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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 Organization Negative Actions or Findings Reporting Exclusions from Participation in Federal or 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

Definitions

A health care practitioner, licensed health care practitioner, licensed practitioner, or practitioner, as used in this Guidebook, is defined 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. See Table C-1, parts 1 and 2.

A dentist is defined as a doctor of dental surgery, dental medicine, or the equivalent who is legally authorized to practice dentistry by a state, or any individual who, without authority, holds himself or herself out to be so authorized.

A physician is defined as a doctor of medicine or osteopathy legally authorized to practice medicine or surgery by a state, or any individual who, without authority, holds himself or herself out to be so authorized.

A health care entity means:

  • A hospital
  • 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
  • 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 engages in professional review activity through a formal peer review process for the purpose of furthering quality health care

For purposes of the second bullet of this definition, an entity includes a health maintenance organization (HMO) that is licensed by a state or determined to be qualified as such by the Department of Health and Human Services (HHS), and any group or prepaid medical or dental practice that meets the criteria of the second bullet.

A formal peer review process is the conduct of professional review activities through formally adopted written procedures that provide for adequate notice and an opportunity for a hearing.

A health care provider means:

  • A provider of services as defined in Section 1861(u) of the Social Security Act
  • Any organization (including an HMO, 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, or
  • Any other organization that, directly or through contracts, provides health care services

A health care supplier means:

  • A provider of medical and other health care services as described in Section 1861(s) of the Social Security Act
  • 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)
  • Any individual or entity under contract to provide such supplies, items, or ancillary services
  • Health plans as defined in NPDB regulations (including employers that are self-insured), or
  • Health insurance producers (including but not limited to agents, brokers, solicitors, consultants, and reinsurance intermediaries)

Table C-1 lists examples of health care practitioners. Table C-2 offers examples of health care entities, providers, and suppliers. Table C-3 provides a summary of reporting requirements and query access for the NPDB.

The following lists of health care practitioners are provided solely for illustration. Since licensure and certification requirements vary from state to state, there may be additional categories of health care practitioners not reflected on the following lists, and there may be categories listed below that do not satisfy the definition of health care practitioner for particular states. Each entity that reports to or queries the NPDB is responsible for determining which categories of health care practitioners are licensed or otherwise authorized by their state to provide health care services.
Behavioral Health Occupations
 Addictions Counselor
 Sex Offender Counselor
 Counselor, Mental Health
 Pastoral Counselor Marriage and Family Therapist Art
  Therapist
 Professional Counselor
 Recreation Therapist Dance Therapist Music Therapist
Chiropractic Service Provider
 Chiropractic Assistant
 Chiropractor
Counselor
 Counselor, Mental Health
 Professional Counselor
 Professional Counselor, Alcohol
 Professional Counselor, Family/Marriage
 Professional Counselor, Substance Abuse
 Marriage and Family Therapist
Dental Service Provider
 Dentist
 Dental Resident
 Dental Assistant
 Dental Therapist/Dental Health Aide
 Dental Hygienist
 Denturist
Dietitian/Nutritionist
 Dietitian
 Nutritionist
Emergency Medical Technician (EMT)
 EMT, Basic
 EMT, Intermediate/Critical Care
 EMT, Paramedic
Eye and Vision Service Provider
 Ocularist
 Optician
 Optometrist
Nurse - Advanced, Registered, Vocational, or Practical
 Clinical Nurse Specialist
 Licensed Practical or Vocational Nurse
 Nurse Anesthetist
 Nurse Midwife
 Nurse Practitioner
 Registered Nurse
Nurse Aide, Home Health Aide and Other Aide
 Certified or Qualified Medication Aide
 Health Care Aide/Direct Care Worker
 Home Health Aide (Homemaker)
 Nurse Aide/Nursing Assistant
Pharmacy Service Provider
 Pharmacist
 Pharmacy Assistant
 Pharmacist Intern
 Pharmacy Technician
Physician
 Osteopathic Physician (DO)
 Osteopathic Physician Resident (DO)
 Physician (MD)
 Physician Resident (MD)
Physician Assistant
Podiatric Service Provider
 Podiatrist
 Podiatric Assistant
Psychologist, Psychological Assistant
 Psychological Assistant/Associate/Examiner
 Psychologist
 School Psychologist
Rehabilitative, Respiratory, and Restorative Service Practitioner
 Massage Therapist
 Occupational Therapist
 Occupational Therapy Assistant
 Physical Therapist
 Physical Therapy Assistant
 Rehabilitation Therapist
 Respiratory Therapist
 Respiratory Therapy Technician
Social Worker
Speech, Language, and Hearing Service Provider
 Audiologist
 Hearing Aid (or Instrument) Specialist/Dealer/Dispenser/Fitter
 Speech/Language Pathologist
Technologist/Technician
 Cytotechnologist
 Medical or Clinical Lab Technician/Technologist
 Nuclear Medicine Technologist
 Radiation Therapy Technologist
 Radiologic Technician/Technologist
 Surgical Technologist/Assistant
Other Health Care Practitioner
 Acupuncturist
 Athletic Trainer
 Homeopath
 Medical Assistant
 Midwife, Lay (Non-Nurse)
 Naturopath
 Orthotics/Prosthetics Fitter
 Perfusionist
 Psychiatric Technician
The following list of health care entities, providers, and suppliers is provided solely for illustration and is not intended to be a comprehensive list.
Individuals

