the reporting entity declines to changethe disputed Adverse Action Report orMedical Malpractice Payment Report ortakes no action, the subject may requestthat the Secretary of HHS review thedisputed report. The Secretary reviewsdisputed reports only for accuracy offactual information and to ensure that theinformation was required to be reported.

The Secretary does not review the meritsof a medical malpractice claim in the caseof a payment or the appropriateness of, orbasis for, a health care entity’s profes-sional review action or a State licensingboard’s action.

To request Secretarial Review of adisputed report, the subject must sign andreturn to the NPDB the Instructions forReview of the Disputed Report by theSecretary of the U.S. Department ofHealth and Human Services attached tothe Report Revised, Voided, or StatusChanged document related to the disputed

report. The dispute and anyaccompanying documentation must besent to the NPDB, not directly to theSecretary.

The subject also must:

• State clearly and briefly in writingwhich facts are in dispute and what thesubject believes are the facts.

• Submit documentation substantiatingthat the reporting entity’s informationis inaccurate. Documentation mustdirectly relate to the facts in disputeand substantially contribute to adetermination of the factual accuracyof the report. Documentation may notexceed 10 pages, includingattachments and exhibits.

• Submit proof that the subjectattempted to resolve the disagreementwith the reporting entity, but wasunsuccessful. Proof may be a copy ofthe subject’s correspondence to thereporting entity and the entity’sresponse, if any.

ChangedReport

toSubject

ChangedReport

Verificationto Reporting

Entity

Reporting EntityResolvesDisputeby Correcting orVoiding Report

ChangedReport toPreviousQueriers

Dispute Overview (2 of 2)


F-4 September 2001

• Wait 30 days from the date ofinitiating discussions with thereporting entity before requestingSecretarial Review to give thereporting entity time to respond to thedispute.

Pertinent Documentation

If the dispute relates to a MedicalMalpractice Payment Report, pertinentdocumentation might include a copy ofthe following:

• Written claim.• Settlement or release document.• Court judgment.• Written findings of arbitration or other

alternative dispute resolutionprocesses.

If necessary, the Secretary will ask thereporting entity to supply additionalinformation confirming that the report wassubmitted in accordance with NPDBregulations. Entities must respond to theSecretary’s request for more informationwithin 15 days. After reviewing alldocumentation related to the dispute, theSecretary will determine whether theinformation in the disputed report isaccurate and should have been reported tothe NPDB.

If the dispute relates to an AdverseAction Report, pertinent documentationmight include a copy of the following:

• The findings of fact andrecommendations of the health careentity, professional society, or Statelicensing board.

• The final report of the hearing panel orother appellate body upon which the

Secretarial Review Results

When the NPDB receives proper notice ofa request for Secretarial Review, thematerials are forwarded to the Secretary ofHHS for review. There are three possibleoutcomes for Secretarial Review of adispute:

• The Secretary concludes that the reportis accurate.

• The Secretary concludes that the reportis inaccurate.

•

Report Accurate as Submitted

If the Secretary concludes that theinformation in the report is accurate, theSecretary sends an explanation of thedecision to the subject. The subject maythen submit, within 30 days, a statementthat is added to the report. The statementis limited to 2,000 characters, includingspaces and punctuation, and is entered intothe NPDB computer system exactly assubmitted. The new Subject Statementreplaces any statement the subjectsubmitted previously. If no new SubjectStatement is received, any existingstatement previously submitted by thesubject is maintained as part of the reportrecord.

The subject of the report, the reportingentity, and all queriers who receivednotice of the disputed report are each senta Report Revised, Voided, or StatusChanged document containing the

description of acts or omissions wasbased.

Secretary’s explanation and the subject’sstatement. Future queriers will receive theSecretary’s and subject’s statements withthe report.

The Secretary concludes that the issuesin dispute are outside the scope ofSecretarial Review.


September 2001 F-5

Report Inaccurate as Submitted

If the Secretary concludes that the report isinaccurate, the Secretary directs the NPDBto correct the information in the report. The subject of the report, the reportingentity, and all queriers who receivednotice of the disputed report are each senta Report Revised, Voided, or StatusChanged document informing them of thecorrection.

If the Secretary concludes that the reportwas submitted in error, the Secretarydirects that the report be voided from theNPDB. The subject of the report, thereporting entity, and all queriers whoreceived notice of the disputed report areeach sent a Report Revised, Voided, orStatus Changed document informing themthat the report has been voided.

Dispute Outside the Scope of SecretarialReview

If the Secretary concludes that the issue indispute is outside the scope of review, theSecretary directs the NPDB to add anentry to that effect to the report and toremove the dispute notation from thereport. The subject may then submit,within 30 days, a statement that is addedto the report. The statement is limited to2,000 characters, including spaces andpunctuation, and is entered into the NPDBcomputer system exactly as submitted. Ifno new Subject Statement is received, anyexisting statement previously submitted bythe subject is maintained as part of thereport record.

The subject of the report, the reportingentity, and all queriers who receivednotice of the disputed report are each senta Report Revised, Voided, or StatusChanged document informing them of theSecretary's decision.

Secretarial Review Overview

• Subject and Reporting Entity Cannot Resolve Dispute• Subject Requests Secretarial Review

PRECEDINGSubject,

Reporting Entity,and Previous

Queriers Notifiedof Outcome

Secretary HHSReviewsDispute

Documentation


F-6 September 2001

Reconsideration of the Secretary’sDecisions on Disputes

Although HHS does not have a formalappeals process for reconsideration of theSecretary's decisions on disputes, HHSdoes review such requests. The subjectmust submit a written request forreconsideration to the office that issued theSecretary's determination. The subjectshould be specific about any newinformation that was unavailable at thetime of Secretarial Review and whichissues the practitioner believes were notappropriately considered during the reviewprocess. The Secretary will either affirmthe prior determination or issue a revisedfinding. HHS, however, gives priority toinitial requests for Secretarial Review.

Improper Requests for SecretarialReview

A request for Secretarial Review isconsidered improper when the report inquestion has not previously been disputedby the subject. Before requestingSecretarial Review, a subject must firstattempt to resolve the disagreement withthe reporting entity and then may disputethe report according to the instructionsprovided on the Notification of a Report inthe Data Bank(s) document.

If a subject submits an improper requestfor Secretarial Review, the NPDB willnotify the subject that the report must firstbe disputed and resolution attempted withthe reporting entity.

Examples of Disputes

Due Process - Alleged Denial

Example: A practitioner alleged that anentity, during professional review, deniedthe practitioner due process because thereviewers ignored the testimony ofmedical experts or other witnesses calledto prove various points the practitioner feltimportant to the defense.

Outcome: The Secretary determined thatthe dispute request was outside the scopeof review and made an entry to that effectin the report. The dispute notation wasremoved from the report.

Due Process - Legal Action Pending

Example: A practitioner disputed a reporton the revocation of his or her clinicalprivileges by a hospital on the basis thatdue process was denied duringprofessional review. The practitionerfurther stated that since he or she hadinitiated a legal action against the hospitalregarding the due process, the reportshould be removed from the NPDB untillegal action is resolved.

Outcome: The Secretary determined thatthe dispute request was outside the scopeof review. The Secretary additionallystated that if a court action resulted in areportable change to the action previouslyreported, a second report must besubmitted by the reporting entity. Thisnew report could make corrections, be arevision to the action, or be a void of theprior report.


September 2001 F-7

Licensure Completion - Trigger Date

Example: A pharmacy student committedan act of alleged malpractice while intraining in the pharmacy of a retail store. The student had no license at the time ofthe alleged act. However, at the time thepayment was made on the student’s behalf,the student had completed training andreceived a license. The practitionerdisputed the report on the basis that apractitioner must be licensed at the time ofthe alleged incident in order for a report tobe made to the NPDB.

Outcome: The Secretary directed that thereport be voided from the NPDB since ithas been determined that the appropriatetrigger date for determining if thepractitioner is licensed is the date onwhich the reported incident occurred, notthe date on which the payment was made.

Narrative Description - Inaccurate

Example: A practitioner disputed a reportof a licensure disciplinary action taken bya State board of medical examiners statingthat the narrative regarding the act oromission was not accurate. Thepractitioner requested that the descriptionbe changed to reflect the findings of theboard.

Outcome: The Secretary reviewed thenarrative against the findings reported bythe State board and determined that thereport would be accurate if the actuallanguage from the board’s findings wereused. The Secretary directed the NPDB tochange the narrative. The dispute notationwas removed from the report.

Narrative Description - LegalSufficiency

The purpose of the narrative descriptionsection of the report is to describe the acts,omissions, or reasons for the actionreported. Section 423(a)(3)(B) of theHealth Care Quality Assurance Act [42U.S.C., Section 11133(a)(3)(B)] requiressuch “description of the acts or omissionsor other reasons for the action.” Thelegislative history states that the narrative“... does not necessarily require anextensive description of the acts oromissions or other reasons for the actionor, if known, for the surrender. It does,however, require sufficient specificity toenable a knowledgeable observer todetermine clearly the circumstances of theaction or surrender.”

A significant number of reports do notmeet these legal requirements. Thefollowing are examples of legallyinadequate descriptions found in thenarrative description section of disputedreports:

Example 1: “Dr. X was found to exhibitimproper and unprofessional conduct.”

Example 2: “The ABC Hospital Boardtook final action on January 2, 1994,instituting a mandatory concurringconsultation and monitoring requirementfor a 6-month period, following an appealby Dr. Y.”

