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Overview Submitting Reports to the NPDB Reporting Medical Malpractice Payments Reporting Adverse Clinical Privileges Actions Reporting Adverse Professional Society Membership Actions Reporting State Licensure and Certification Actions Reporting Federal Licensure and Certification Actions Reporting Peer Review Organization Negative Actions or Findings Reporting Private Accreditation Organizations Negative Actions or Findings Reporting Exclusions from Participation in Federal and State Health Care Programs Reporting Federal or State Health Care-Related Criminal Convictions Reporting Health Care-Related Civil Judgments Reporting Other Adjudicated Actions or Decisions

Appendix A: Glossary

This glossary contains terms that relate to the NPDB, and the definitions apply only to their usage in conjunction with the NPDB and its policies and procedures. Please refer to the appropriate sections of this Guidebook for policy guidance.

A

Administrator - A registered entity's administrator gives authority to individuals in each organization to manage NPDB activities. In particular, the administrator is responsible for creating and maintaining user accounts for all individuals in the organization who query or report.

Adverse Action Report - The report format used to submit actions, other than medical malpractice payments and convictions and judgments, taken against a health care practitioner, entity, provider, or supplier.

Affiliated or Associated - Defined in NPDB regulations as "health care entities with which a subject of a final adverse action has a business or professional relationship. This includes, but is not limited to, organizations, associations, corporations, or partnerships. This also includes a professional corporation or other business entity composed of a single individual."

Authorized Agent - An individual or organization that an eligible entity designates to query and/or report to the NPDB on its behalf.

Authorized Submitter - An individual empowered by an eligible entity to submit reports or queries to the NPDB. The authorized submitter certifies the legitimacy of information in a query or report submitted to the NPDB.

Authorized User - See Authorized Submitter.

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B

Basis for Action Codes - A list of reasons for taking an adverse action and the corresponding codes used on reports submitted to the NPDB.

Board of Medical Examiners - Defined in NPDB regulations as "a body or subdivision of such body which is designated by a state for the purpose of licensing, monitoring, and disciplining physicians or dentists. This term includes a Board of Osteopathic Examiners or its subdivision, a Board of Dentistry or its subdivision, or an equivalent body as determined by the state. Where the Secretary, pursuant to section 423(c)(2) of the HCQIA (42 U.S.C. 11112(c)), has designated an alternate entity to carry out the reporting activities of § 60.12 of this part due to a Board's failure to comply with § 60.8 of this part, the term Board of Medical Examiners or Board refers to this alternate entity." See also State Licensing Board, State Licensing or Certification Authority, and State Medical or Dental Board.

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C

Certification - The term "certification" has two distinct meanings.

  • First, the term is related to licensure, because licensure includes certification and other forms of authorization to provide health care services. Based on State laws and requirements, States may "license," "certify," or "register" certain types of health care practitioners, entities, providers, or suppliers.
  • Second, the term also is used to refer to certification of a health care practitioner, entity, provider, or supplier to participate in a Government health care program. In this context, certification includes certification agreements and contracts for participation in a Government health care program.

Certifying Official - An individual selected and empowered by an eligible entity to certify the legitimacy of registration for participation in the NPDB.

Clinical Privileges - Defined in NPDB regulations as "the authorization by a health care entity to a health care practitioner for the provision of health care services, including privileges and membership on the medical staff." The term "medical staff" also includes network participation and panel membership.

Continuous Query - An NPDB query service that notifies subscribing entities, within one business day, of the receipt of a new or updated NPDB report that names any of their enrolled practitioners as subjects.

Correction Report - Corrects an error or omission in a previously submitted report by replacing the current version of the report.

Criminal Conviction - For NPDB purposes, a criminal conviction includes:

  • A judgment of conviction that has been entered against an individual or entity in a Federal, State or local court, regardless of whether an appeal is pending or the conviction or other record relating to criminal conduct has been expunged
  • A finding of guilt against an individual or entity that is made in a Federal, State, or local court
  • A plea of guilty or nolo contendere by an individual or entity that has been accepted by a Federal, State, or local court, and
  • When an individual or entity has entered into participation in a first offender, deferred adjudication, or other arrangement or program where conviction has been withheld

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D

Data Bank Control Number (DCN) - The identification number assigned by the NPDB that is used to identify each query and report.

Data Bank Identification Number (DBID) - A unique, 15-digit identification number assigned to eligible entities and authorized agents when they register with the NPDB.

Dentist - Defined in NPDB regulations as "a doctor of dental surgery, doctor of dental medicine, or the equivalent who is legally authorized to practice dentistry by a state (or who, without authority, holds himself or herself out to be so authorized)."

