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Guidebook Cover Page

Table of Tables

Table of Figures

Chapter A: Introduction and General Information

Preface Background

Eliminating Duplication Between the NPDB and HIPDB Laws Governing NPDB Operations

General Information

Disclosure of NPDB Information Interpretation of NPDB Information Civil Liability Protection Confidentiality and Security of NPDB Information

Fees Official Language Terminology Differences Q&A: General Information

Q&A 1 Q&A 2 Q&A 3

Chapter B: Eligible Entities

Overview What is an Eligible Entity? Defining Eligible Entities

Boards of Medical Examiners Drug Enforcement Administration and HHS Office of Inspector General Federal Agencies Health Care Entities Health Plans Medical Malpractice Payers Peer Review Organizations Private Accreditation Organizations Professional Societies Quality Improvement Organizations State Agencies Administering or Supervising the Administration of State Health Care Programs State Law Enforcement Agencies State Law or Fraud Enforcement Agencies State Licensing and Certification Authorities State Licensing Boards State Medicaid Fraud Control Units

Registering with the NPDB

E-authentication and Identity Proofing Certifying Official Administrator Registration Renewal

NPDB Identification Numbers

Deactivating a DBID Lost DBID

Update Entity Information Who May Report and Query on Behalf of Eligible Entities

Authorized NPDB Users Authorized Agents

Q&A: Eligible Entities

Q&A 1 Q&A 2 Q&A 3 Q&A 4 Q&A 5 Q&A 6 Q&A 7 Q&A 8 Q&A 9 Q&A 10 Q&A 11

Chapter C: Subjects of Reports

Overview Definitions Self-Queries Subject Information

Correcting an Address Correcting Information in the Report

Q&A: Subjects of Reports

Q&A 1 Q&A 2 Q&A 3 Q&A 4 Q&A 5

Chapter D: Queries

Overview

Hospitals Other Health Care Entities Agencies Administering Government Health Care Programs, Including Private Entities Administering Such Programs Under Contract Federal Law Enforcement Officials and Agencies Federal Licensing and Certification Agencies Health Plans Professional Societies Quality Improvement Organizations State Agencies Administering or Supervising the Administration of a State Health Care Program State Law Enforcement Agencies and State Medicaid Fraud Control Units State Licensing and Certification Agencies State Medical Boards of Examiners or Other State Authorities that License Health Care Practitioners Health Care Practitioners, Entities, Providers, and Suppliers Attorney Access

Authorized Agents Centralized Credentialing Delegated Credentialing Submitting a Query

Querying Through an Authorized Agent Subject Information

Query Processing

Subject Database Query Responses Missing Query Responses Notifying the NPDB of a Missing Report

Retrieving Historical Query Summaries Confidentiality Q&A: Queries

Q&A 1 Q&A 2 Q&A 3 Q&A 4 Q&A 5 Q&A 6 Q&A 7 Q&A 8 Q&A 9 Q&A 10 Q&A 11 Q&A 12

Chapter E: Reports

Overview

Reporting Requirements Terminology Differences Time Frame for Reporting Deceased Practitioners Report Retention Civil Liability Protection Official Language

Submitting Reports to the NPDB

Report Formats Types of Reports Notice of Appeal Narrative Descriptions Methods for Submitting a Report Basis for Action Codes Report Processing Submitting a Copy of the Report to the Appropriate State Licensing Board or State Licensing or Certification Authority IQRS Draft Capability Subject Database Retrieving Historical Report and Query Summaries Q&A: Submitting Reports

Q&A 1 Q&A 2 Q&A 3 Q&A 4 Q&A 5 Q&A 6 Q&A 7

Reporting Medical Malpractice Payments

Interpretation of Medical Malpractice Payment Information Payments by Individuals Payments for Sole Shareholder Corporations Payments for Corporations and Hospitals Identifying Practitioners Written Complaint or Claim Dismissal of a Defendant from a Lawsuit Confidential Terms of a Settlement or Judgment Insurance Policies that Cover More than One Practitioner One Payment for More than One Practitioner Residents and Interns Students Practitioner Fee Refunds Waiver of Debt Loss Adjustment Expenses High-Low Agreements Payments by Multiple Payers Subrogation-Type Payments Structured Settlements Offshore Payers Payments Made Prior to Settlement Reporting of Medical Malpractice Payments by Authorized Agents Submitting a Copy of the Report to the State Licensing Board Sanctions for Failing to Report to the NPDB Q&A: Reporting Medical Malpractice Payments