Example 3: “See attached letter.”

Outcomes: The Secretary required thereporting entities to correct the reports toinclude more descriptive/explicativenarratives. The contents of attachmentsare not entered into reports.


F-8 September 2001

Narrative Description - Misleading

Example: A practitioner disputed ahospital’s report that he resigned whileunder investigation. The narrative statedthat there were no questions ofprofessional competence or conduct, butthat the issues that led to the investigationand the resignation were problems in thepractitioner’s bedside manner.

Outcome: The Secretary found that thereport should be voided because the reasonfor the investigation as shown in thenarrative was unrelated to professionalcompetence or conduct. The hospitalchanged the narrative of the report toindicate that the investigation wasundertaken as a matter of professionalcompetence due to a misdiagnosis of apatient in the emergency room. Thepractitioner disputed this revised report. The Secretary reviewed the correctedreport and the supporting materialsubmitted by the hospital and found thatthe corrected report showed a reportableevent.

It is unclear why the hospital submittedthe initial report with language in thenarrative that made the resignation appearunreportable. This case serves toemphasize the importance of providingaccurate and complete information whencomposing the narrative section of areport.

Privileges - Resignation and SurrenderWhile Under Investigation

Example: A practitioner disputed a reportthat he had resigned privileges during aninvestigation concerning professionalcompetence. The practitioner disputed thereport on the basis that he was unaware ofany investigation and did not believe onewas ongoing at the time. The practitioneralso stated that he did not resign in orderto avoid a review, but because his contractwas expiring and he had found a new job.

Secretary’s Response: The Secretaryrequested that the entity submitcontemporaneous documentation showingthat the entity had undertaken aninvestigation of the physician. Suchdocumentation might have includedfindings of reviewers or directives of theexecutive committee or other professionalreview bodies in the hospital, or minutesfrom a professional review entity. Theentity was unable or unwilling to provideany documentation that an investigationwas occurring at the time the practitionerleft. Since no contemporaneousdocumentation of an ongoing investigationwas provided, the Secretary determinedthat the report should be voided.

The Secretary also stated that thepractitioner need not be aware of anongoing investigation at the time of theresignation in order for the entity toreport the resignation to the NPDB,since many investigations start withoutany formal allegation being madeagainst the practitioner. The reason thepractitioner gives for leaving an entitywhile under investigation is irrelevantto reportability of the resignation.


September 2001 F-9

Privileges - Suspension and HospitalMotivation

Example: A practitioner disputed thereport of a suspension of clinicalprivileges. The practitioner claimed thatthe motivation for the action was apersonality conflict with the chairman ofhis department, a matter unrelated toprofessional competence.

Outcome: The Secretary determined thatthe dispute request was outside the scopeof review since the motivation of thehospital or individuals involved in the caseis not reviewed by the Secretary and madean entry to that effect in the report. Thedispute notation was removed from thereport.

Professional Review - AlternativeEmployment Termination Procedure

Example: A practitioner disputed a reportof the revocation of clinical privileges. The hospital has a system of professionalreview established under its bylaws anddelivers health care services. The hospitalalso has an “employment terminationprocedure.” The employment terminationprocedure was used by the hospital to enda practitioner’s employment without useof the professional review process. Thepractitioner’s privileges were revoked bythe employment termination process, butno action was taken through theprofessional review process.

The practitioner was given no option inhow the termination would occur.

Outcome: The Secretary directed that thereport be voided from the NPDB since theprofessional review process had not beenfollowed in terminating the practitioner’sprivileges. The termination was not aprofessional review action.

Some hospitals have stated that if theyfollow professional review procedures toremove the practitioner’s privileges, theymust then follow employment terminationprocedures in order to fire the practitioner.Hospitals have stated that by followingthe employment termination procedures,practitioners’ privileges will automaticallyterminate. One hospital required allphysicians on staff to waive their rights tothe professional review process as acondition of employment. Health careentities are reminded that in order to bereportable to the NPDB, adverse actionsmust be the result of professional review.

Residency Status

Example: A licensed medical residentdisputed a Medical Malpractice PaymentReport on the basis that she was in trainingat the time of the incident.

Outcome: The Secretary determined thatthe dispute request was outside the scopeof review and made an entry to that effectin the report. The payment is reportable ifthe practitioner (regardless of residentstatus) is named in both the claim andsettlement or judgement and a payment ismade on his or her behalf. The disputenotation was removed from the report.

Responsibility for Treatment

Example: A practitioner disputed aMedical Malpractice Payment Reportbecause she saw the patient only once andwas not responsible.

Outcome: The Secretary determined thatthe dispute request was outside the scopeof review and made an entry to that effectin the report. The number of times apatient is seen by a practitioner or thelevel of responsibility is irrelevant to


F-10 September 2001

reporting a medical malpractice payment. The dispute notation was removed fromthe report.

Settlement - Subject Disagrees

Example: A practitioner disputed aMedical Malpractice Payment Report onthe basis that he did not concur with thesettlement.

Outcome: The Secretary determined thatthe dispute request was outside the scopeof review since the practitioner’sagreement to a settlement is irrelevant tothe reportability of the payment. TheSecretary made an entry to that effect inthe report, and the dispute notation wasremoved from the report.

Settlement - Subject Dismissed fromLawsuit

Example: A practitioner disputed aMedical Malpractice Payment Report onthe basis that she was dismissed from thelawsuit by summary judgment before thesettlement. The order granting summaryjudgment provided that the practitioner bedismissed from the lawsuit as having noliability, and that the plaintiff make norecovery against the practitioner.

Outcome: The Secretary directed theNPDB to void the report since no claimexisted against the practitioner and nopayment was made on his or her behalf. Although the insurance company mayhave named the practitioner in the releaseor settlement, any payment made wouldnot be on behalf of this practitioner due tothe summary judgment order.

Suspension - Indefinite Length

Example: A practitioner disputed a reportof a summary suspension of clinicalprivileges on the basis that the suspensionwas less than 30 days. The hospitalreported the suspension of thepractitioner’s clinical privileges on the10th day of an indefinite suspension. Attendant to the suspension was arequirement that the practitioner completea specific course of action (a psychiatricevaluation). When that action wascompleted, the hospital’s professionalreview body reinstated the practitioner’sclinical privileges. The practitionercompleted the required action on the 20thday of the suspension and clinicalprivileges were immediately restored. Thesuspension of the practitioner’s clinicalprivileges did not exceed 30 days, but thehospital did not request that the report bevoided from the NPDB.

Outcome: The Secretary directed theNPDB to void the report since the durationof the suspension of the practitioner’sclinical privileges did not exceed 30 days.

When a summary suspension isindefinite in length, it should not bereported until it has been in effect formore than 30 days.

Suspension - Summary

Example: A report was made to theNPDB regarding a summary suspensionbased on a practitioner’s professionalcompetence, which did not last more than30 days. The hospital took no reportableaction following the summary suspension.The practitioner disputed the report sincethe length of the suspension was less than30 days. The practitioner resigned a yearlater while still under investigation by the


September 2001 F-11

hospital for the same type of professionalcompetency issue. The hospital submitteda report of the practitioner’s resignationwhile under investigation. Thepractitioner disputed this report on thegrounds that the same issue had previouslybeen reported to the NPDB.

Outcome: The Secretary directed theNPDB to void the first report since thesuspension did not exceed 30 days. TheSecretary determined the second report tobe correct as submitted since theresignation of the practitioner wassubmitted while under investigation forissues related to professional competence.

The practitioner was correct that thereason for the report was the same;however, reportability hinges not upon thenature of the problem or incident, but onthe circumstances under which the reportwas made (the suspension versus theresignation while under investigation).

1. I am the executor of my wife’sestate. I received notification of areport about her in the NPDB. CanI dispute the report?

Yes. To dispute a report on yourwife’s behalf, you must providedocumentation that you have beenappointed the executor or legalrepresentative of her estate. Acceptable documentation can be aphotocopy of her will or other legaldocumentation showing you as theexecutor/legal representative.

No. A subject must inform thereporting entity, in writing, of thedisagreement with the report and thebasis for that disagreement, but there isno requirement that the dispute mustbe resolved within a certain amount oftime.

3. If a subject wishes to dispute areport, does the subject have tosubmit a statement at the time ofdispute?

No. The subject may provide astatement with the initiation of dispute,but is not required to do so. A SubjectStatement may be submitted at anytime.

4. Must a subject initiate a dispute inorder to add a statement to areport?

No. The subject of a report may add astatement to a report independently ofthe dispute process.

5. If the Secretary rules a dispute to bebeyond the scope of review andplaces a notation to this effect in theNPDB, can the subject also add astatement?

Yes. Subjects are notified of thisoption by the Secretary. A SubjectStatement added to the report afterdispute resolution replaces any priorSubject Statement.

2. When a subject attempts to resolve adisagreement with a reportingentity, must the dispute be resolvedwithin a certain time frame?


warnerc


NPDB Guidebook Chapter G Fees

September 2001 G-1

Query Fees

Entity Query Fees

Fees are charged for all queries submittedto the NPDB. The query fee is based onthe cost of processing requests and pro-viding information to eligible entities. The fee is levied on a per-name basis. When multiple-name (i.e., batch) queriesare submitted, the number of names in thequery is multiplied by the per-name fee. Ifan eligible entity has registered for boththe NPDB and the HIPDB and hasselected the option to query both DataBanks (in Section D of the EntityRegistration form), each query isprocessed against both Data Banks andassessed the current fee for each DataBank.

