During the credentialing process, a health plan verifies the accuracy of information on a prospective network provider's application.One true statement regarding this process is that the health plan:
The Festival Health Plan is in the process of recruiting physicians for its provider network. Festival requires its network physicians to be board certified. The following individuals are provider applicants whose qualifications are being considered:Applicant 1 has completed his surgical residency, and he recently passed a qualifying examination in his field.Applicant 2 has completed her residency in dermatology, and she is scheduled to take qualifying examinations in the next Six months.Applicant 3 completed his residency in pediatric medicine six years ago, but he has not yet passed a qualifying examination in his field.With regard to these applicants, it can correctly be stated that only:
The Justice Health Plan is eligible to submit reportable actions against medical practitioners to the National Practitioner Data Bank (NPDB). Justice is considering whether it should report the following actions to the NPDB:Action 1 - A medical malpractice insurer made a malpractice payment on behalf of a dentist in Justice's network for a complaint that was settled out of court.Action 2 - Justice reprimanded a PCP in its network for failing to follow the health plan's referral procedures.Action 3 - Justice suspended a physician's clinical privileges throughout the Justice network because the physician's conduct adversely affected the welfare of a patient.Action 4 - Justice censured a physician for advertising practices that were not aligned with Justice's marketing philosophy.Of these actions, the ones that Justice most likely must report to the NPDB include Actions:
The NPDB specifies the entities that are eligible to request information from the data bank, as well as the conditions under which requests are allowed. In general, entities that are eligible to request information from the NPDB include:
Participating providers in a health plan's network must undergo recredentialing on a regular basis. During recredentialing, a health plan typically reviews:
By definition, a measure of the extent to which a health plan member can obtain necessary medical services in a timely manner is known as:
