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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. | |
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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. | |
|---|---|
Health Care Facility Administrator Other Health Care-Related Occupations Accountant Bookkeeper Business Manager Business Owner Corporate Officer Insurance Agent/Broker Researcher, Clinical Salesperson 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 Managed Care Organization Health Maintenance Organization Preferred Provider Organization Provider-Sponsored Organization Religious/Fraternal Benefit Society Plan Nursing Facility/Skilled Nursing Facility Other Health Care Facility Adult Day Care Facility Ambulatory Clinic/Center Ambulatory Surgical 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 dentists | ||
| 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) |
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| Professional societies with formal peer review | Certain adverse professional society membership actions related to professional competence or conduct | Physicians and dentists Other practitioners (optional) |
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| 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 |
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| 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.