The act of submitting a query to the NPDBis considered an agreement to pay theassociated fee. A fee is assessed when aquery is:

• Processed by the NPDB, regardless ofwhether there is information on fileregarding a subject.

• Rejected by the NPDB because it isimproperly completed or lacksrequired information.

Even when an entity designates anauthorized agent to query and/or report onbehalf of the entity, the entity is ultimatelyresponsible for payment. Contractualarrangements with authorized agentsshould include procedures for payment ofquery fees.

Query fees are subject to change. TheSecretary of HHS announces any changesin the Federal Register. Query fees arebased on the date of receipt at the NPDB.

Self-Query Fees

A practitioner may submit a self-query atany time. Self-query requests forindividuals are automatically sent to boththe NPDB and the HIPDB, and self-queriers are assessed a fee for each DataBank. All self-queries must be submittedthrough the NPDB-HIPDB web site atwww.npdb-hipdb.com. After completingthe on-line application, a self-queriershould print the formatted copy, sign it (inink) in the presence of a notary public, andmail the notarized form to the NPDB-HIPDB at the address noted on the form.

Methods of Payment

The NPDB accepts payment by credit card(VISA, MasterCard, or Discover) or pre-authorized Electronic Funds Transfer(EFT). All self-query fees must be paidby credit card. Personal checks, moneyorders, or cash are not accepted.

Entities choosing to pay by credit card donot have to make advance arrangementswith the NPDB. The user should enter thecredit card number and expiration date onthe appropriate IQRS screen whencreating a query. (Note: Credit cardinformation must be entered each time aquery file is created; the IQRS does notcurrently store this information.)

Entities choosing to pay by EFT mustsubmit an Electronic Funds TransferAuthorization form before EFT paymentscan be processed. The form is available atwww.npdb-hipdb.com. Entities mustprovide their Data Bank IdentificationNumber (DBID), bank routing code,account number, the type of account(checking or savings), attach a voidedblank check to the form, and sign the formin ink to establish an EFT. Once the

Chapter G Fees NPDB Guidebook

G-2 September 2001

completed form has been submitted, theNPDB-HIPDB will establish electroniccommunications with the entity’s bank. This process takes approximately twoweeks. The entity will receive verificationby mail that the EFT account has been setup successfully. Entities should verify theinformation for accuracy and, if there areany errors, mark their corrections on thedocument, sign and date it, and return it tothe NPDB-HIPDB. If the information iscorrect, the entity should retain it forfuture reference.

Once an entity receives verification, itmay begin to pay for query fees usingEFT. Query charges will be deductedautomatically from the entity’s designatedEFT account. Unlike the process ofpaying by credit card, the user does notneed to enter EFT account informationwhen creating a query.

Entities are responsible for ensuring thatadequate funds are present in their accountat the time queries are submitted forprocessing to avoid interruption andpotential termination of services with theData Banks. If an entity’s EFTinformation changes, the entity isresponsible for notifying the Data Banksby submitting a new Electronic FundsTransfer Authorization form.

Eligible entities may elect to have outsideorganizations query and/or report to theData Banks on their behalf. Such anorganization is referred to as theauthorized agent (see Chapter D, Queries,for more information about authorizedagents). The entity may choose to havethe query charge assessed to either theagent’s or the entity’s credit card or EFTaccount. Agents that plan to charge queryfees to their EFT account must completean Electronic Funds Transfer

Authorization form before EFT paymentscan be processed. If the entity intends forthe fees for queries submitted by the agentto be assessed to either the agent’s or theentity’s EFT account, the entity mustindicate this preference on the AuthorizedAgent Designation form, available atwww.npdb-hipdb.com.

Entities and agents may view querycharges on the Billing History screenwithin the IQRS. This screen provides themost current information available forentities and agents to better reconcilequery charge amounts as they appear ontheir EFT or credit card statements. Foreach query submission, the Billing Historyscreen provides the following information:the Data Bank Control Number (DCN)assigned to the query submission, the DataBank(s) queried, the number of queriesprocessed and charged compared to thetotal number of queries in that submission,the date the credit card or EFT accountwas charged, the amount charged, the typeof payment used, the last four digits of theaccount number, and the processing statusof the bill.

Entities also receive a Charge Receipt withtheir query responses. This document,along with the information on the BillingHistory screen, may be used by entities foraccounting purposes. The Charge Receiptprovides a list of the queried subjects, thesearch results, and the associated queryfees.

An EFT Charge Receipt also contains thefollowing information:

• Data Bank Identification Number(DBID)

• Entity Name• Entity Address• Payment Method


September 2001 G-3

• Account Number• Transaction Date (Date Queried)• Transaction Number• Current Date• Number of Subjects in Query• Number of Subjects Processed With

Charge• Number of Subjects Previously

Processed• Number of Subjects Not Processed• Fee Per Subject• Total Charge

A Credit Card Charge Receipt contains thefollowing information:

• Data Bank Identification Number(DBID)

• Entity Name• Entity Address• Payment Method• Account Number• Expiration Date• Transaction Date (Date Queried)• Transaction Number• Date Charged• Number of Subjects in Query• Number of Subjects Processed With

Charge• Number of Subjects Previously

Processed• Number of Subjects Not Processed• Fee Per Subject• Total Charge

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 names

processed within a query, regardless of thedate that each per-name fee was charged.

Account Discrepancies

If your EFT account information (e.g.,routing number, bank accountinformation) changes, you must submit anew Electronic Funds TransferAuthorization form that contains the newinformation. You must ensure that youraccount information is kept current toavoid interruption of NPDB services.

The NPDB-HIPDB collects outstandingquery fee balances. The NPDB-HIPDBwill request the entity to complete anAccount Balance Transfer Request form toauthorize settlement of an outstandingbalance. The form is available atwww.npdb-hipdb.com. There is no timelimitation associated with the collection ofan unpaid query charge.

Reconciliation of credit card statementsmust be done through the bank that issuedthe credit card. If you believe that yourcredit card or your EFT account should becredited or debited, contact theNPDB-HIPDB Customer Service Centerfor assistance. The NPDB will researchthe discrepancy and provide you with aresolution or a request for moreinformation.

Chapter G Fees NPDB Guidebook

G-4 September 2001

Credits and Debits

The NPDB issues credits when:

• A fee is incorrectly assessed.• The NPDB causes a data processing

error.

The NPDB issues debits when:

• A credit is mistakenly applied to anaccount.

• An original charge is not paid.

Requests for credits should be madewithin a 60-day period. If you suspect thatyour bill is incorrect, or if you need moreinformation about a transaction on yourbill, please write us as soon as possible. We must hear from you no later than 60days after you submitted the query onwhich the error or problem appeared. Youmay call us at 1-800-767-6732 to reportthe error, but doing so will not preserveyour rights. Your letter must provide thefollowing information:

• Your name and credit card or EFTaccount number

• The dollar amount of the suspectederror

• A description of the error andexplanation of why you believe thereis an error

• Your entity’s and/or agent’s DataBank Identification Number (DBID)

• Your telephone number• Your signature• A copy of your bill

The NPDB has the right to collect alloutstanding balances without priorapproval from the customer. Thiscollection authority does not expire.

the time period set forth by the NPDB-HIPDB. After this period, no refunds willbe warranted. In the event of a merger oracquisition of another entity, the neworganization is responsible for payment ofany outstanding debt of the priororganization.

Bankruptcy

Entities are responsible for notifying theNPDB of bankruptcy in writing and mustinclude the following information:

• DBID• Entity Name• Entity Address• Type of Bankruptcy - Chapter 7,

Chapter 9, Chapter 11, or StateLiquidation

If your organization is undergoingbankruptcy, the outstanding balance is stillcollectable until final resolution of thebankruptcy. Failure to make payments tothe Data Bank(s) can result in yourorganization being terminated from accessto the Data Bank(s).


1. How does an entity request a creditfrom the NPDB?

The entity may request a credit bysubmitting the necessary details andsupporting documentation (e.g., thequery Data Bank Control Number,query batch number if part of amultiple-name submission, and billingstatement) to the NPDB in writing.

If your organization is due a credit, thecredit must be requested in writing within


September 2001 G-5

statements sent to you by the bankthat issued your credit card, nor canthe NPDB address or investigateunauthorized charges. Please contactthe bank that issued the credit card forassistance.


If your hospital has ongoing businessand is functioning as a hospital whileconcluding its liquidation, even undera debtor-in-possession, it mustcontinue to query the NPDB. If it isin liquidation solely for the purpose ofsale of assets and there is no ongoingbusiness as a hospital, there is noreason for your organization to queryand your DBID will be deactivated. Your organization is responsible fornotifying the NPDB of its status. Ifthe hospital comes under newownership, the new owner mustregister with the NPDB and isresponsible for fulfilling its reportingand querying obligations.


Yes. Your hospital will be chargedfor all queries submitted after theNPDB receives notice of the filing ofthe Petition for Bankruptcy. Organizations that have an obligationto query the NPDB (i.e., hospitals)must still meet their queryingobligations.


the NPDB receives notice of the filingof the Petition for Bankruptcy. Organizations that have an obligationto query the NPDB (i.e., hospitals)must still meet their queryingobligations.

