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Physician Information Validation

Security Health Plan collects and verifies all provider credentials in accordance with NCQA standards for primary source verification. Board certification is verified using American Board of Medical Specialists (ABMS), American Osteopathic Association (AOA), American Board of Podiatric Orthopedics and Primary Podiatric Medicine (ABPOPPM), American Board of Oral and Maxillofacial Surgery (ABOMS), American Board of Podiatric Surgery (ABPS), or American Medical Association (AMA) physician master file.

Item Description Source* Frequency of Validation Limitations
Physician Name
Credentialing and recredentialing application and provider update forms At initial credentialing and recredentialing We are not always notified of a name change prior to the physician's recredentialing
Gender
Credentialing and recredentialing application Self-reported - not validated Some physicians may not provide this information
Specialty The specialty or sub-specialty area in which the physician provides care Credentialing and recredentialing application and provider update forms At initial credentialing, recredentialing, or when notified of a change in specialty
Hospital Affiliations The hospital(s) where the physician has admitting privileges Credentialing and recredentialing application Self-reported - not all are validated When physicians change service locations, hospital affiliations may not be updated
Medical Group Affiliations The medical group(s) the physician is employed or associated with Credentialing and recredentialing application and provider update forms At initial credentialing and recredentialing and when notified that a physician has changed or terminated with a medical group We are not always notified when a physician changes medical group affiliations
Board Certification Indicates what specialty the physician is trained in Credentialing and recredentialing application and provider update forms At initial credentialing and recredentialing, and when certification expires per monthly reports Physicians may not renew board certifications
Acceptance of New Patients Indicates if the physician is accepting new patients at the location(s) he/she provides care Recredentialing application and provider update forms Self-reported - not validated We are not always notified of changes
Languages Spoken by the Physician or Clinical Staff Languages fluently spoken by the physician in addition to English Credentialing and recredentialing application Self-reported - not validated Not all physicians provide this information
Office Locations The location of all offices where the physician works Credentialing and recredentialing application and provider update forms At initial credentialing and recredentialing, and when notified of location change We are not always notified of changes

*Credentialing occurs when the provider and/or facility affiliates with the health plan. Subsequently, recredentialing occurs every three years.

Hospital Information Validation

Security Health Plan verifies the name, location, and accreditation of each affiliated hospital no less than every three years.

Joint Commission (JCAHO) accreditation is recognized nationwide as a symbol of quality and safety that reflects an organization's commitment to meeting certain performance standards. Hospital Compare, provided by the United States Department of Health and Human Services (HHS), is information that will help you compare the quality of care provided by our affiliated hospitals. Security Health Plan strongly encourages affiliated hospitals to participate in organizations that focus on safety activities and reporting such as Checkpoint, Leapfrog and the Wisconsin Collaborative for Healthcare Quality, Inc. (WCHQ).

Item Description Source Frequency of Validation
Hospital Name Marketing name of the hospital Initial contracting with Security Health Plan and update notification forms At initial contracting, recredentialing and when notified of a hospital's name change
Address Street address of the hospital At initial contracting with Security Health Plan and practice update forms At initial contracting, recredentialing and when notified of a hospital's name change
Accreditation Accreditation is a voluntary process through which a hospital is able to measure the quality of its services against nationally recognized standards Upon initial contracting with Security Health Plan, a copy of the hospital's accreditation certificate or letter of notification is requested. Contracting staff will verify that the hospital has met all state and federal licensing and regulatory requirements and has been approved by a recognized accrediting body. Security Health Plan requires initial and ongoing assessment reviews (at least every three years) of hospitals with which it contracts for member services. The QA Committee reviews issues identified that raise a significant concern regarding the hospital's ability to render quality health services to members.
Accreditation Status Accreditation status includes the following:
Accredited
Provisional
Denied
Not accredited
www.qualitycheck.org Security Health Plan requires initial and ongoing assessment reviews (at least every three years) of hospitals with which it contracts for member services. The QA Committee reviews issues identified that raise a significant concern regarding the hospital's ability to render quality health services to members.