Q&A 1 Q&A 2 Q&A 3 Q&A 4 Q&A 5 Q&A 6 Q&A 7 Q&A 8 Q&A 9 Q&A 10 Q&A 11 Q&A 12 Q&A 13 Q&A 14 Q&A 15 Q&A 16 Q&A 17

Reporting Adverse Clinical Privileges Actions

Administrative Actions Multiple Adverse Actions Denials or Restrictions Withdrawal of Applications Nonrenewals Investigations Temporary Clinical Privileges Summary Suspensions Proctors Residents and Interns Length of Restrictions Confidentiality Laws Related to Drug and Alcohol Treatment Submitting a Copy of the Report to a State Licensing Board Sanctions for Failing to Report to the NPDB Q&A: Reporting Clinical Privileges Actions

Reporting Adverse Professional Society Membership Actions

Submitting a Copy of the Report to the State Licensing Board Sanctions for Failing to Report to the NPDB Q&A: Reporting Professional Society Membership Actions

Q&A 1 Q&A 2 Q&A 3 Q&A 4 Q&A 5 Q&A 6 Q&A 7

Reporting State Licensure and Certification Actions

Formal Proceeding Certification Administrative Fines and Formal Money Penalties Publicly Available Information Stayed Actions Summary or Emergency Suspensions and Other Nonfinal Actions Denials of Initial and Renewal Applications Withdrawals or Nonrenewals of Applications While Under Investigation Voluntary Surrenders Consent Agreements Private Agreements Confidentiality Laws Related to Drug and Alcohol Treatment Impaired Practitioners Nurse Licensure Compact Sanctions for Failing to Report Q&A: Reporting State Licensure and Certification Actions

Reporting Federal Licensure and Certification Actions

Certification Administrative Fines and Formal Money Penalties Publicly Available Information Stayed Actions Denials of Initial and Renewal Applications Withdrawal of Application While Under Investigation Voluntary Surrender of License Confidentiality Laws Related To Drug and Alcohol Treatment Sanctions for Failing to Report to the NPDB Q&A: Reporting Federal Licensure or Certification Actions

Q&A 1 Q&A 2 Q&A 3 Q&A 4

Reporting Peer Review Organization Negative Actions or Findings

Submitting a Copy of the Report to the State Licensing or Certification Authority Q&A: Reporting Peer Review Organization Negative Actions or Findings

Q&A 1 Q&A 2 Q&A 3 Q&A 4

Reporting Private Accreditation Organization Negative Actions or Findings

Submitting a Copy of the Report to the State Licensing or Certification Authority Q&A: Reporting Private Accreditation Organizations Negative Actions or Findings

Q&A 1 Q&A 2 Q&A 3

Reporting Exclusions from Participation in Federal or State Health Care Programs

Sanctions for Failing to Report Q&A: Reporting Exclusions from Federal or State Health Care Programs

Q&A 1 Q&A 2 Q&A 3 Q&A 4 Q&A 5

Reporting Federal or State Health Care-Related Criminal Convictions

Nolo Contendere/No Contest Plea Injunctions First Offender, Deferred Adjudication, or Other Arrangement or Program Where Conviction Has Been Withheld Sanctions for Failing to Report to the NPDB Q&A: Reporting Federal or State Healthcare-Related Criminal Convictions

Q&A 1 Q&A 2 Q&A 3 Q&A 4 Q&A 5 Q&A 6 Q&A 7 Q&A 8

Reporting Health Care-Related Civil Judgments

Sanctions for Failing to Report to the NPDB Q&A: Reporting Civil Judgments

Q&A 1 Q&A 2 Q&A 3 Q&A 4 Q&A 5

Reporting Other Adjudicated Actions or Decisions

Other Adjudicated Actions or Decisions Taken in Conjunction with Clinical Privileges Actions Sanctions for Failing to Report to the NPDB Q&A: Reporting Other Adjudicated Actions or Decisions

Q&A 1 Q&A 2 Q&A 3 Q&A 4 Q&A 5 Q&A 6 Q&A 7 Q&A 8 Q&A 9

Chapter F: Subject Statements and the Dispute Process

Chapter H: Information Sources

NPDB Customer Service Center NPDB Addresses

General Information Aggregate Research Data Interpretation of NPDB Statutes and Regulations

Federal Employer Identification Number

Appendix A: Glossary

Appendix B: Acronym Guide

Appendix C: Change History

Download the NPDB Guidebook (PDF - 2.13 MB)

Q&A: Reporting Federal or State Health Care-Related Criminal Convictions

The Department of Justice (DOJ) pursued a criminal health care fraud case against a physician for billing for unprovided services. The physician pleaded guilty to health care fraud. Then, the OIG excluded the physician from participating in federal health care programs due to his criminal conviction of an offense related to fraud in connection with the delivery of a health care item or service. How should this be reported to the NPDB?

The criminal conviction of the health care practitioner is related to the delivery of a health care item or service and, therefore, the DOJ should report this as a criminal conviction. The OIG must separately report the exclusion. Exclusions from participation in a federal or state health care program should be reported as an exclusion.

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