6. My hospital has been liquidated bythe State. Can it continue to querythe NPDB?

If your hospital has ongoing businessand is functioning as a hospital whileconcluding its liquidation, it mustcontinue to query the NPDB. Oncethe liquidation process has concludedor your organization has no ongoingbusiness as a hospital, there is noreason for your organization to queryand your DBID will be deactivated. Your organization is responsible fornotifying the NPDB of its status. Ifthe hospital comes under newownership, the new owner mustregister with the NPDB and isresponsible for fulfilling its reportingand querying obligations.

2. Does the NPDB reconcile creditcard mistakes?

The NPDB cannot answer questionsregarding credit card account Yes. Your organization will be

charged for all queries submitted after

warnerc


NPDB Guidebook Chapter H Information Sources

September 2001 H-1

NPDB-HIPDB Web SiteAssistance

The National Practitioner Data Bank-Healthcare Integrity and Protection DataBank (NPDB-HIPDB) web site, located atwww.npdb-hipdb.com, allows you tointeract with the NPDB-HIPDB moreeasily and quickly. By using yourpersonal computer and the Internet, youcan instantly access:

• The Integrated Querying andReporting Service (IQRS) where DataBank querying and reporting occurs. The IQRS contains several securityfeatures to prevent unauthorized accessand ensure the confidentiality ofinformation.

• The Self-Query Options screen, whereyou may complete an individual ororganization self-query application andthen print a formatted copy fornotarization before mailing it to theNPDB-HIPDB. You may also viewthe status of a self-query that waspreviously transmitted to the DataBank(s).

• The NPDB and HIPDB Guidebooks.

• Fact Sheets and Forms, including theEntity Registration form, AuthorizedAgent Registration form, AuthorizedAgent Designation form, andElectronic Funds TransferAuthorization form.

• A list of authorized agents.

• The NPDB and HIPDB governingstatutes and regulations.

• The NPDB and HIPDB interactivetraining programs.

• General information on the DataBanks.

• Instructions and requirements forquerying and reporting, includingsubject self-queries.

• Answers to frequently asked questions(FAQ).

• Criteria for entity eligibility.

• Information on the dispute process.

• An archive of NPDB-HIPDBnewsletters and other publications.

The NPDB-HIPDB web site includesinformation on how to contact the DataBanks. Please visit the web site toinstantly access information and findanswers to your questions.

NPDB-HIPDB Customer ServiceCenter

For additional assistance, contact theNPDB-HIPDB Customer Service Centerby e-mail at [email protected], or byphone at 1-800-767-6732 (TDD703-802-9395).

Information specialists are available tospeak with you weekdays from 8:30 a.m.to 6:00 p.m. (5:30 p.m. on Fridays)Eastern Time. The NPDB-HIPDBCustomer Service Center is closed on allFederal holidays.

Chapter H Information Sources NPDB Guidebook

H-2 September 2001

Data Bank Addresses

Requests for general information about theData Banks and requests for Dispute andSecretarial Review materials should beaddressed to:

National Practitioner Data BankHealthcare Integrity and Protection DataBankP.O. Box 10832Chantilly, VA 20153-0832

Overnight mail delivery address:

National Practitioner Data BankHealthcare Integrity and Protection DataBank4094 Majestic LanePMB-332Fairfax, VA 22033

Phone numbers:

NPDB-HIPDB Customer Service Center:1-800-767-6732Outside the U.S.: 1-703-802-9380Fax: 1-703-502-1222TDD 1-703-802-9395

Requests for aggregate research data*must be addressed to:

Division of Quality AssuranceResearch and Disputes Branch7519 Standish PlaceSuite 300Rockville, MD 20857

* There may be a charge for some datarequests.

Interpretation of NPDB Statutesand Regulations

The Division of Quality Assurance,Bureau of Health Professions, HealthResources and Services Administration,Department of Health and HumanServices, is the Government agencyresponsible for administering the NPDBand for interpreting NPDB requirements. Matters that deal specifically with thelegal interpretation of statutory andregulatory authority, should be directed to:

Associate Director for PolicyDivision of Quality AssurancePolicy Branch7519 Standish PlaceSuite 300Rockville, MD 20857

The Privacy Act and the NPDB

The Privacy Act (5 USC §552a) protectsthe contents of Federal systems of recordson individuals, like those in the NPDBfrom disclosure without the individual’sconsent, unless the disclosure is for aroutine use of the system of records aspublished annually in the FederalRegister. The published routine use ofNPDB information, which are based onthe laws and the regulations under whichthe NPDB operates, does not includedisclosure to the general public.

Write to the address in the Interpretationof NPDB Statute and Regulations section,above, for more information.


September 2001 H-3

The Freedom of Information Actand the NPDB

The NPDB, as an agency of the UnitedStates, is required to release records to thepublic with certain exceptions under theprovisions of the Freedom of InformationAct (FOIA), 5 USC §552. The lawcreating the NPDB, the Health CareQuality Improvement Act of 1986, asamended, Title IV of P.L. 99-660,provides for limited access to NPDBinformation by certain authorizedindividuals and entities and, under theprovisions of the Privacy Act, 5 USC§552a, protects practitioner informationfrom unauthorized access. The limitedaccess provision of the Health CareQuality Improvement Act of 1986, asamended, may affect the disclosurerequirements of FOIA. The HealthResources and Services Administration ofthe Department of Health and HumanServices processes FOIA requests. Forinformation about the FOIA as it relates tothe NPDB, please direct your inquiry to:

HRSA Freedom of Information OfficerHealth Resources and ServicesAdministration7519 Standish PlaceSuite 300Rockville, MD 20857(301) 443-2865

Federal Employer IdentificationNumber

The Federal Employer IdentificationNumber (FEIN) is used by paying entitiesfor billing purposes as a vendoridentification number. The vendor name,address, and FEIN for the NPDB are asfollows:

HRSA, Department of Health and HumanServices7519 Standish PlaceSuite 300Rockville, MD 20857

FEIN: 52-082-1668

State Medical and Dental Boards

Addresses and phone numbers for StateMedical and Dental Boards are listed inalphabetical order by State. Streetaddresses that are different than mailingaddresses are listed in italics. Thisinformation is current as of the publicationdate of this Guidebook.


H-4 September 2001

ALABAMA

Alabama State Board of Medical ExaminersP.O. Box 946Montgomery, AL 36101-0946848 Washington AvenuePhone: (334) 242-4116Fax: (334) 242-4155Web Site: http://www.albme.org/E-mail: [email protected]

Alabama Medical Licensure CommissionP.O. Box 887Montgomery, AL 36101-0887Phone: (334) 242-4153Fax: (334) 242-4155Web Site: http://www.albme.org/E-mail: [email protected]

Board of Dental Examiners of Alabama2327 Pansy Street, Suite BHuntsville, AL 35801Phone: (205) 533-4638Fax: (205) 533-4690E-mail: [email protected]

ALASKA

Alaska State Medical Board3601 C Street, Suite 722Anchorage, AK 99503-5986Phone: (907) 269-8160Fax: (907) 269-8156Web Site: http://www.dced.state.ak.us/occ/pmed.htm

Alaska Board of Dental ExaminersP.O. Box 110806Juneau, AK 99811-0806Phone: (907) 465-2542Fax: (907) 465-2974Web Site: http://www.dced.state.ak.us/occ/pden.htm

ARIZONA

Arizona Board of Medical Examiners9545 E. Doubletree Ranch RoadScottsdale, AZ 85258-5539Phone: (480) 551-2700Toll Free: 877-255-2212Fax: (480) 551-2704Web Site:http://www.docboard.org/bomex/index.htmE-mail: [email protected]

Arizona Board of Osteopathic Examiners inMedicine and Surgery9535 E. Doubletree Ranch RoadScottsdale, AZ 85258Phone: (480) 657-7703Fax: (480) 657-7715Web Site: http://www.azosteoboard.org/E-mail: [email protected]

Arizona Board of Dental Examiners5060 North 19th Avenue, Suite 406Phoenix, AZ 85015Phone: (602) 242-1492Fax: (602) 242-1445

ARKANSAS

Arkansas State Medical Board2100 Riverfront Drive, Suite 200Little Rock, AR 72202Phone: (501) 296-1802Fax: (501) 296-1805Web Site: http://www.armedicalboard.org/E-mail: [email protected]

Arkansas State Board of Dental Examiners101 East Capitol, Suite 111Little Rock, AR 72201Phone: (501) 682-2085Fax: (501) 682-3543Web Site: http://www.asbde.org/E-mail: [email protected]

CALIFORNIA

Medical Board of California1426 Howe Avenue, Suite 54Sacramento, CA 95825-3236Phone: (916) 263-2466Toll Free: 800-633-2322Fax: (916) 263-2387Web Site: http://www.medbd.ca.gov/

Osteopathic Medical Board of California2720 Gateway Oaks Drive, Suite 350Sacramento, CA 95833Phone: (916) 263-3100Fax: (916) 263-3117Web Site: http://www.docboard.org/cx/E-mail: [email protected]


September 2001 H-5

Dental Board of California1432 Howe Avenue, Suite 85-BSacramento, CA 95825Phone: (916) 263-2300Fax: (916) 263-2140Web Site: http://www.dca.ca.gov/r_r/dentalbd.htm

COLORADO

Colorado State Board of Medical Examiners1560 Broadway, Suite 1300Denver, CO 80202-5140Phone: (303) 894-7690Fax: (303) 894-7692Web Site: http://www.dora.state.co.us/medicalE-mail: [email protected]

