Provider Data Information, Source and Frequency Validated

Definition: Health New England Network associated with the plan selected by the member or employer group.

Fully-Funded HMO and Fully-Funded PPO
On Your ID Card: Look at your ID Card. If the Group # starts with any number except "5" (see GIC) you are covered under a Fully-Funded plan. You can find the type of plan (HMO, POS, PPO, HDHP) on the right hand side of your card.
Description: Most of the plans we offer through employer groups are Fully-Funded plans. This means that the premium paid to Health New England is used to pay for medical care and pharmacy services.

Self-Funded (ASO) HMO and Self-Funded (ASO) PPO
On Your ID Card: Look at your ID Card. If the Group # starts with the letter "S" you are covered under a Self-Funded plan.
Description: Some larger employer groups choose Self-Funded or ASO plans. ASO stands for "Administrative Services Only." Under these plans, the group pays a fee to Health New England. Health New England processes claims and performs other activities needed to manage the plan. The employer group pays for medical care and pharmacy services.

GIC Self-Funded
On Your ID Card: Look for the GIC logo on your ID Card.
Description: GIC stands for Group Insurance Commission. The GIC plan covers people who work for the Commonwealth of Massachusetts and certain municipalities (cities or towns). The GIC plan has a tiered provider network. That means that providers are assigned different copay levels (or tiers) based on access, quality and performance.
The GIC provider search can be found here: healthnewengland.org/gic-provider-search

Medicare Advantage
On Your ID Card: Look for the words "Health New England Medicare Advantage" at the bottom of your ID card.
Description: Health New England’s Medicare Advantage (MA) Plans cover those who are eligible for Medicare Parts A and B. Health New England MA Plans are available to residents of Hampden, Hampshire, Franklin, and Berkshire Counties.
The Medicare Advantage provider search can be found here: healthnewengland.org/medicare/provider-lookup

BeHealthy Partnership
On Your ID Card: Look for the Health New England BeHealthy Partnership logo on your ID card.
Description: Health New England's BeHealthy Partnership plan covers those who are eligible for coverage under the state MassHealth program. Health New England BeHealthy Partnership is available to residents of Hampden, Hampshire, Franklin, and Berkshire Counties.

Accepting New Patients

Definition: The provider agrees to become a medical caregiver to a member that he or she has not previously seen.

Source: This information is self-reported and verified during the initial credentialing process and every two years the provider's re-credentialing application, which is a signed document in which the provider confirms the information is accurate and complete. HNE also conducts outreach to the provider for data validation on a regular basis. This information may also be verified more often, if appropriate, outside of the re-credentialing or data validation processes.

Frequency Validated: On initial credentialing and at least every two years at re-credentialing, as well as regular outreach. Since a provider's office status may change at any time, members should check with the provider's office.

Board Certification

Definition: When a provider is board certified, this means that he or she has graduated from a medical school; completed residency (training in a hospital); trained under supervision in a specialty and passed exams given by a medical specialty board.

Source: This information is self-reported and verified during the initial credentialing process and every two years on the provider's re-credentialing application, which is a signed document in which the provider confirms the information is accurate and complete. HNE also conducts outreach to the provider for data validation on a regular basis.

Frequency Validated: On initial credentialing and at least every two years at re-credentialing, as well as regular outreach, and upon board certification expiration. Validation is conducted through one of the following primary sources:

• ABMS: American Board of Medical Specialties (http://www.abms.org)
• AOA: American Osteopathic Association (http://www.osteopathic.org)
• ABPM: American Board of Podiatric Medicine (http://www.abpmed.org)
• ABOMS: American Board of Oral and Maxillofacial Surgery (http://www.aboms.org)
• BACB: Behavioral Analyst Certification Board (http://www.bacb.com)

Gender

Definition: Self-explanatory.

Source: This information is self-reported and verified during the initial credentialing process and every two years on the provider’s re-credentialing application, which is a signed document in which the provider confirms the information is accurate and complete. HNE also conducts outreach to the provider for data validation on a regular basis.

