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Other adjudicated actions or decisions*Practitioners, providers, and suppliers
*Hospitals, other health care entities, professional societies, and quality improvement organizations are not authorized to receive certain adverse actions reported under Section 1921, including exclusions from state health care programs, health care-related criminal convictions and civil judgments in state court, and other adjudicated actions or decisions.
** NPDB regulations authorize state law or fraud enforcement agencies to query the NPDB. The regulations define a "state law or fraud enforcement agency" as including, but not limited to, these entities.
The sections following Table D-1 contain detailed information about what entities and individuals must or may query the NPDB, including information about the type of information available to the specific entities or individuals and how the specific entities and individuals are permitted to use the information they obtain from the NPDB.
When an entity queries the NPDB, the NPDB determines how the entity is registered with the NPDB before releasing information, and it releases only lawfully permitted information based on the entity's registration. Consequently, queriers do not have to know what categories of information are available to them, although the sections below explain the type of information available. However, because the NPDB releases information based upon an entity's registration, entities that query the NPDB must make sure they are properly registered. Most authorized entities are only permitted to query the NPDB at specific times, such as when a practitioner is applying for privileges or a license, or for a specific reason. Entities must be certain that they are querying only for authorized purposes.
Hospitals
Hospitals are the only health care entities mandated by federal law to query the NPDB. Each hospital must request information from the NPDB as follows:
• When a physician, dentist, or other health care practitioner applies for medical staff appointment (courtesy or otherwise) or for clinical privileges at the hospital, including temporary privileges.
• Every 2 years (biennially) on all physicians, dentists, and other health care practitioners who are on its medical staff (courtesy or otherwise) or who hold clinical privileges at the hospital.
Hospitals are the only health care entities mandated by federal law to query the NPDB.
The biennial query may be done in accordance with regular medical staff reappointment and clinical privilege re-delineation. Additionally, hospitals are required to query the NPDB each time a practitioner wishes to add to or expand existing privileges. Hospitals also must query when a practitioner applies for temporary privileges. Hospitals are not required to query more than once every 2 years on a practitioner who is continuously on staff unless the practitioner wishes to add to or expand existing privileges or when a practitioner submits an application for temporary privileges. For example, if a practitioner applies for temporary clinical privileges four times in 1 year, the hospital must query the NPDB on each of those four occasions.
Hospitals are required to query on courtesy staff who are considered part of the medical staff, even if afforded only nonclinical professional courtesies such as use of the medical library and continuing education facilities. If a hospital extends nonclinical practice courtesies without appointing practitioners to a medical staff category, querying is not required on those practitioners.
Locum Tenens
A hospital is required to query the NPDB each time a locum tenens practitioner makes an application for temporary privileges. To reduce the query burden, hospitals that frequently use particular locum tenens practitioners may choose to appoint such practitioners to their consultant staff or other appropriate staff category in accordance with their bylaws and then query on the practitioners when their 2-year appointment is due for renewal.
Residents and Interns
Whether a hospital is required to query on an intern or resident depends upon whether the intern or resident is a member of the medical staff. Health care entities are not required to query the NPDB on medical and dental residents, interns, or staff fellows (collectively referred to as house staff), even though they are often licensed, when they are trainees in structured programs of supervised graduate medical education and not members of the medical staff.
There is no difference between the house staff of the clinical facility belonging to the formal medical education program and the house staff rotating to a clinical facility providing a clinical training site for the formal medical educational program. Hospitals are not required to query the NPDB on house staff providing services as part of their formal medical education.
However, hospitals are required to query on house staff when such individuals are appointed to the medical staff or granted clinical privileges to practice outside the parameters of the formal medical education program (e.g., moonlighting in the intensive care unit or emergency department of that hospital).
Physicians, Dentists, and Other Health Care Practitioners
In addition to the mandatory requirements for querying, hospitals may request information from the NPDB at any time they deem necessary with respect to professional review activity. Furthermore, hospitals and their human resources and recruiting departments may query on all types of health care practitioners (e.g., nurses, nurse aides, physical therapists) with respect to making determinations regarding employment or affiliation relationships.
Results of Hospital Queries
Hospitals must query in the following situations:
• When a physician, dentist, or other health care practitioner applies for medical staff appointment (courtesy or otherwise) or for clinical privileges, including temporary privileges
• Every 2 years (biennially) on all physicians, dentists, and other health care practitioners who are on the medical staff (courtesy or otherwise) or who hold clinical privileges
• When a health care practitioner wishes to add to or expand existing privileges and when a practitioner submits an application for temporary privileges
• Each time a locum tenens health care practitioner makes an application for temporary privileges
• On residents and interns when such individuals are appointed to the medical staff or granted clinical privileges to practice outside the parameters of a formal medical education program
Generally, hospitals may query when the hospital is entering into an employment or affiliation relationship with the health care provider, or when the hospital is engaging in professional review activity.
