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Appendices
APPENDIX A
Clinician Data Fields
Physician
10 Physician (MD)
15 Physician Intern/Resident (MD)
20 Osteopathic Physician (DO)
25 Osteopathic Physician Intern/Resident(DO)
Physician Assistant
642 Phys. Asst., Allopathic
645 Phys. Asst., Osteopathic
Advanced Practice Nurse
110 Nurse Anesthetist
120 Nurse Midwife
130 Nurse Practitioner
135 Advanced Practice Nurse
141 Clinical Nurse Specialist
APPENDIX B
Adverse Actions Data Fields
Licensure Actions
1110 Revocation of License (Individual)
1125 Probation of License (Individual)
1135 Suspension of License (Individual)
1138 Summary/Emergency Limitation/Restriction on License
1139 Summary/Emergency Suspension of License.
1140 Reprimand or Censure of License (Individual)
1144 Reprimand, Censure, Voluntary Surrender of License (Individual)
1145 Voluntary Surrender of License (Individual)
1146 Voluntary Limitation/Restriction on License (Individual)
1147 Limitation or Restriction on License/ Practice (Individual)
1148 Denial of License (Renewal Only) (Individual)
1172 Administrative Fine/Monetary Penalty (Licensure) (Individual)
1173 Publicly Available Fine/Monetary Penalty (Licensure) (Individual)
1199 Other Licensure Action
1280 Licensure Restored or Reinstated (Complete)(Individual)
1282 License Restored or Reinstated(Conditional)(Individual)
1283 License Restored or Reinstated (Legacy Report)(Individual)
1285 License Restoration or Reinstatement Denied (Individual)
1295 Reduction of Previous Licensure Action (Individual)
1296 Extension of Previous Licensure Action (Individual)
Exclusions from Federal and State Government Programs
1500 Debarment from Federal Programs (Individual)
1505 Exclusion from Federal Health Care Program (Individual)
1507 Exclusion from a State Health Care Program (Individual)
1508 Excl. from Medicare, Medicaid & all Other Fed. Programs. (Individual)
1509 Exclusion from Medicare & State Health Care Programs (Individual.)
1515 Reinstatement (Exclusion) (Individual)
1516 Reinstatement Denied (Exclusion)(Individual)
Clinical Privileges Actions
1610 Revocation of Clinical Privileges/Panel Membership (Individual)
1630 Suspension of Clinical Privileges/Panel Membership (Individual)
1632 Summary/Emergency Suspension of Clinical Privileges/PM (Individuals)
1634 Voluntary Limitation/Restriction/Rdct Clin Priv/Panel Member Investigation
1635 Voluntary Surrender of Clin. Priv/Panel Member. Under Investigation (Individual)
1636 Voluntary Acceptance of Restrictions on Privileges
1640 Reduction of Clinical Privileges/Panel Membership (Individual)
1645 Other Restriction of Clinical Priv/Panel Membership (Individual)
1650 Denial of Clinical Privileges (Individual)
1680 Clin. Priv. /Panel Member Restored/Reinstated (Complete) (Individual)
1681 Clin. Priv/Panel Member Restored/Reinstated (Conditional) (Individual)
1689 Clinical Privileges/Panel Membership Reinstatement Denied (Individual)
1690 Reduction of Previous Action (Clin Priv/Panel Membership) (Individual)
1695 Extension of Previous Action (Clin Priv/Panel Membership) (Individual)
1699 Reversal of Previous Clin Priv/PM Action, Appeal or Review (Individual)
Professional Society Actions
1710 Revocation of Professional Society Membership (Individual)
1730 Suspension of Professional Society Membership (Individual)
1745 Other Restriction/Limitation on Prof. Soc. Membership (Individual)
1750 Denial of Professional Society Membership (Subsequent) (Individual)
1780 Professional Society Membership Reinstated (Complete) (Individual)
1781 Professional Society Membership Reinstated (Conditional) (Individual)
1789 Professional Society Membership Reinstatement Denied (Individual)
1790 Reduction of Previous Action (Prof Soc Membership) (Individual)
1795 Extension of Previous Action (Prof Society Membership) (Individual)
1799 Reversal of Previous Prof Soc Action, Appeal or Review (Individual)
APPENDIX C
Basis for Action Data Fields
01 Alcohol and/or Other Substance Abuse
03 Narcotics Violation
05 Fraud (Unspecified)
06 Insurance Fraud (Medicare and Other Federal Gov. Program)
07 Insurance Fraud (Medicaid or Other State Gov. Program)
08 Insurance Fraud (Non-Government or Private Insurance)
09 Fraud in Obtaining License or Credentials
10 Unprofessional Conduct
11 Incompetence
12 Malpractice
13 Negligence
14 Patient Abuse
15 Patient Neglect
16 Misappropriation of Patient Property or Other Property
19 Criminal Conviction
20 Mental Disorder
22 Advertising or Marketing Services or Products That Are Discriminatory,