Frequency Validated: On initial credentialing and at least every two years at re-credentialing, as well as regular outreach.

Hospital Affiliation

Definition: The HNE participating hospital where the provider has been granted privileges to provide medical care.

Source: This information is self-reported and verified during the initial credentialing process and every two years on the provider's re-credentialing application, which is a signed document in which the provider confirms the information is accurate and complete. HNE also conducts outreach to the provider for data validation on a regular basis.

Frequency Validated: On initial credentialing and at least every two years at re-credentialing, as well as regular outreach.

Language

Definition: Languages spoken by the provider, in addition to English. The office staff may, or may not, speak the same or other languages as the provider.

Source: This information is self-reported and verified during the initial credentialing process and every two years on the provider's re-credentialing application, which is a signed document in which the provider confirms the information is accurate and complete. HNE also conducts outreach to the provider for data validation on a regular basis.

Frequency Validated: On initial credentialing and at least every two years at re-credentialing, as well as regular outreach.

Last Name

Definition: Self-explanatory.

Source: This information is self-reported and verified during the initial credentialing process and every two years on the provider’s re-credentialing application, which is a signed document in which the provider confirms the information is accurate and complete. HNE also conducts outreach to the provider for data validation on a regular basis.

Frequency Validated: On initial credentialing and at least every two years at re-credentialing, as well as regular outreach.

Office Location

Definition: A list of practice locations (street, city, state) at which the provider will see members.

Source: This information is self-reported and verified during the initial credentialing process and every two years or more often on the provider's re-credentialing application, which is a signed document in which the provider confirms the information is accurate and complete. HNE also conducts outreach to the provider for data validation on a regular basis.

Frequency Validated: On initial credentialing and at least every two years at re-credentialing, as well as regular outreach.

Practice Name (Medical Group Affiliation)

Definition: The name of a group practice to which a provider belongs to or is associated with, if applicable.

Source: This information is self-reported and verified during the initial credentialing process and every two years on the provider’s re-credentialing application, which is a signed document in which the provider confirms the information is accurate and complete. HNE also conducts outreach to the provider for data validation on a regular basis.

Frequency Validated: On initial credentialing and at least every two years at re-credentialing, as well as regular outreach.

Specialty

Definition: The provider’s special field of practice or expertise. The provider will only be listed in a requested specialty that Health New England can verify, and that the provider has the education and training to support the requested specialty.

Source: This information is self-reported and verified during the initial credentialing process and every two years on the provider’s re-credentialing application, which is a signed document in which the provider confirms the information is accurate and complete. HNE also conducts outreach to the provider for data validation on a regular basis.

Frequency Validated: On initial credentialing and at least every two years at re-credentialing, as well as regular outreach.

Hospital Accreditation Status

Definition: A process of evaluating an institution/facility to determine whether it meets the standards set up by the accrediting body, and granting recognition of the fact. Accreditation is a process performed by a non-governmental agency at the request of the institution.

Source: This information is self-reported and verified during the initial credentialing process and every three years on the hospital’s re-credentialing application, which is a signed document in which the provider confirms the information is accurate and complete, as well as regular outreach to the hospital for data validation.

Frequency Validated: On initial credentialing and at least every three years through one or the following primary sources:

• AAAHC: Accreditation Association for Ambulatory Health Care, Inc. (http://www.aaahc.org)
• AABB: Advancing Transfusion and Cellular Therapies Worldwide (http://www.aabb.org)
• AASM: American Academy of Sleep Medicine (http://www.aasmnet.org)
• ABC: American Board for Certification in Orthotics, Prosthetics & Pedorthics (http://www.abcop.org)
• ACHC: Accreditation Commission for Health Care (http://www.achc.org)
• ACR: American College of Radiology (http://www.acr.org)
• BOC: Board of Certification / Accreditation (http://www.bocusa.org)
• CAP: College of American Pathologists (http://www.cap.org)
• CARF: CARF International (http://www.carf.org)
• CHAP: Community Health Accreditation Partner (http://www.chapinc.org)
• CLIA: Clinical Laboratory Improvement Amendments (https://www.cms.gov/clia)
• COA: Council on Accreditation (http://coanet.org)
• DNVGL: Det Norske Veritas Germanischer Lloyd DNV GL Healthcare (http://dnvglhealthcare.com)
• HFAP: Healthcare Facilities Accreditation Program (http://www.hfap.org)
• IAC: Intersocietal Accreditation Commission (http://www.intersocietal.org)
• The Joint Commission (formerly JCAHO: Joint Commission on Accreditation of Healthcare Organizations) (http://www.jointcommission.org)