Hospitals receive the following types of information in response to their queries:
• Medical malpractice payment information
• Licensure actions by boards of medical examiners
• Licensing and certification actions taken by states
• Federal licensing and certification actions
• Adverse actions taken by health care entities against clinical privileges, including professional review actions taken by professional societies
• Negative actions or findings by peer review organizations or private accreditation entities
• Health care-related criminal convictions
• Health care-related civil judgments
• Exclusions from participating in federal or state health care programs
• Other health care-related adjudicated actions or decisions
Failure to Query
If a hospital does not query on a practitioner when required, the hospital is presumed to be aware of the information reported to the NPDB concerning the practitioner. A hospital's failure to query on a practitioner may give a plaintiff's attorney or plaintiff representing himself or herself access to NPDB information on that practitioner for use in litigation against the hospital.
Other Health Care Entities
Other health care entities generally may query the NPDB:
• When they have or may be entering into employment or affiliation relationships with health care practitioners
• When health care practitioners apply for clinical privileges or medical staff appointments
• When they are engaging in professional review activity
Other health care entities receive the following types of information in response to their queries:
• Medical malpractice payment information
• Licensure actions by boards of medical examiners
• Licensure and certification actions taken by states
• Adverse actions taken by health care entities against clinical privileges, including professional review actions taken by professional societies
• Negative actions or findings by peer review organizations or private accreditation entities
• Health care-related criminal convictions when reported by federal agencies or health plans
• Health care-related civil judgments when reported by federal agencies or health plans
• Exclusions from participating in federal or state health care programs when reported by federal agencies or health plans
• Other health care-related adjudicated actions or decisions when reported by federal agencies or health plans
Agencies Administering Government Health Care Programs, Including Private Entities Administering Such Programs Under Contract
Federal and state agencies administering government health care programs, including private entities administering such programs under contract, may query:
• When they are determining the fitness of individuals to provide health care services
• When they are protecting the health and safety of individuals receiving health care through programs they administer
• When they are protecting the fiscal integrity of programs they administer
Agencies administering government health care programs, including private entities administering such programs under contract, receive the following types of information in response to their queries:
• Licensure and certification actions taken by states
• Federal licensing and certification actions
• Negative actions or findings by peer review organizations or private accreditation entities
• Health care-related criminal convictions
• Health care-related civil judgments
• Exclusions from participating in federal or state health care programs
• Other health care-related adjudicated actions or decisions
Federal Law Enforcement Officials and Agencies
Federal law enforcement officials and agencies may query the NPDB:
• When they are determining the fitness of individuals to provide health care services
• When they are protecting the health and safety of individuals receiving health care through programs they administer
• When they are protecting the fiscal integrity of programs they administer
Federal law enforcement officials and agencies receive the following types of information in response to their queries:
• Licensure and certification actions taken by states
• Federal licensing and certification actions
• Negative actions or findings by peer review organizations or private accreditation entities
• Federal or state health care-related criminal convictions
• Health care-related civil judgments
• Exclusions from participating in federal or state health care programs
• Other health care-related adjudicated actions or decisions
Federal Licensing and Certification Agencies
Federal licensing and certification agencies responsible for the licensing or certification of health care practitioners, providers, or suppliers may query the NPDB:
• When they are determining the fitness of individuals to provide health care services
• When they are protecting the health and safety of individuals receiving health care through programs that they administer
• When they are protecting the fiscal integrity of the programs they administer
Federal licensing and certification agencies responsible for the licensing or certification of health care practitioners, providers, or suppliers receive the following types of information in response to their queries:
• Licensure and certification actions taken by states
• Federal licensing and certification actions
• Negative actions or findings by peer review organizations or private accreditation entities
• Federal or state health care-related criminal convictions
• Health care-related civil judgments
• Exclusions from participating in federal or state health care programs
• Other health care-related adjudicated actions or decisions
Health Plans
Health plans may query the NPDB:
• When they are determining the fitness of individuals to provide health care services
• When they are protecting the health and safety of individuals receiving health care through programs they administer
• When they are protecting the fiscal integrity of programs they administer
Health plans receive the following types of information in response to their queries:
• Licensure and certification actions taken by states
• Federal licensing and certification actions
• Negative actions or findings by peer review organizations or private accreditation entities
• Federal or state health care-related criminal convictions
• Health care-related civil judgments
• Exclusions from participating in federal or state health care programs
• Other health care-related adjudicated actions or decisions
Professional Societies
Professional societies generally may query the NPDB:
• When entering into an employment or affiliation (membership) relationship with a health care practitioner
• When engaging in a professional review activity
Professional societies receive the following types of information in response to their queries:
• Medical malpractice payment information
• Licensure actions by boards of medical examiners
• Licensure and certification actions taken by states
• Adverse actions taken by health care entities against clinical privileges, including professional review actions taken by professional societies