Health Care Facility Administrator
Other Health Care-Related Occupation
 Accountant
 Bookkeeper
 Business Manager
 Business Owner
 Corporate Officer
 Researcher, Clinical
 Salesperson
Organizations

Accountable Care Organizations
Ambulance Service/Transportation Company
Group or Practice
 Chiropractic Group/Practice
 Dental Group/Practice
 Medical Group/Practice
 Mental Health/Substance Abuse
 Group/Practice
 Optician/Optometric Group/Practice
 Physical/Occupational Therapy Group/Practice
 Podiatric Group/Practice
Health Care Supplier/Manufacturer
 Biological Products Manufacturer
 Blood Bank
 Durable Medical Equipment Supplier
 Eyewear Equipment Supplier
 Fiscal/Billing/Management Agent
 Nursing/Health Care Staffing Service
 Organ Procurement Organization
 Pharmacy
 Pharmaceutical Manufacturer
 Portable X-Ray Supplier
 Purchasing Service
Health Insurance Company/Provider
Home Health Agency/Organization
Hospice/Hospice Care Provider
Hospital
 Federal Hospital
 General/Acute Care Hospital
 Psychiatric Hospital
 Rehabilitation Hospital
Hospital Unit
 Psychiatric Unit
 Rehabilitation Unit
Laboratory/CLIA Laboratory
Nursing Facility/Skilled Nursing Facility
Managed Care Organization
 Health Maintenance Organization
 Preferred Provider Organization
 Provider-Sponsored Organization
 Religious/Fraternal Benefit Society Plan
Other Health Care Facility
 Adult Day Care Facility
 Ambulatory Surgical Center
 Ambulatory Clinic/Center
 End Stage Renal Disease Facility
 Health Center/Federally Qualified Health
  Center/Community Health Center
 Intermediate Care Facility for Individuals
  with Mental Retardation/Substance Abuse
 Mammography Service Provider
 Mental Health Center/Community Mental
  Health Center
 Outpatient Rehabilitation Facility/
  Comprehensive Outpatient Rehabilitation Facility
 Radiology/Imaging Center
 Residential Treatment Facility/Program
 Rural Health Clinic
Research Center/Facility

Table C-3: Summary of Reporting Requirements and Query Access, Part 1

Law Who Reports? What is Reported Who is Reported? Who May Query/Request Information?
Title IV Medical malpractice payers Medical malpractice payments resulting from a written claim or judgment Practitioners Hospitals (required by law)

Other health care entities with formal peer review

Professional societies with formal peer review

State medical and dental boards and other state licensing boards

Plaintiff's attorney/pro se plaintiff (limited circumstances)

Health care practitioners (self-query)

Researchers (de-identified statistical data only)
State medical and dental boards Certain adverse licensure actions related to professional competence or conduct Physicians and dentist
Hospitals

Other health care entities with formal peer review
Certain adverse clinical privileges actions related to professional competence or conduct Physicians and dentists

Other practitioners (optional)
Professional societies with formal peer review Certain adverse professional society membership actions related to professional competence or conduct Physicians and dentists

Other practitioners (optional)
DEA DEA controlled-substance registration actions* Practitioners
OIG Exclusions from participation in Medicare, Medicaid, and other federal health care programs* Practitioners

*This information is reported to the NPDB under Title IV based on a memorandum of understanding.

Table C-3: Summary of Reporting Requirements and Query Access, Part 2

Law Who Reports? What is Reported Who is Reported? Who May Query/Request Information?
Section 1921 Peer review organizations Negative actions or findings by peer review organizations Practitioners Hospitals and other health care entities*

Professional societies with formal peer review*

Quality improvement organizations*

State licensing and certification authorities

Agencies administering federal health care programs, including private entities administering such programs under contract

Federal licensing and certification agencies

Health plans

State law enforcement agencies***

State Medicaid fraud control units***

State agencies administering or supervising the administration of state health care programs***

Federal law enforcement officials and agencies

Practitioners, entities, providers, and suppliers (self-query)

Researchers (de-identified, statistical data only)
Private accreditation organizations Negative actions or findings by private accreditation organizations Entities, providers, and suppliers
State licensing and certification authorities State licensing and certification actions Practitioners, entities, providers, and suppliers
State law enforcement agencies***

State Medicaid fraud control units***

State agencies administering or supervising the administration of state health care programs***

State prosecutors
Exclusions from a state health care program

Health care-related civil judgments in state court

Health care-related state criminal convictions

Other adjudicated actions or decisions
Practitioners, providers, and suppliers

Section 1128E

Federal agencies

Federal prosecutors

Health plans

Federal licensing and certification actions**

Exclusions from a federal health care program**

Health care-related federal or state criminal convictions**

Health care-related civil judgments in federal or state court

Other adjudicated actions or decisions
Practitioners, providers, and suppliers

* As more fully explained in Chapter D: Queries, these entities have access to most of the information reported under Section 1921 and Section 1128E.
** Reported by federal agencies only.
*** NPDB regulations define "state law or fraud enforcement agency" as including but not limited to these entities.

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