Hospital Location and Phone Number

Definition: A list of hospital locations (street, city, state) at which the hospital will see members.

Source: This information is self-reported and verified during the initial credentialing process and every three years on the hospital’s re-credentialing application, which is a signed document in which the hospital confirms the information is accurate and complete, as well as regular outreach to the hospital for data validation.

Frequency Validated: On initial credentialing and at least every three years at re-credentialing, as well as regular outreach.

Hospital Name

Definition: Self-explanatory.

Source: This information is self-reported and verified during the initial credentialing process and every three years on the hospital’s re-credentialing application, which is a signed document in which the hospital confirms the information is accurate and complete, as well as regular outreach to the hospital for data validation.

Frequency Validated: On initial credentialing and at least every three years at re-credentialing, as well as regular outreach.

Hospital Quality Data from Recognized Sources

Definition: Detailed information about a hospital’s performance and how it compares to similar organizations. Hospital Quality Data is intended to provide consumers with quality of care information in order to make more informed decisions about their healthcare.

Source: This information is self-reported and verified during the initial credentialing process and every three years on the hospital’s re-credentialing application, which is a signed document in which the provider confirms the information is accurate and complete.

Frequency: On initial credentialing and at least every three years through one or the following sources:

• The Joint Commission (formerly JCAHO: Joint Commission on Accreditation of Healthcare Organizations): http://www.jointcommission.org
  • The Summary of Quality Information provides a high level overview of important quality of care indicators at a hospital. These quality of care indicators are important factors to take into consideration when selecting a health care organization.
• CMS Hospital Compare: https://www.medicare.gov/hospitalcompare/search.html
  • Hospital Compare is a consumer-oriented website that provides information on how well hospitals provide recommended care to their patients. This information can help consumers make informed decisions about health care. Hospital Compare allows consumers to select multiple hospitals and directly compare performance measure information related to heart attack, heart failure, pneumonia, surgery and other conditions. These results are organized by:
    • Patient Survey Results
    • Timely and Effective Care
    • Readmissions, Complications, and Deaths
    • Use of Medical Imaging
    • Linking Quality to Payment
    • Medicare Volume
• Leap Frog: https://www.leapfroggroup.org/
  • The Leapfrog initiatives have been built upon the fact that hospital performance transparency is critical to the optimal functioning of the healthcare marketplace. Leapfrog's public reporting initiatives offer valuable benchmarking capabilities to hospitals, as well as provide consumers and purchasers of healthcare with the quality and safety they need to make informed choices about their, or their employees' care.

Facility Name

Definition: Self-explanatory.

Source: This information is self-reported and verified during the initial credentialing process and every three years on the provider’s re-credentialing application, which is a signed document in which the provider confirms the information is accurate and complete. HNE also conducts outreach to the provider for data validation on a regular basis.

Frequency Validated: On initial credentialing and at least every three years at re-credentialing, as well as regular outreach.

Office Location

Definition: A list of practice locations (street, city, state) at which the provider will see members.

Source: This information is self-reported and verified during the initial credentialing process and every three years or more often on the provider's re-credentialing application, which is a signed document in which the provider confirms the information is accurate and complete. HNE also conducts outreach to the provider for data validation on a regular basis.

Frequency Validated: On initial credentialing and at least every three years at re-credentialing, as well as regular outreach.