What is an Eligible Entity?
Entities that participate in the NPDB are defined in the provisions of Title IV, Section 1921, Section 1128E, and implementing regulations. In addition, a few federal agencies also participate with the NPDB through federal memorandums of understanding. Eligible entities are responsible for complying with all reporting and/or querying requirements that apply; some entities may qualify as more than one type of eligible entity. Each eligible entity must certify its eligibility in order to report to the NPDB, query the NPDB, or both.
Information from the NPDB is available only to those entities specified as eligible in the statutes and regulations. Not all entities have the same reporting requirements or level of query access.
Each of the three major statutes governing NPDB operations has its own set of eligible entities, with specific reporting and querying requirements. The terminology and requirements under each statute are distinct. While the NPDB operates as a single data bank, the information that entities are required to report and are authorized to receive when they query is based on their eligibility under each statute. In some cases, the information required to be reported to the NPDB under each statute overlaps with information reported under another statute, but certain eligible entities may only be authorized to receive information collected under one of those statutes. Likewise, entities that are authorized to report under one or more statutes must comply with each unique reporting requirement.
To be eligible to query the NPDB, an entity must be:
- Under the authority of Title IV
- A hospital
- A health care entity that provides health care services and follows a formal peer review process for the purpose of furthering quality health care
- A professional society that follows a formal peer review process for the purpose of furthering quality health care, or
- A board of medical examiners or other state licensing board
- Under the authorities of Section 1921 and Section 1128E
- A hospital
- A health care entity that provides health care services and follows a formal peer review process for the purpose of furthering quality health care
- A professional society that follows a formal peer review process for the purpose of furthering quality health care
- A health plan
- A quality improvement organization
- A state licensing or certification authority
- A state law enforcement agency
- A state Medicaid fraud control unit
- A state agency administering or supervising the administration of a state health care program
- An agency administering a federal health care program, including a private entity administering such a program under contract
- A federal agency responsible for the licensing or certification of health care practitioners, providers, or suppliers, or
- A federal law enforcement official or agency
To be eligible to report to the NPDB, an entity must be:
- Under the authority of Title IV
- An entity that makes a medical malpractice payment
- A hospital or other health care entity that takes an adverse clinical privileging action as a result of professional review
- A professional society that takes an adverse membership action as a result of professional review
- A board of medical examiners that takes an adverse action
- The Drug Enforcement Administration (DEA) when it takes a controlled substance registration action, or
- The Department of Health and Human Services (HHS) Office of Inspector General (OIG) when it makes an exclusion from federal health care programs
- Under the authority of Section 1921 and Section 1128E
- A state licensing or certification authority
- A peer review organization
- A private accreditation organization that takes a negative action or finding against a health care entity, provider, or supplier
- A state law enforcement agency
- A federal or state prosecutor
- A state Medicaid fraud control unit
- A state agency administering or supervising the administration of a state health care program
- A federal government agency, or
- A health plan
In addition, the Department of Defense (DOD), the Department of Veterans Affairs (DVA), and certain agencies within HHS report to the NPDB under memorandums of understanding that generally govern reporting, rather than this Guidebook.
Eligible entities may use authorized agents to assist with reporting and/or querying.
Table B-1 summarizes the reporting and querying authorities of eligible entities.
Table B-1: Eligible Entities that Report to and Query the NPDB, Part 1
Each of the three major statutes governing NPDB operations has its own set of eligible entities with specific reporting and querying requirements. Eligible entities are responsible for complying with all reporting and/or querying requirements that apply; some entities may qualify as more than one type of eligible entity.
Title IV Requirements
| Entity | Report | Query |
|---|---|---|
| Medical malpractice payers |
Required | Not Authorized |
| Hospitals | Required | Required |
| Health care entities that provide health care services and follow a formal peer review process for the purpose of furthering quality health care | Required | Optional |
| Professional societies that follow a formal peer review process for the purpose of furthering quality health care | Required | Optional |
| Boards of medical examiners | Required | Optional |
| Other state licensing boards | Optional | |
| DEA | Required | |
| OIG | Required | Not Authorized |
Refer to Table B-1, Part 2, for additional information on reporting and querying requirements.
"Not Authorized" indicates that the statute contains no provision for an entity reporting to or querying the NPDB.
Table B-1: Eligible Entities that Report to and Query the NPDB, Part 2
Each of the three major statutes governing NPDB operations has its own set of eligible entities with specific reporting and querying requirements. Eligible entities are responsible for complying with all reporting and/or querying requirements that apply; some entities may qualify as more than one type of eligible entity.
Section 1921 and Section 1128E Requirements
| Entity | Report | Query |
|---|---|---|
| Hospitals* | Not Authorized | Optional** |
| Health care entities that provide health care services and follow a formal peer review process for the purpose of furthering quality health care | Optional** | |
| Professional societies that follow a formal peer review process for the purpose of furthering quality health care | Not Authorized | Optional** |
| Health plans | Optional | |
| Quality improvement organizations | Not Authorized | Optional** |
| State licensing and certification authorities | Required (§ 1921) | Optional |
| Peer review organizations | Not Authorized | |
| Private accreditation organizations | Required (§ 1921) | |
| State law enforcement agencies, including state prosecutors*** | Required (§ 1921) | Optional |
| State Medicaid fraud control units*** | Required (§ 1921) | Optional |
| State agencies administering or supervising the administration of state health care programs*** | Required (§ 1921) | Optional |
| Agencies administering federal health care programs, including private entities administering such programs under contract | Required (§ 1128E) | Optional |
| Federal licensing and certification agencies | Required (§ 1128E) | Optional |
| Federal law enforcement officials and agencies, including federal prosecutors | Required (§ 1128E) | Optional |
* Under Title IV, hospitals are required to query the NPDB.
** As described in Chapter D: Queries, with a few limited exceptions, these entities have access to all of the information reported under Section 1921 and Section 1128E.
*** NPDB regulations define "state law or fraud enforcement agency" as including but not limited to these entities.
Refer to Table B-1, Part 1, for additional information on reporting and querying requirements.
"Not Authorized" indicates that the statutes contain no provision for an entity reporting to or querying the NPDB.