Department of Health and Human Services - The Federal department charged by Congress with administering, or delegating the administration of, the NPDB.

Dispute Process - The procedures by which a health care practitioner, entity, provider, or supplier can dispute the accuracy of information reported to the NPDB.

Draft Report - A report in progress that is temporarily electronically stored in the NPDB without being submitted to the NPDB for processing.

Drug Enforcement Administration (DEA) - The Federal agency that registers physicians, dentists, and other health care practitioners to dispense controlled substances and assigns them DEA numbers. DEA is a Federal law enforcement agency within the Department of Justice.

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E

Electronic Report Forwarding Service - An NPDB service that forwards NPDB reports to State licensing boards if both the reporting entity and the board agree to participate in the service. The reporting entity remains responsible for ensuring that necessary reports are forwarded to appropriate State boards.

Eligible Entity - An entity that is authorized to query and/or report to the NPDB under the provisions of Title IV of Public Law 99-660, the Health Care Quality Improvement Act of 1986; Section 1921 of the Social Security Act; Section 1128E of the Social Security Act; or as specified in 45 CFR Part 60.

Exclusion - Defined in NPDB regulations as "a temporary or permanent debarment of an individual or entity from participation in any Federal or State health-related program, in accordance with which items or services furnished by such person or entity will not be reimbursed under any Federal or State healthrelated program."

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F

Formal Peer Review Process - Defined in NPDB regulations as "the conduct of professional review activities through formally adopted written procedures which provide for adequate notice and an opportunity for a hearing."

Formal Proceeding - Defined in NPDB regulations as "a proceeding held before a state licensing or certification authority, peer review organization, or private accreditation entity that maintains defined rules, policies, or procedures for such a proceeding."

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G

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H

Health Care Entity - Defined in NPDB regulations as

"(1) A hospital;

"(2) An entity that provides health care services, and engages in professional review activity through a formal peer review process for the purpose of furthering quality health care, or a committee of that entity; or

"(3) A professional society or a committee or agent thereof, including those at the national, state, or local level, of health care practitioners that engages in professional review activity through a formal peer review process, for the purpose of furthering quality health care.

"(4) For purposes of paragraph (2) of this definition, an entity includes: a health maintenance organization which is licensed by a state or determined to be qualified as such by the Department of Health and Human Services; and any group or prepaid medical or dental practice which meets the criteria of paragraph (2)."

See also Hospital and Professional Society.

Health Care Practitioner, Licensed Health Care Practitioner, Licensed Practitioner, or Practitioner - Defined in NPDB regulations as "an individual who is licensed or otherwise authorized by a state to provide health care services (or any individual who, without authority, holds himself or herself out to be so licensed or authorized)."

Health Care Provider - Defined in NPDB regulations as "a provider of services as defined in section 1861(u) of the Social Security Act; any organization (including a health maintenance organization, preferred provider organization or group medical practice) that provides health care services and follows a formal peer review process for the purpose of furthering quality health care, and any other organization that, directly or through contracts, provides health care services."

Health Care Supplier - Defined in NPDB regulations as "a provider of medical and other health care services as described in section 1861(s) of the Social Security Act; or any individual or entity, other than a provider, who furnishes, whether directly or indirectly, or provides access to, health care services, supplies, items, or ancillary services (including, but not limited to, durable medical equipment suppliers, manufacturers of health care items, pharmaceutical suppliers and manufacturers, health record services [such as medical, dental, and patient records], health data suppliers, and billing and transportation service suppliers). The term also includes any individual or entity under contract to provide such supplies, items, or ancillary services; health plans as defined in this section (including employers that are self-insured); and health insurance producers (including but not limited to agents, brokers, solicitors, consultants, and reinsurance intermediaries)."

Health Plan - Defined in NPDB regulations as "a plan, program or organization that provides health benefits, whether directly, through insurance, reimbursement or otherwise, and includes but is not limited to:

"(1) A policy of health insurance;

"(2) A contract of a service benefit organization;

"(3) A membership agreement with a health maintenance organization or other prepaid health plan;

"(4) A plan, program, agreement, or other mechanism established, maintained, or made available by a self-insured employer or group of self-insured employers, a health care practitioner, provider, or supplier group, thirdparty administrator, integrated health care delivery system, employee welfare association, public service group or organization or professional association;

"(5) An insurance company, insurance service, or insurance organization that is licensed to engage in the business of selling health care insurance in a state and which is subject to state law which regulates health insurance; and

"(6) An organization that provides benefit plans whose coverage is limited to outpatient prescription drugs."