Colorado State Board of Dental Examiners1560 Broadway, Suite 1310Denver, CO 80202Phone: (303) 894-7758Fax: (303) 894-7764Web Site: http://www.dora.state.co.us/dentalE-mail: [email protected]

CONNECTICUT

Connecticut Department of Public Health410 Capitol AvenueP.O. Box 340308Hartford, CT 06134-0308Phone: (860) 509-8000Web Site: http://www.state.ct.us/dph/

DELAWARE

Delaware Board of Medical PracticeP.O. Box 1401Dover, DE 19903Cannon Building, Suite 203, 861 Silver Lake Blvd.,Dover, DE 19904Phone: (302) 739-4522 Ext. 211Fax: (302) 739-2711

Delaware State Board of Dental ExaminersP.O. Box 1401Dover, DE 19903Cannon Building, Suite 203, 861 Silver Lake Blvd.,Dover, DE 19904Phone: (302) 739-4522 Ext. 220Fax: (302) 739-2711

DISTRICT OF COLUMBIA

District of Columbia Board of Medicine825 N. Capitol Street, N.E., 2nd FloorWashington, DC 20002Phone: (202) 442-9200Fax: (202) 442-9431Web Site: http://www.dchealth.com

District of Columbia Board of DentistryDepartment of Consumer and Regulatory Affairs614 H Street, N.W., Room 904Washington, DC 20001Phone: (202) 727-7478

FLORIDA

Florida Board of Medicine4052 Bald Cypress Way, Bin CO3Tallahassee, FL 32399-3253Phone: (850) 245-4131Fax: (850) 922-3040Web Site: http://www.doh.state.fl.us/mqa/medical/mehome.htm

Florida Board of Osteopathic Medicine4052 Bald Cypress Way, Bin CO6Tallahassee, FL 32399-3256Phone: (850) 488-0595Fax: (850) 921-6184Web Site: http://www.doh.state.fl.us/mqa/osteopath/oshome.htm

Florida Board of Dentistry4052 Bald Cypress Way, Bin CO6Tallahassee, FL 32399-3256Phone: (850) 488-0595Fax: (850) 921-6184Web Site: http://www.doh.state.fl.us/mqa/dentistry/dnhome.htm

GEORGIA

Georgia Composite State Board of MedicalExaminers2 Peachtree Street, 6th FloorAtlanta, GA 30303-3465Phone: (404) 656-3913Fax: (404) 656-9723Web Site: http://www.sos.state.ga.us/ebd-medical/


H-6 September 2001

Georgia Board of Dentistry237 Coliseum DriveMacon, GA 31217-3858Phone: (478) 207-1680Fax: (478) 207-1685Web Site: http://www.sos.state.ga.us/ebd-dentistry/

HAWAII

Hawaii Board of Medical ExaminersP.O. Box 3469Honolulu, HI 968011010 Richards St., Honolulu, HI 96813Phone: (808) 586-2708Fax: (808) 586-2689Licensing: (808) 586-3000Fax: (808) 586-3031

Hawaii Board of Dental ExaminersP.O. Box 3469Honolulu, HI 96801Phone: (808) 586-2702Fax: (808) 586-2704Licensing: (808) 586-3000Fax: (586) 586-3031

IDAHO

Idaho State Board of MedicineP.O. Box 83720Boise, ID 83720-0058Westgate Office Plaza, 1755 Westgate Drive, Suite140Phone: (208) 327-7000Fax: (208) 327-7005

Idaho State Board of DentistryP.O. Box 83720Boise, ID 83720-0021Phone: (208) 334-2369Fax: (208) 334-3247Web Site: http://www2.state.id.us/isbd

ILLINOIS

Illinois Department of Professional Regulation320 W. Washington StreetSpringfield, IL 62786Phone: (217) 785-0800Fax: (217) 782-7645Web Site: http://www.dpr.state.il.us/WHO/med.cfm

Illinois Board of DentistryDepartment of Professional Regulation320 W. Washington StreetSpringfield, IL 62786Phone: (217) 785-0800Web Site: http://www.dpr.state.il.us/WHO/dent.cfm

INDIANA

Indiana Health Professions Bureau402 W. Washington Street, Room W041Indianapolis, IN 46204Phone: (317) 232-2960Fax: (317) 233-4236Web Site: http://www.ai.org/hpb

Indiana State Board of Dentistry402 W. Washington Street, Room W041Indianapolis, IN 46204Phone: (317) 233-4406Web Site: http://www.accessindiana.com/hpb/isbde/

IOWA

Iowa Board of Medical Examiners400 S.W. 8th Street, Suite CDes Moines, IA 50309-4686Phone: (515) 281-5171Fax: (515) 242-5908Web Site: http://www.docboard.org/ia/ia_home.htmE-mail: [email protected]

Iowa Board of Dental Examiners400 S.W. 8th Street, Suite DDes Moines, IA 50309Phone: (515) 281-5157Fax: (515) 281-7969Web Site: http://www.state.ia.us/dentalboard/

KANSAS

Kansas State Board of Healing Arts235 S. Topeka BoulevardTopeka, KS 66603-3068Phone: (785) 296-7413Fax: (785) 296-0852Web Site: http://www.ksbha.org/E-mail: [email protected]

http://www.cis.state.mi.us/bhser/


September 2001 H-7

Kansas Dental Board3601 S.W. 29th Street, Suite 134Topeka, KS 66614-2062Phone: (785) 273-0780Fax: (785) 273-7545E-mail: [email protected]

KENTUCKY

Kentucky Board of Medical Licensure310 Whittington Parkway, Suite 1BLouisville, KY 40222Phone: (502) 429-8046Fax: (502) 429-9923Web Site: http://www.state.ky.us/agencies/kbml

Kentucky Board of Dentistry10101 Linn Station RoadLouisville, KY 40223Phone: (502) 423-0573Fax: (502) 423-1239

LOUISIANA

Louisiana State Board of Medical ExaminersP.O. Box 30250New Orleans, LA 70190-0250630 Camp Street, New Orleans, LA 70130Phone: (504) 524-6763Fax: (504) 599-0503Web Site: http://www.lsbme.org/E-mail: [email protected]

Louisiana State Board of Dentistry365 Canal Street, Suite 2680New Orleans, LA 70130Phone: (504) 568-8574Fax: (504) 568-8598Web Site: http://www.lsbd.org

MAINE

Maine Board of Licensure in Medicine137 State House StationAugusta, ME 04333-0137Phone: (207) 287-3601Fax: (207) 287-6590Web Site: http://www.docboard.org/me/me_home.htm

Maine Board of Osteopathic Licensure142 State House Station2 Bangor StreetAugusta, ME 04333-0142Phone: (207) 287-2480Fax: (207) 287-3015Web Site: http://www.docboard.org/me-osteo/

Maine Board of Dental Examiners143 State House Station2 Bangor StreetAugusta, ME 04333-0143Phone: (207) 287-3333Fax: (207) 287-8140Web Site: http://www.state.me.us/pfr/auxboards/denhome.htm

MARYLAND

Maryland Board of Physician Quality Assurance4201 Patterson AvenueBaltimore, MD 21215-0095Phone: (410) 764-4777Toll Free: 1-800-492-6836Fax: (410) 358-2252Web Site: http://www.docboard.org/md/default.htmE-mail: [email protected]

Maryland Board of Dental ExaminersSpring Grove Hospital CenterBenjamin Rush Building55 Wade AvenueBaltimore, MD 21228Phone: (410) 402-8500Fax: (410) 358-0128

MASSACHUSETTS

Massachusetts Board of Registration in Medicine10 West StreetBoston, MA 02111Phone: (617) 727-3086Fax: (617) 451-9568Web Site: http://www.massmedboard.orgE-mail: [email protected]

Massachusetts Board of Registration in Dentistry239 Causeway Street, Suite 500Boston, MA 02114Phone: (617) 727-9928Web Site: http://www.state.ma.us/reg/boards/dn

http://www.state.nh.us/medicine

http://www.nmbme.org/


H-8 September 2001

MICHIGAN

Michigan Board of MedicineP.O. Box 30670Lansing, MI 48909-7518611 W Ottawa Street, 1st Floor, Lansing, MI 48933Phone: (517) 373-6873Fax: (517) 373-2179Web Site: http://www.cis.state.mi.us/bhser/

Michigan Board of Osteopathic Medicine andSurgeryP.O. Box 30670Lansing, MI 48909-7518611 W Ottawa Street, 1st Floor, Lansing, MI 48933Phone: (517) 373-6873Fax: (517) 373-2179Web Site: http://www.cis.state.mi.us/bhser/

Michigan Board of DentistryP.O. Box 30670-7518Lansing, MI 48909611 W Ottawa Street, 1st Floor, Lansing, MI 48933Phone: (517) 373-9102Fax: (517) 373-2179

MINNESOTA

Minnesota Board of Medical Practice2829 University Avenue S.E., Suite 400Minneapolis, MN 55414-3246Phone: (612) 617-2130Fax: (612) 617-2166Web Site: http://www.bmp.state.mn.us

Minnesota Board of Dentistry2829 University Avenue, S.E., Suite 450Minneapolis, MN 55414-3249Phone: (612) 617-2250Fax: (612) 617-2260Web Site: http://www.dentalboard.state.mn.us

MISSISSIPPI

Mississippi State Board of Medical Licensure1867 Crane Ridge Drive, Suite 200-BJackson, MS 39216Phone: (601) 987-3079Fax: (601) 987-4159Web Site: http://www.msbml.state.ms.us

