NPDB Guide to Reporting Other Adjudicated Actions or Decisions

Before Submitting:

Are you a federal government agency, 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, or a health plan that has taken an adjudicated action or decision against a health care practitioner, provider or supplier, that:

• Is a formal or official final action,
• Includes the availability of a due process mechanism, and
• Is 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 privileges actions and similar panel decisions made by health plans (must be reported separately)
• Overpayment determinations and denial of claims determinations made by federal agencies, state law or fraud enforcement agencies, or health plans
• Business or administrative decisions taken by health plans that results in contract terminations unrelated to health care fraud, abuse, or quality of care

Submit an Initial Adverse Action Report within 30 days of when the action was taken

Report Modifications (when needed):

The NPDB notifies the subject of the report when the report is submitted, and when any of these modifications are made.

• Did you organization take an action that modifies or relates to a previously reported action (including reinstatements)? If yes, Submit a Revision to Action report.
• Did your organization determine there is an error or omission in a previously submitted report? If yes, submit a Correction Report.
• Was it determined that an action should not have been reported because:
  • The report was erroneously submitted?
  • The action is not reportable?
  • The action was revered or overturned?
  These are the only reasons for which a report may be voided.
• Did a practitioner appeal a previously reported action? Submit a Notice of Appeal