High-Low Agreement - A contractual agreement between a plaintiff and a defendant's insurer that defines the parameters of a payment the plaintiff may receive after a trial or arbitration proceeding.

Hospital - Defined in NPDB regulations as "an entity described in paragraphs (1) and (7) of Section 1861(e) of the Social Security Act." See also Health Care Entity.

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I

Initial Report - The first report of a payment or action submitted to and processed by the NPDB.

Integrated Querying and Reporting Service - An electronic, Internet-based system for querying and reporting to the NPDB.

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J

Judgment or Conviction Report - The report format used to report Federal or State health care-related criminal convictions and civil judgments.

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K

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L

Licensed Health Care Practitioner, Licensed Practitioner, Health Care Practitioner or Practitioner - See Health Care Practitioner, Licensed Health Care Practitioner, or Practitioner.

Locum Tenens Practitioner - A health care practitioner who fills a position for another health care practitioner on a temporary basis.

Loss Adjustment Expense - An expense other than those in compensation of injuries, such as attorney fees, billable hours, copying costs, expert witness fees, and deposition and transcript costs.

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M

Medical Malpractice Action or Claim - Defined in NPDB regulations as "a written complaint or claim demanding payment based on a health care practitioner's provision of or failure to provide health care services, and includes the filing of a cause of action based on the law of tort, brought in any state or federal court or other adjudicative body." See also Medical Malpractice Payment.

Medical Malpractice Payer - An entity that makes a medical malpractice payment through an insurance policy or otherwise for the benefit of a health care practitioner in settlement of, or in satisfaction in whole or in part of, a claim or judgment against that practitioner.

Medical Malpractice Payment - A monetary exchange as a result of a settlement or judgment of a written complaint or claim demanding payment based on a health care practitioner's provision of or failure to provide health care services; the written complaint or claim may include, but is not limited to, the filing of a cause of action, based on the law of tort, brought in any State or Federal court or other adjudicative body. See also Medical Malpractice Action or Claim.

Medical Malpractice Payment Report - The format used by medical malpractice payers to report to the NPDB a medical malpractice payment made for the benefit of a health care practitioner.

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N

National Practitioner Data Bank -A confidential information clearinghouse created by Congress with the primary goals of improving health care quality, protecting the public, and reducing health care fraud and abuse in the United States.

Negative Actions or Findings by a Federal or State licensing or certification authority, peer review organization, or private accreditation entity - Defined in NPDB regulations as

"(1) A final determination of denial or termination of an accreditation status from a private accreditation entity that indicates a risk to the safety of a patient(s) or quality of health care services;

"(2) Any recommendation by a peer review organization to sanction a health care practitioner; or

"(3) Any negative action or finding that, under the state's law, is publicly available information and is rendered by a licensing or certification authority, including but not limited to, limitations on the scope of practice, liquidations, injunctions, and forfeitures. This definition also includes final adverse actions rendered by a Federal or state licensing or certification authority, such as exclusions, revocations, or suspension of license or certification, that occur in conjunction with settlements in which no finding of liability has been made (although such a settlement itself is not reportable under the statute). This definition excludes administrative fines or citations and corrective action plans and other personnel actions, unless they are:

"(i) Connected to the delivery of health care services; or

"(ii) Taken in conjunction with other adverse licensure or certification actions such as revocation, suspension, censure, reprimand, probation, or surrender."

Notice of Appeal - A report notifying the NPDB that a subject has formally appealed a previously reported adverse action. A notice of appeal is separate and distinct from a subject's dispute of an NPDB report.

NPDB Customer Service Center - Provides information and support to NPDB users. Questions may be directed to information specialists at the Customer Service Center by email at help@npdb.hrsa.gov or by phone at 800-767-6732 (800-SOS-NPDB) The TDD number is 703-378-3919. The number to call from outside the United States is 703-802-9380.

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O

Office of Inspector General - An agency of the Department of Health and Human Services that performs several functions in connection with the NPDB, including:

  • Exercising delegated authority to impose civil money penalties on those who violate the confidentiality provisions of Title IV
  • Imposing civil money penalties on medical malpractice payers that fail to report payments to the NPDB
  • Reporting to the NPDB exclusions from Federal health care programs and related civil money penalties, and
  • Along with other Federal Inspectors General, querying the NPDB as a law enforcement agency

Other Adjudicated Actions or Decisions - Defined in NPDB regulations as "formal or official final actions taken against a health care practitioner, provider, or supplier by a Federal government agency, a state law or fraud enforcement agency, or a health plan, which include the availability of a due process mechanism, and are based on acts or omissions that affect or could affect the payment, provision, or delivery of a health care item or service."