Mississippi State Board of Dental Examiners600 East Amite Street, Suite 100Jackson, MS 39201-2801Phone: (601) 944-9622

Fax: (601) 944-9624Web Site: http://www.msbde.state.ms.us/

MISSOURI

Missouri State Board of Registrationfor the Healing Arts3605 Missouri Blvd.P.O. Box 4Jefferson City, MO 65102Phone: (573) 751-0098Fax: (573) 751-3166Web Site:http://www.ecodev.state.mo.us/pr/healartsE-mail: [email protected]

Missouri State Dental Board3605 Missouri Blvd.P.O. Box 1367Jefferson City, MO 65102Phone: (573) 751-0040Fax: (573) 751-8216Web Site: http://www.ecodev.state.mo.us/pr/dental/E-mail: [email protected]

MONTANA

Montana Board of Medical Examiners301 South Park, 4th FloorP.O. Box 200513Helena, MT 59620-0513Phone: (406) 841-2360Fax: (406) 841-2363Web Site: http://www.com.state.mt.us/License/POL/pol_boards/med_board/board_page.htmE-mail: [email protected]

Montana Board of Dentistry301 South Park, 4th FloorP.O. Box 200513Helena, MT 59620-0513Phone: (406) 841-2390Fax: (406) 841-2305Web Site: http://www.com.state.mt.us/License/POL/pol_boards/den_board/board_page.htmE-mail: [email protected]

http://www.op.nysed.gov/


September 2001 H-9

NEBRASKA

Nebraska State Board of Examinersin Medicine and SurgeryP.O. Box 94986Lincoln, NE 68509-4986301 Centennial Mall SouthPhone: (402) 471-2118Fax: (402) 417-3577Web Site: http://www.hhs.state.ne.us/crl/crlindex.htm

Nebraska Board of Examiners in DentistryP.O. Box 94986Lincoln, NE 68509-4986Phone: (402) 471-2118

NEVADA

Nevada Board of Medical ExaminersP.O. Box 7238Reno, NV 895101105 Terminal Way, Suite 301, Reno, Nevada89502Phone: (775) 688-2559Fax: (775) 688-2321Toll Free: (888) 890-8210Web Site: http://www.state.nv.us/medical/E-mail: [email protected]

Nevada State Board of Osteopathic Medicine2950 E. Flamingo Road, Suite E-3Las Vegas, NV 89121-5208Phone: (702) 732-2147Fax: (702) 732-2079

Nevada State Board of Dental Examiners2295-B Renaissance Dr.Las Vegas, NV 89119Phone: (702) 486-7044Toll Free: 1-800-DDS-EXAMFax: (702) 486-7046Web Site: http://www.nvdentalboard.orgE-mail: [email protected]

NEW HAMPSHIRE

State of New Hampshire Board of Medicine2 Industrial Park Drive, Suite 8Concord, NH 03301-8520Phone: (603) 271-1203Fax: (603) 271-6702Web Site: http://www.state.nh.us/medicine

New Hampshire Board of Dental Examiners2 Industrial Park DriveConcord, NH 03301-8520Phone: (603) 271-4561Fax: (603) 271-6702Web Site: http://webster.state.nh.us/dental/

NEW JERSEY

New Jersey State Board of Medical ExaminersP.O. Box 183Trenton, NJ 08625-0183140 E. Front Street, 2nd FloorPhone: (609) 826-7100Fax: (609) 984-3930Web Site: http://www.state.nj.us/lps/ca/medical.htm

New Jersey State Board of Dentistry124 Halsey StreetP.O. Box 45005Newark, NJ 07101Phone: (973) 504-6405Fax: (973) 273-8075Web Site: http://www.state.nj.us/lps/ca/medical.htm

NEW MEXICO

New Mexico State Board of Medical Examiners491 Old Santa Fe TrailLamy Building, 2nd FloorSanta Fe, NM 87501Phone: (505) 827-5022Toll Free: 1-800-945-5845Fax: (505) 827-7377Web Site: http://www.nmbme.org

New Mexico Board of Osteopathic ExaminersBoard2055 Pacheco Street, Suite 400P.O. Box 25101Santa Fe, NM 87505Phone: (505) 476-7120Fax: (505) 827-7095Web Site: http://www.rld.state.nm.us/b&c/osteopathic_examiners_board.htmE-mail: [email protected]


H-10 September 2001

New Mexico Board of Dental Health Care2055 Pacheco Street, Suite 400Santa Fe, NM 87504Phone: (505) 476-7125Web Site:http://www.rld.state.nm.us/b&c/dental/index.htmE-mail: [email protected]

NEW YORK

Office of Professional Medical ConductNew York State Department of Health433 River Street, Suite 303Troy, NY 12180Phone: (518) 402-0855Fax: (518) 402-0866Web Site: http://www.health.state.ny.us/E-mail: [email protected]

New York State Board for MedicineCultural Education Center, Room 3023Empire State PlazaAlbany, NY 12230Phone: (518) 474-3841Fax: (518) 486-4846Web Site: http://www.op.nysed.govE-mail: [email protected]

New York State Board for DentistryCultural Education CenterRoom 3035Albany, NY 12230Phone: (518) 474-3838Fax: (518) 473-6995Web Site: http://www.op.nysed.govE-mail: [email protected]

NORTH CAROLINA

North Carolina Medical BoardP.O. Box 20007Raleigh, NC 276191201 Front Street, Suite 100, Raleigh, NC 27609Phone: (919) 326-1100Fax: (919) 326-1130Web Site: http://www.docboard.org/nc/E-mail: [email protected]

North Carolina State Board of Dental ExaminersP.O. Box 32270Raleigh, NC 27622-22703716 National Drive, Raleigh, NC 27612Phone: (919) 781-4901Fax: (919) 571-4197Web Site: http://www.ncdentalboard.org/E-mail: [email protected]

NORTH DAKOTA

North Dakota State Board of Medical ExaminersCity Center Plaza418 E. Broadway, Suite 12Bismarck, ND 58501Phone: (701) 328-6500Fax: (701) 328-6505Web Site: http://www.ndbomex.com/

North Dakota State Board of Dental ExaminersP.O. Box 7246Bismarck, ND 58507-7246Phone: (701) 258-8600Fax: (701) 224-9824Web Site: http://www.nddentalboard.org/E-mail: [email protected]

OHIO

State of Ohio Medical Board77 S. High Street, 17th FloorColumbus, OH 43266-0315Phone: (614) 466-3934Complaint Line: 1-800-554-7717Fax: (614) 728-5946Web Site: http://www.state.oh.us/med/

Ohio State Dental Board77 S. High Street, 18th FloorColumbus, OH 43266-0306Phone: (614) 466-2580Fax: (614) 752-8995Web Site: http://webtest.state.oh.us/den/

http://www.tsbde.state.tx.us/


September 2001 H-11

OKLAHOMA

Oklahoma Board of Medical Licensure andSupervisionP.O. Box 18256Oklahoma City, OK 73154-02565104 N. Francis Street, Suite C, Oklahoma City,OK 73118Phone: (405) 848-6841Fax: (405) 848-8240Web Site: http://www.osbmls.state.ok.us/E-mail: [email protected]

Oklahoma Board of Osteopathic Examiners4848 N. Lincoln Boulevard, Suite 100Oklahoma City, OK 73105-3321Phone: (405) 528-8625Fax: (405) 557-0653Web Site: http://www.docboard.org/ok/ok.htm

Oklahoma Board of Dentistry6501 N. Broadway, Suite 220Oklahoma City, OK 73116Phone: (405) 848-1364Fax: (405) 848-3279Web Site: http://www.state.ok.us/~dentist/E-mail: [email protected]

OREGON

Oregon Board of Medical Examiners620 Crown Plaza1500 S.W. First AvenuePortland OR, 97201-5826Phone: (503) 229-5770Fax: (503) 229-6543Web Site: http://www.bme.state.or.us/E-mail: [email protected]

Oregon Board of Dentistry1515 S.W. 5th Avenue, Suite 602Portland, OR 97201-5451Phone: (503) 229-5520Fax: (503) 229-6606Web Site: http://www.oregondentistry.org/E-mail: [email protected]

PENNSYLVANIA

Pennsylvania State Board of MedicineP.O. Box 2649Harrisburg, PA 17105-2649Phone: (717) 787-1400Fax: (717) 787-7769Web Site: http://www.dos.state.pa.us/bpoa/medbd/mainpage.htmE-mail: [email protected]

Pennsylvania State Board of Osteopathic MedicineP.O. Box 2649Harrisburg, PA 17105-2649Phone: (717) 783-4858Fax: (717) 787-7769Web Site: http://www.dos.state.pa.us/bpoa/ostbd/mainpage.htmE-mail: [email protected]

Pennsylvania State Board of DentistryP.O. Box 2649Harrisburg, PA 17105-2649Phone: (717) 783-7162Fax: (717) 787-7769Web Site: http://www.dos.state.pa.us/bpoa/denbd/mainpage.htmE-mail: [email protected]

RHODE ISLAND

Rhode Island Board of Medical Licensureand DisciplineDepartment of Health3 Capitol Hill, Room 205Providence, RI 02908-5097Phone: (401) 222-3855Fax: (401) 222-2158Web Site: http://www.docboard.org/ri/main.htm

