Helpful Definitions
Provider Definitions
The information in the Provider search tool is provided to us by the health care provider (for example, your provider) and the hospitals with which we contract. Data are verified through the credentialing process. Credentialing is the process of checking the accuracy of the reported qualifications of licensed health professionals or organizations. It also involves reviewing a provider's background, such as education and training, to ensure certain professional requirements are met. Initial credentialing occurs when a health care provider or hospital first applies to provide services to members in our network. Re-credentialing occurs at least every three years thereafter. Information on our providers is also obtained through the contracting process. Contracting is the process by which the health care practitioner or hospital enters into an agreement to provide services to our members.
Some doctors may not do some kinds of care based on religious or moral beliefs.
Ancillary Provider - One who gives care such as skilled nursing care or home care or transportation. They may also be those who offer facility-based services like lab services. Examples include:
- Chiropractors
- Optometrists
- Podiatrists
- Durable medical equipment providers
- Home health agencies
- Hospice programs
- Orthopedics and prosthetics providers
- Dental Provider—One who deals with care of the teeth, gums and mouth.
Hospital - A place that provides care and treatment for the sick or the injured.
Hospital Affiliations - The hospitals in the health plan network where a provider can admit or treat patients. This is given to us by the provider. They may do this when they go through credentialing. Or it could be when they apply for a contract. The data is obtained at initial credentialing, every three years at recredentialing, and/or any time during the contracting process. Please note that the data is supplied to us by the provider. Only hospitals that are part of our network are listed. If a hospital is not in our network, it will not be listed.
Primary Care Physician (PCP) - A member’s personal doctor. He or she manages all the member’s health care needs.
Provider - someone who works with the plan to give members care. This includes:
- Doctors
- Hospitals
- Pharmacies
- Laboratories
- Other medical people
Board Certification - Board certification is achieved when a doctor has successfully completed a program and testing for a particular specialty. Board certification indicates a physician's expertise in a particular specialty and/or subspecialty of medical practice. A physician's board certification status, including expiration date (if applicable), is verified directly with one of the following agencies:
- American Board of Medical Specialties (ABMS)
- American Osteopathic Association (AOA)
- Royal College of Physicians and Surgeons of Canada
- College of Family Physicians of Canada
For specialties in which the physician has achieved certification, the specialty will be listed as "Board Certified." Board certification is verified at initial credentialing and every three years at re-credentialing. Board certification status is also updated with the ABMS upon expiration, but there may be some situations when data are not current due to the timing of Web site updates. For a majority of physicians, a member can verify a doctor's current board certification status directly through the American Board of Medical Specialties at www.abms.org. Board certification is current if the doctor is listed on the ABMS Web site as "General" or "Specialty" certified. Hospital Affiliations—The hospitals in the health plan network where the provider has admitting or attending privileges. This information is self-reported by the provider through the credentialing application or contracting process. The data are obtained at initial credentialing, every three years at re-credentialing, and/or any time during the contracting process. Please note that the data are self-reported by the provider, and only hospitals participating with the health plan are listed. If a hospital does not contract with the health plan, it will not be listed.
Specialty Physician - One who has skills in a certain area. This may be:
- A certain branch of medicine
- Specific procedures
- Patients of a certain age
- Specific body systems
- Certain types of diseases
Languages Spoken by Health Care Providers or Staff - This lists the languages spoken at a provider’s office. They could be spoken by the provider. Or it could be by members of their staff. It only refers to languages other than English. This information is obtained through the credentialing application or contracting process and is updated periodically through provider network outreach. Please note that the provider gives us this data. If they do not tell us, it will not be listed in our directory.
Facility Name - The name of the office, clinic or hospital where a member gets treatment. This information is self-reported by the provider through the credentialing application or contracting process.
Accreditation - A process in which certification of competency, authority or credibility is presented.
Acceptance of New Patients - Indicates, for certain types of plans, whether the practitioner is accepting new patients. This information is self-reported by the health care provider through the credentialing application or contracting process. It is validated at the onset of contracting and updated as reported by the provider.
Medical Group Affiliations - A listing of all medical groups with which the health care provider is associated (when applicable). This information is self-reported by the provider or the medical group through the credentialing application or contracting process. If the provider does not provide this information, it will not be included in this directory. The data are obtained at initial credentialing, every three years at re-credentialing, and/or any time during the contracting process. Languages Spoken by Health Care Providers or Staff—Indicates any languages (other than English) spoken by the practitioner or clinical staff in the office. This information is obtained through the credentialing application or contracting process and is updated periodically through provider network outreach. Please note that the data are self-reported by the provider. If the provider does not provide this information, it will not be included in this directory.
Location - The address of the provider office, clinic or hospital is reported by the provider, clinic, or hospital through the credentialing application or contracting process. This data are obtained during the contracting process and updated when reported by the provider, clinic or hospital upon relocation.