This definition excludes:

  • Clinical privileging actions taken by Federal agencies or State law and fraud enforcement agencies, and similar paneling decisions made by health plans
  • Overpayment determinations made by Federal or State government programs, their contractors, or health plans
  • Denial of claims determinations made by Federal agencies, State law or fraud enforcement agencies, or health plans, and
  • Business or administrative decisions taken by health plans that result in contract terminations unrelated to health care fraud, or abuse, or quality of care (e.g., when a practitioner's contract is terminated because the practitioner no longer practices at a facility in the health plan's network, or a health plan terminates all provider contracts in a certain geographic area because it ceases business operations in that area)

For health plans that are not government entities, an action taken following adequate notice and the opportunity for a hearing that meets the standards of due process set out in Title IV also would qualify as a reportable action.

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P

Peer Review Organization - Defined in NPDB regulations as "an organization with the primary purpose of evaluating the quality of patient care practices or services ordered or performed by health care practitioners measured against objective criteria which define acceptable and adequate practice through an evaluation by a sufficient number of health care practitioners in such an area to ensure adequate peer review. The organization has due process mechanisms available to health care practitioners. This definition excludes utilization and quality control peer review organizations described in Part B of Title XI of the Social Security Act (referred to as QIOs) and other organizations funded by the Centers for Medicare & Medicaid Services (CMS) to support the QIO program."

Physician - Defined in NPDB regulations as "a doctor of medicine or osteopathy legally authorized to practice medicine or surgery by a state (or who, without authority, holds himself or herself out to be so authorized)."

Practitioner, Health Care Practitioner, Licensed Practitioner, or Licensed Health Care Practitioner - See Health Care Practitioner, Licensed Health Care Practitioner, or Practitioner.

Private Accreditation Entity or Organization - Defined in NPDB regulations as "an entity or organization that:

"(1) Evaluates and seeks to improve the quality of health care provided by a health care entity, provider, or supplier;

"(2) Measures a health care entity's, provider's, or supplier's performance based on a set of standards and assigns a level of accreditation;

"(3) Conducts ongoing assessments and periodic reviews of the quality of health care provided by a health care entity, provider, or supplier; and

"(4) Has due process mechanisms available to health care entities, providers, or suppliers."

Professional Review Action - Defined in NPDB regulations as "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 health care practitioner which affects or could affect adversely the health or welfare of a patient or patients; and

"(3) Which adversely affects or may adversely affect the clinical privileges or membership in a professional society of the health care practitioner.

"(4) This term excludes actions which are primarily based on:

"(i) The health care practitioner's association, or lack of association, with a professional society or association;

"(ii) The health care practitioner's fees or the health care practitioner's advertising or engaging in other competitive acts intended to solicit or retain business;

"(iii) The health care practitioner's participation in prepaid group health plans, salaried employment, or any other manner of delivering health services whether on a fee-for-service or other basis;

"(iv) A health care practitioner's association with, supervision of, delegation of authority to, support for, training of, or participation in a private group practice with, a member or members of a particular class of health care practitioner or professional; or

"(v) Any other matter that does not relate to the competence or professional conduct of a health care practitioner."

Professional Review Activity - Defined in NPDB regulations as "an activity of a health care entity with respect to an individual health care practitioner

"(1) To determine whether the health care practitioner may have clinical privileges with respect to, or membership in, the entity;

"(2) To determine the scope or conditions of such privileges or membership; or

"(3) To change or modify such privileges or membership."

Professional Society - A membership association of health care practitioners at the national, State, or local level that follows a formal peer review process for the purpose of furthering quality health care. Managed care organizations are not considered professional societies. See also Health Care Entity.

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Q

Quality Improvement Organization - Defined in NPDB regulations as "a utilization and quality control peer review organization (as defined in Part B of Title XI of the Social Security Act) that:

"(1) (i) Is composed of a substantial number of the licensed doctors of medicine and osteopathy engaged in the practice of medicine or surgery in the area and who are representative of the practicing physicians in the area, designated by the Secretary under Section 1153, with respect to which the entity shall perform services under this part, or

"(ii) Has available to it, by arrangement or otherwise, the services of a sufficient number of licensed doctors of medicine or osteopathy engaged in the practice of medicine or surgery in such area to assure that adequate peer review of the services provided by the various medical specialties and subspecialties can be assured;

"(2) Is able, in the judgment of the Secretary, to perform review functions required under Section 1154 in a manner consistent with the efficient and effective administration of this part and to perform reviews of the pattern of quality of care in an area of medical practice where actual performance is measured against objective criteria which define acceptable and adequate practice; and

"(3) Has at least one individual who is a representative of consumers on its governing body."

Query - A request for information submitted to the NPDB.

Querying and Reporting XML Service - An Extensible Markup Language (XML) reporting and querying interface. QRXS is an electronic submission service for high-volume queriers or reporters who wish to interface their data processing systems with the NPDB.

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R

Report - A report of an adverse action or medical malpractice payment submitted to the NPDB. NPDB information is reported on one of three report formats: Medical Malpractice Payment Report, Adverse Action Report, or Judgment or Conviction Report.

Revision-to-Action Report - A report of an action relating to and modifying an adverse action previously reported to the NPDB. A Revision-to-Action Report does not replace a previously reported adverse action but, rather, is treated as a separate action that pertains to the previous action.

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S

Secretary - Defined in NPDB regulations as "the Secretary of Health and Human Services and any other officer or employee of the Department of Health and Human Services to whom the authority involved has been delegated."

Section 1128E - Section 1128E of the Social Security Act. Enacted as Section 221(a) of the Health Insurance Portability and Accountability Act of 1996, Public Law 104-191. One of the three enabling statutes underlying the NPDB.

Section 1921 - Section 1921 of the Social Security Act. Enacted as Section 5 of the Medicare and Medicaid Patient and Program Protection Act of 1987, Public Law 100-93. One of the three enabling statutes underlying the NPDB.

Self-Query - A health care practitioner's, entity's, provider's, or supplier's request for information about himself, herself, or itself contained in the NPDB.

State - Defined in NPDB regulations as "the fifty states, the District of Columbia, Puerto Rico, the Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands."

State Agency Administering or Supervising the Administration of a State Health Care Program - State agencies that administer (as well as those that provide payment for services) or supervise the administration of a State health care program, as defined in Section 1128(h) of the Social Security Act. These entities also are included in the definition of a State law or fraud enforcement agency because they have a role in investigating and preventing health care fraud and abuse and take certain final adverse actions consistent with that role. See also State Law or Fraud Enforcement Agency.

State Law Enforcement Agency - See State Law or Fraud Enforcement Agency.

State Law or Fraud Enforcement Agency - Defined in NPDB regulations as "includes, but is not limited to:

"(1) A state law enforcement agency;

"(2) A state Medicaid fraud control unit (as defined in section 1903(q) of the Social Security Act); and

"(3) A state agency administering (including those providing payment for services) or supervising the administration of a state health care program (as defined in Section 1128(h) of the Social Security Act.)"

See also State Agency Administering or Supervising the Administration of a State Health Care Program.

State Licensing Board - A generic term used to refer to State medical and dental boards, as well as those bodies responsible for licensing, certifying, or otherwise authorizing physicians, dentists, or other health care practitioners to provide health care services. See also Board of Medical Examiners, State Licensing or Certification Authority, and State Medical or Dental Board.

State Licensing or Certification Agency - Defined in NPDB regulations as "includes, but is not limited to, any authority of a state (or of a political subdivision thereof) responsible for the licensing or certification of health care practitioners (or any peer review organization or private accreditation entity reviewing the services provided by health care practitioners), health care entities, providers, or suppliers. Examples of such state agencies include Departments of Professional Regulation, Health, Social Services (including State Survey and Certification and Medicaid Single State agencies), Commerce, and Insurance." See also Board of Medical Examiners, Peer Review Organization, Private Accreditation Entity or Organization, State Licensing or Certification Authority, State Licensing Board, and State Medical or Dental Board.

State Licensing or Certification Authority - A State Government body that

  • Licenses, certifies, registers, or otherwise authorizes health care practitioners, entities, providers, or suppliers to provide health care services; and/or
  • Certifies physicians, dentists, other health care practitioners, entities, providers, or suppliers for participation in a Federal or State health care program.

Examples of such State agencies include departments of professional regulation, health, social services (including State survey and certification and Medicaid single State agencies), commerce, and insurance. See also Board of Medical Examiners, State Licensing Board, and State Medical or Dental Board.

State Medicaid Fraud Control Unit - Defined in Section 1903(q) of the Social Security Act. These entities also are included in the definition of a State law or fraud enforcement agency. See State Law or Fraud Enforcement Agency.

State Medical or Dental Board - A board of medical examiners. See also Board of Medical Examiners, State Licensing Board, and State Licensing or Certification Authority.

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T

Title IV - Title IV of the Health Care Quality Improvement Act of 1986, Public Law 99-660. One of the three enabling statutes underlying the NPDB.

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U

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V

Void Report - A report format used to withdraw a report in its entirety. Also called a Void.

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W

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X

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Y

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Z

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