Rhode Island Board of Examiners in Dentistry3 Capitol Hill, Room 404Providence, RI 02908-5097Phone: (401) 222-2151


H-12 September 2001

SOUTH CAROLINA

South Carolina Board of Medical ExaminersP.O. Box 11289Columbia, SC 29211-1289Koger Office Park, Kingstree Building110 Centerview Drive, Suite 202, Columbia, SC29210Phone: (803) 896-4500Fax: (803) 896-4515Web Site: http://www.llr.state.sc.us./me.htmE-mail: [email protected]

South Carolina Board of DentistryP.O. Box 11329Columbia, SC 29211-1329Koger Office Park, Kingstree Building,110 Centerview Drive, Columbia, SC 29210Phone: (803) 896-4599Fax: (803) 896-4596Web Site: http://www.llr.state.sc.us/denlic.htm

SOUTH DAKOTA

South Dakota Board of Medicaland Osteopathic Examiners1323 S. Minnesota AvenueSioux Falls, SD 57105Phone: (605) 334-8343Fax: (605) 336-0270Web Site: http://www.state.sd.us/dcr/medical/med-hom.htm

South Dakota State Board of DentistryP.O. Box 1037Pierre, SD 57501Phone: (605) 224-1282Fax: (605) 224-7426Web Site: http://www.state.sd.us/dcr/dentistry/dent-hom.htmE-mail: [email protected]

TENNESSEE

Tennessee Board of Medical Examiners1st Floor, Cordell Hull Building425 5th Avenue NorthNashville, TN 37247-1010Phone: (615) 532-4384Fax: (615) 532-5369Web Site: http://170.142.76.180/bmf-bin/BMFproflist.pl

Tennessee Board of Osteopathic Examiners1st Floor, Cordell Hull Building425 5th Avenue NorthNashville, TN 37247-1010Phone: (615) 532-4384Fax: (615) 532-5369Web Site: http://170.142.76.180/bmf-bin/BMFproflist.pl

Tennessee Board of Dentistry1st Floor, Cordell Hull Building425 5th Avenue NorthNashville, TN 37247-1010Phone: (615) 532-3202Fax: (615) 532-5369Web Site: http://170.142.76.180/bmf-bin/BMFproflist.pl

TEXAS

Texas State Board of Medical ExaminersP.O. Box 2018Austin, TX 78768-2018333 Guadalupe, Tower 3, Suite 630,Austin, TX 78701Phone: (512) 305-7010Fax: (512) 305-7008Complaint Line: 1-800-201-9353Web Site: http://www.tsbme.state.tx.us/

Texas State Board of Dental Examiners333 Guadalupe, Tower 3, Suite 800Austin, TX 78701Phone: (512) 463-6400Fax: (512) 463-7452Web Site: http://www.tsbde.state.tx.us/

UTAH

Utah Physicians Licensing BoardDivision of Occupational and ProfessionalLicensingP.O. Box 146741Salt Lake City, UT 84114-6741160 East 300 South, 4th Floor, Salt Lake City,UT 84102Phone: (801) 530-6628Fax: (801) 530-6511Web Site: http://www.commerce.state.ut.us/dopl/dopl1.htmE-mail: [email protected]


September 2001 H-13

Utah Board of Dentists and Dental HygienistsDivision of Occupational and ProfessionalLicensingP.O. Box 146741Salt Lake City, UT 84114-6741160 East 300 South, Salt Lake City, UT 84102Phone: (801) 530-6740Fax: (801) 530-6511Web Site: http://www.commerce.state.ut.us/dopl/dopl1.htmE-mail: [email protected]

VERMONT

Vermont Board of Medical Practice109 State StreetMontpelier, VT 05609-1106Phone: (802) 828-2673Fax: (802) 828-5450Web Site:http://www.docboard.org/vt/vermont.htm

Vermont Board of Osteopathic Physiciansand SurgeonsOffice of Professional Regulation26 Terrace Street, Drawer 09Montpelier, VT 05609-1101Phone: (802) 828-2373Fax: (802) 828-2465Web Site: http://www.vtprofessionals.org/oprbegin.htm

Vermont Board of Dental Examiners26 Terrace Street, Drawer 09Montpelier, VT 05609-1106Phone: (802) 828-2390Fax: (802) 828-2465Web Site: http://vtprofessionals.org/dentists/

VIRGINIA

Virginia Board of Medicine6606 W. Broad Street, 4th FloorRichmond, VA 23230-1717Phone: (804) 662-9908Fax: (804) 662-9943Web Site: http://www.dhp.state.va.us/levelone/med.htmE-mail: [email protected]

Virginia Board of Dentistry6606 W. Broad Street, 4th FloorRichmond, VA 23230-1717Phone: (804) 662-9906Web Site: http://www.dhp.state.va.us/levelone/den.htmE-mail: [email protected]

WASHINGTON

Washington State Department of HealthMedical Quality Assurance CommissionP.O. Box 47866Olympia, WA 98504-78661300 Quince Street S.E., Olympia, WA 98501Phone: (360) 236-4800Fax: (360) 586-4573Web Site: http://www.doh.wa.gov/medical/default.htm

Washington Board of Osteopathic Medicineand SurgeryP.O. Box 47870Olympia, WA 98504-78701300 Quince Street S.E., Olympia, WA 98501Phone: (360) 236-4945Fax: (360) 586-0745Web Site: http://www.doh.wa.gov/hsqa/hpqad/Osteopath/default.htm

Dental Quality Assurance CommissionP.O. Box 47867Olympia, WA 98504-78671300 Quince Street S.E., Olympia, WA 98501Phone: (360) 236-4863Fax: (360) 664-9077Web Site: http://www.doh.wa.gov/hsqa/hpqad/Dental/default.htm

WEST VIRGINIA

West Virginia Board of Medicine101 Dee DriveCharleston, WV 25311Phone: (304) 558-2921Fax: (304) 558-2084Web Site: http://www.wvdhhr.org/wvbom/

West Virginia Board of Osteopathy334 Penco RoadWeirton, WV 26062Phone: (304) 723-4638Fax: (304) 723-2877E-mail: [email protected]


H-14 September 2001

West Virginia Board of Dental ExaminersP.O. Drawer 1459Beckley, WV 25802-1459Phone: (304) 252-8266Fax: (304) 252-2779E-mail: [email protected]

WISCONSIN

Wisconsin Medical Examining BoardDepartment of Regulation and LicensingP.O. Box 8935Madison, WI 53708-89351400 E. Washington Avenue, Room 142, Madison,WI 53703Phone: (608) 266-2112Fax: (608) 267-0644Web Site: http://badger.state.wi.us/agencies/drl/Regulation/html/dod279.htmlE-mail: [email protected]

Wisconsin Dentistry Examining BoardBureau of Health ProfessionsDepartment of Regulation & LicensingP.O. Box 8935Madison, WI 537081400 E. Washington AvenuePhone: (608) 266-2811Web Site: http://www.drl.state.wi.us/agencies/drl/Regulation/html/dod087.html

WYOMING

Wyoming Board of Medicine211 West 19th StreetColony Building, 2nd FloorCheyenne, WY 82002Phone: (307) 778-7053Fax: (307) 778-2069

Wyoming Board of Dental ExaminersP.O. Box 272Kemmerer, WY 83101Phone: (307) 777-6529

U.S. TERRITORIES

The following U.S Territories are defined as Statesin §60.3 of the Data Bank Regulations.

AMERICAN SAMOA

Department of Medical ServicesAmerican Samoa GovernmentLBJ Tropical Medical CenterTurner DrivePago Pago, AS 96799Phone: 011 (684) 633-4590Fax: 011 (684) 633-1869Web Site: http://www.samoanet.com/asg/

GUAM

Guam Board of Medical ExaminersHealth Professional Licensing OfficeP.O. Box 2816Hagatna, GU 96932Phone: 011 (671) 475-0251Fax: 011 (671) 477-4733Web Site: http://www.visitguam.org/GVB/Govindex.html

NORTHERN MARIANAS

CNMI Board of Professional LicensingP.O. Box 2078Saipan, MP 96950Phone: (670) 234-5897Fax: (670) 234-6040Web Site: http://www.mariana-islands.gov.mp/contact.htm

PUERTO RICO

Puerto Rico Board of Medical ExaminersP.O. Box 13969San Juan, PR 00908Kennedy Avenue, ILA Bldg., Hogar del Obrero,Portuario, Piso 8, Puerto Nuevo 00920Phone: (787) 782-8989Fax: (787) 782-8733

Puerto Rico Board of Dental ExaminersP.O. Box 10200San Juan, PR 00908Phone: (787) 725-8161

VIRGIN ISLANDS

Virgin Islands Board of Medical ExaminersDepartment of Health48 Sugar EstateSt. Thomas, VI 00802Phone: (340) 774-0117Fax: (340) 777-4001

NPDB Guidebook Index

September 2001 Index-1

INDEX

AAccount Discrepancies ......................................................................................................................................................... G-3

Outstanding Balances ...................................................................................................................................................... G-3Reconciliation of Credit Card Statements ................................................................................................................... G-3–5

Addresses............................................................................................................................................See Data Bank AddressesAdverse Clinical Privileges Action Reports ....................................................................................................................... E-17Adverse Licensure Reports ................................................................................................................................................. E-24Adverse Professional Society Membership Action Reports ............................................................................................... E-26Attorney Access.................................................................................................................................................................... D-5Authorized Agents ................................................................................................................................................................ B-7