• Negative actions or findings by peer review organizations or private accreditation entities
• Health care-related criminal convictions when reported by federal agencies or health plans
• Health care-related civil judgments when reported by federal agencies or health plans
• Exclusions from participating in federal or state health care programs when reported by federal agencies or health plans
• Other health care-related adjudicated actions or decisions when reported by federal agencies or health plans
Quality Improvement Organizations
Quality improvement organizations may query the NPDB:
• When they are determining the fitness of individuals to provide health care services
• When they are protecting the health and safety of individuals receiving health care through programs they administer
• When they are protecting the fiscal integrity of programs they administer
Quality improvement organizations receive the following types of information in response to their queries:
• Licensure and certification actions taken by states
• Negative actions or findings by peer review organizations or private accreditation entities
• Health care-related criminal convictions when reported by federal agencies or health plans
• Health care-related civil judgments when reported by federal agencies or health plans
• Exclusions from participating in federal or state health care programs when reported by federal agencies or health plans
• Other health care-related adjudicated actions or decisions when reported by federal agencies or health plans
State Agencies Administering or Supervising the Administration of a State Health Care Program
State agencies administering or supervising the administration of a state health care program may query the NPDB:
• When they are determining the fitness of individuals to provide health care services
• When they are protecting the health and safety of individuals receiving health care through programs they administer
• When they are protecting the fiscal integrity of programs they administer
State agencies administering or supervising the administration of a state health care program receive the following types of information in response to their queries:
• Licensure and certification actions taken by states
• Federal licensing and certification actions
• Negative actions or findings by peer review organizations or private accreditation entities
• Federal or state health care-related criminal convictions
• Health care-related civil judgments
• Exclusions from participating in federal or state health care programs
• Other health care-related adjudicated actions or decisions
State Law Enforcement Agencies and State Medicaid Fraud Control Units
State law enforcement agencies and state Medicaid fraud control units may query the NPDB:
• When they are determining the fitness of individuals to provide health care services
• When they are protecting the health and safety of individuals receiving health care through programs they administer
• When they are protecting the fiscal integrity of programs they administer
State law enforcement agencies and state Medicaid fraud control units receive the following types of information in response to their queries:
• Licensure and certification actions taken by states
• Federal licensing and certification actions
• Negative actions or findings by peer review organizations or private accreditation entities
• Federal or state health care-related criminal convictions
• Health care-related civil judgments
• Exclusions from participating in federal or state health care programs
• Other health care-related adjudicated actions or decisions
State Licensing and Certification Agencies
State licensing and certification agencies may query the NPDB:
• When they are determining the fitness of individuals to provide health care services
• When they are protecting the health and safety of individuals receiving health care through programs that they administer
• When they are protecting the fiscal integrity of the programs they administer
State licensing and certification agencies receive the following types of information in response to their queries:
• Licensure and certification actions taken by states
• Federal licensing and certification actions
• Negative actions or findings by peer review organizations or private accreditation entities
• Federal or state health care-related criminal convictions
• Health care-related civil judgments
• Exclusions from participating in federal or state health care programs
• Other health care-related adjudicated actions or decisions
State Medical Boards of Examiners or Other State Authorities that License Health Care Practitioners
State medical boards of examiners or other state authorities that license health care practitioners may query the NPDB at any time. These authorities receive the following types of information in response to their queries:
• Medical malpractice payment information
• Licensure actions by boards of medical examiners
• Adverse actions taken by health care entities against clinical privileges, including professional review actions taken by professional societies
Note that entities that qualify as state medical boards of examiners or other state authorities that license health care practitioners also qualify as state licensing and certification agencies and therefore are eligible to receive information listed under that section.
Health Care Practitioners, Entities, Providers, and Suppliers
Health care practitioners, entities, providers, and suppliers may request information concerning themselves from the NPDB (Self-Query) at any time.
Attorney Access
A plaintiff's attorney or a plaintiff representing himself or herself is permitted to obtain certain information from the NPDB under the following limited conditions:
• A medical malpractice action or claim must have been filed by the plaintiff against a hospital in a state or federal court or other adjudicative body;
• The practitioner on whom the information is requested must be named in the action or claim; and
• Evidence must be submitted to the Department of Health and Human Services demonstrating that the hospital failed to submit a mandatory query to the NPDB regarding the practitioner named by the plaintiff in the action.
Evidence that the hospital failed to query the NPDB must be obtained by the plaintiff from the hospital through discovery in the litigation process. This evidence is not available to the plaintiff through the NPDB.
The plaintiff's attorney must submit all of the following to the NPDB:
• A letter requesting authorization to obtain information
• Supporting evidence that the hospital did not make a mandatory query of the NPDB regarding the practitioner named by the plaintiff in the action or claim
• Identifying information about the practitioner on whom the attorney wishes to query
The letter should be sent to one of the following addresses:
Standard MailOvernight MailNational
P.O. Box 10832
Chantilly, VA 20153-0832National Practitioner Data Bank
4094 Majestic Lane
PMB-332
Fairfax, VA 22033
Paragraph 30 of 30
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