Designating Authorized Agents....................................................................................................................................... B-8Authorized Submitter............................................................................................................................................................ B-7

BBackground

Final Regulations............................................................................................................................................................. A-1Health Care Quality Improvement Act of 1986............................................................................................................... A-1Hearings....................................................................................................................................................................... A-1–2Public Law 99-660 .......................................................................................................................................................... A-2

Bankruptcy........................................................................................................................................................ D-11–12, G-4–5

CCivil Liability Protection ...................................................................................................................................................... A-2Confidentiality Provisions ................................................................................................................................................ A-3–5

Appropriate Uses of NPDB Information ..................................................................................................................... A-4–5Authorized Agents’ Responsiblities ................................................................................................................................ A-4The Privacy Act.......................................................................................................................................................A-4, A-6

Coordination Between the NPDB and the HIPDB................................................................................................................ A-6Correction ..........................................................................................................................................See Reporting: CorrectionCredits and Debits................................................................................................................................................................. G-4Customer Service Center ...................................................................................................................................................... H-1

DData Bank Addresses ............................................................................................................................................................ H-2Data Bank Identification Number ......................................................................................................................................... B-5

Deactivate a DBID .......................................................................................................................................................... B-5Lost Your DBID? ............................................................................................................................................................ B-6Reactivate a DBID........................................................................................................................................................... B-6

DBID ...............................................................................................................................See Data Bank Identification NumberDefining Health Care Practitioners ....................................................................................................................................... H-1Disclosure of NPDB Information

Eligible Entities ............................................................................................................................................................... A-5Dispute Process......................................................................................................................................................................F-1

Examples of Disputes .......................................................................................................................................................F-6Secretarial Review............................................................................................................................................................F-3Subject Disputes ...............................................................................................................................................................F-2Subject Statements............................................................................................................................................................F-1

EEligible Entities .............................................................................................................................................................. B-1–10

Index NPDB Guidebook

Index-2 September 2001

For Querying ................................................................................................................................................................... D-1For Reporting ...................................................................................................................................................................E-1

FFederal Employer Identification Number ............................................................................................................................. H-3Fees................................................................................................................................................................................... G-1–2

Entity Query Fees............................................................................................................................................................ G-1Payment Methods ............................................................................................................................................................ G-1Self-Query Fees............................................................................................................................................................... G-1

FEIN .................................................................................................................... See Federal Employer Identification NumberFOIA........................................................................................................................................See Freedom of Information ActFreedom of Information Act ................................................................................................................................................. H-3

HHealth Care Entities

Hospitals.......................................................................................................................................................................... B-2Other Health Care Entities............................................................................................................................................... B-2

Healthcare Integrity and Protection Data Bank .................................................................................................................... A-6High-Low Agreements ........................................................................................................................................................E-13HIPDB ........................................................................................................ See Healthcare Integrity and Protection Data Bank

IICD .......................................................................................................................................... See Interface Control DocumentICD Transfer Program .................................................................................................................................................. D-6, E-4Immunity Protection .....................................................................................................................See Civil Liability ProtectionInitial Report..................................................................................................................................See Reporting: Initial ReportIntegrated Querying and Reporting Service.................................................................................................................. D-6, E-3Interface Control Document ......................................................................................................................................... D-6, E-4Interpretation of NPDB Information..................................................................................................................................... A-3IQRS................................................................................................................ See Integrated Querying and Reporting ServiceITP ....................................................................................................................................................See ICD Transfer Program

LLiquidation ........................................................................................................................................................................... G-5Loss Adjustment Expenses ..................................................................................................................................................E-12

MMedical Malpractice Payers ................................................................................................................................................. B-4Medical Malpractice Payment Reports..................................................................................................................................E-8

NNational Practitioner Data Bank ........................................................................................................................................... A-1NPDB ................................................................................................................................See National Practitioner Data Bank

OOfficial Language ................................................................................................................................................................. A-6

PPayment Methods ............................................................................................................................................................. G-1–2

Credit Card ...................................................................................................................................................................... G-1Electronic Funds Transfer ............................................................................................................................................... G-1

Privacy Act ........................................................................................................................................................................... H-4

NPDB Guidebook Index

September 2001 Index-3

Professional Societies ........................................................................................................................................................... B-3

QQuerying ............................................................................................................................................................................... D-1

Correcting Querying Information .................................................................................................................................... D-9Equipment Needed to Query Electronically .................................................................................................................... D-7Failure to Query............................................................................................................................................................... D-9Hospitals.......................................................................................................................................................................... D-1Mandatory Querying Requirements ................................................................................................................................ D-1Professional Societies ...................................................................................................................................................... D-3Query Processing............................................................................................................................................................. D-7Query Responses ............................................................................................................................................................. D-8Querying Through an Authorized Agent ......................................................................................................................... D-7Residents and Interns....................................................................................................................................................... D-3State Licensing Boards .................................................................................................................................................... D-3Submitting a Query to the NPDB .................................................................................................................................... D-6Types of Queries ............................................................................................................................................................. D-5

RRegistering with the NPDB .................................................................................................................................................. B-4

Certifying Official ........................................................................................................................................................... B-4Entity Recertification ...................................................................................................................................................... B-5Entity Registration Form ................................................................................................................................................. B-4Registration Verification ................................................................................................................................................. B-4

Reporting .........................................................................................................................................................................E-1–36Adverse Clinical Privileges Actions ........................................................... See Adverse Clinical Privileges Action ReportsAdverse Licensure Actions.......................................................................................See Adverse Licensure Action ReportsAdverse Professional Society Membership Actions ........... See Adverse Professional Society Membership Action ReportsCorrection........................................................................................................................................................................ E-5Draft Capability ............................................................................................................................................................... E-4Initial Report.................................................................................................................................................................... E-4Medical Malpractice Payments ..........................................................................See Medical Malpractice Payment ReportsReport Processing............................................................................................................................................................ E-6Report Responses ............................................................................................................................................................ E-6Reporting by Authorized Agents ................................................................................................................................... E-14Residents and Interns..................................................................................................................................................... E-11Revision to Action........................................................................................................................................................... E-5Sanctions for Failing to Report to the NPDB ................................................................................................................ E-27Students ......................................................................................................................................................................... E-12Submitting Reports to the NPDB Via ITP or Diskette .................................................................................................... E-4Submitting Reports Via the IQRS ................................................................................................................................... E-3Time Frame for Reporting to the NPDB.......................................................................................................................... E-1Void Previous Report ...................................................................................................................................................... E-5

Revision to Action ................................................................................................................See Reporting: Revision to Action

SSecretarial Review ...................................................................................................... See Dispute Process: Secretarial ReviewSelf-Query ............................................................................................................................................................................ C-4State Licensing Boards ......................................................................................................................................................... B-3State Medical and Dental Boards.................................................................................................................................... H-3–14Subject Database................................................................................................................................................................... D-8Subject Information in the NPDB......................................................................................................................... C-4, D-8, E-2

TTitle IV of Public Law 99-660..........................................................................................See Background: Public Law 99-660

Index NPDB Guidebook

Index-4 September 2001

UUser IDs................................................................................................................................................................................ B-6

VVoid ................................................................................................................................. See Reporting: Void Previous Report

NPDB Guidebook Appendix A Glossary

September 2001 Appendix A-1

APPENDIX A: Glossary

This 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.

Appendix A Glossary NPDB Guidebook

Appendix A-2 September 2001

dentist — 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, to



identify 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.



medical 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 [email protected] 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 healthor 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, orother health care practitioner’s association, or lack of association, with a professional



society or association; (b) the physician’s, dentist’s, or other health care practitioner’sfees or the physician’s, dentist’s, or other health care practitioner’s advertising orengaging in other competitive acts intended to solicit or retain business; (c) thephysician’s, dentist’s, or other health care practitioner’s participation in prepaid grouphealth plans, salaried employment, or any other manner of delivering health serviceswhether on a fee-for-service or other basis; (d) a physician’s, dentist’s, or other healthcare practitioner’s association with, supervision of, delegation of authority to, supportfor, training of, or participation in a private group practice with, a member or members ofa particular class of health care practitioner or professional; or (e) any other matter thatdoes 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.

http://www.npdb-hipdb.org/pointer/npdb.html



State — 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.

NPDB Guidebook Appendix B Laws and Regulations

September 2001 Appendix B-1

APPENDIX B: Laws and Regulations

The 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.html

Title IV Regulations, complete text of the 45 CFR Part 60, October 17, 1989.http://www.npdb-hipdb.com/info/legislation/45cfr60.html

Civil Money Penalties, 42 CFR Part 1003.http://www.npdb-hipdb.com/info/legislation/42cfr.html

Freedom 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.html

Privacy 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.html

Final 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.pdf

Notice 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.pdf

http://www.npdb-hipdb.com/info/legislation/title4.html

http://www.npdb-hipdb.com/info/legislation/45cfr60.html

http://www.npdb-hipdb.com/info/legislation/42cfr.html

http://www.npdb-hipdb.com/info/legislation/foia.html

http://www.npdb-hipdb.com/info/legislation/privacy.html

http://www.npdb-hipdb.com/pubs/fedreg3-1-99.pdf

http://www.npdb-hipdb.com/pubs/fedreg3-1-99.pdf

warnerc


NPDB Guidebook Appendix C Abbreviations

September 2001 Appendix C-1

APPENDIX C: Abbreviations

AAR 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 Number