Misleading, False, or Deceptive
29 Practicing Beyond Scope of Practice
30 Allowing Unlicensed Person to Practice
31 Noncompliance with Health and Safety Requirements
32 Lack of Appropriately Qualified Professionals
34 Financial Insolvency
39 License Action by Fed., State, or Local Licensing Authority
40 Exclusion/Suspension from Fed or State HC Program
41 Entities Owned/Controlled by Sanctioned Individual
42 Individuals Controlling Sanctioned Entities
43 Employing/Contracting With Individual Excluded From Fed/St HC Program
44 Default on Health Education Loan or Scholarship Obligations
45 Failure to Maintain Records or Provide Medical, Financial or Other Required
Information
46 Failure to Grant Immediate Access
47 Failure to Take Corrective Action
48 Failure to Obtain Surety Bond
49 Failure to Comply w/ Composition of Enrollment Requirements
51 Failure to Perform Contractual Obligations
52 Incompetence, Malpractice, Negligence (Legacy Format Reports.)
53 Failure to Provide Med Reasonable or Necessary Items/Services
54 Furnishing Unnecessary or Substandard Items/Services
55 Improper or Abusive Billing Practices
56 Submitting False Claims
57 Fraud, Kickbacks and Other Prohibited Activities
58 Imposition of Civil Money Penalty or Assessment
59 Peer Review Organization Recommendation
60 Felony Conviction Related to Health Care Fraud
61 Felony Conviction Re: Controlled Substance Violation
62 Program-Related Conviction
63 Conviction Re: Patient Abuse or Neglect
64 Conviction Re: Fraud
65 Conviction Re: Obstruction of an Investigation
66 Conviction Re: Controlled Substances
69 Criminal Conviction, Not Classified
71 Conflict of Interest
74 Violation of Federal or State Antitrust Statute
75 Violation of Drug-Free Workplace Act
76 Violation of Immigration & Nationality Act Employment Provisions
77 Viol. of ADA or Applicable Federal and State Laws
78 Viol. of Civil Rights Act or Applicable Fed and State Laws
80 Physical Impairment
81 Misrepresentation of Credentials
82 Debarment from Federal or State Program
83 Hospital Privileges Restricted, Suspended or Revoked
91 Noncompl. W. Priv. Accred. Standards
92 Noncompl. W. Private Accreditation Standards That Pose a Substantial Risk to
the Safety of Patient Care or Quality of Health Care Services
99 Other (Not Classified)
A1 Failure to Meet the Initial Requirements of a License
A2 Failure to Comply with Continuing Education or Competency Requirements
A3 Failure to Meet Licensing Board Reporting Requirements
A4 Practicing Without a Valid License
A5 Violation of or Failure to Comply with Licensing Board Order
A6 Violation of Federal or State Statutes, Regulations or Rules
A7 Surrendered License to Practice
A8 Clinical Priv. Restricted, Suspended or Revoked by Another Hospital or Health
Care Facility
A9 Failure to Meet or Comply w/ Contractual Obligations or Particular Requirements
AA Failure to Comply with Corrective Action Plan
AB Practicing Beyond the Scope of Privileges
AC Failure to Maintain Equipment/Missing or Inadequate Equipment
AD Surrendered Clinical Privileges
B1 Nolo Contendre Plea 09
C1 Failure to Obtain Informed Consent
C2 Failure to Comply with Patient Consultation Requirements
C3 Breach of Confidentiality
D1 Sexual Misconduct
D2 Non-Sexual Dual Relationship or Boundary Violation
D3 Exploiting a Patient for Financial Gain
E1 Insurance Fraud (Medicare, Medicaid or Other Insurance)
E2 Providing or Ordering Unnecessary Tests or Services
E3 Filing False Reports or Falsifying Records 09/09/2002
E4 Fraud, Deceit or Material Omission in Obtaining License or Credentials
E5 Misleading, False or Deceptive Advertising or Marketing
F1 Immediate Threat to Health or Safety
F2 Unable to Practice safely by Reason of Alcohol or Other Substance Abuse
F3 Unable to Practice Safely by Reason of Psychological Impairment or Mental
Disorder
F4 Unable to Practice Safely by Reason of Physical Illness or Impairment
F5 Unable to Practice Safely
F6 Substandard or Inadequate Care
F7 Substandard or Inadequate Skill Level
F8 Failure to Consult or Delay in Seeking Consultation w Supervisor/Proctor
F9 Patient Abandonment
FA Inappropriate Refusal to Treat
FB Excessive Malpractice Cases/Extensive Malpractice History
FC Negligent Credentialing
G1 Improper or Inadequate Supervision or Delegation
G2 Allowing or Aiding Unlicensed Practice
H1 Narcotics Violation or Other Violation of Drug Statutes
H2 Unauthorized Prescribing of Medication
H3 Unauthorized Dispensing of Medication
H4 Unauthorized Administration of Medication
H5 Error in Prescribing, Dispensing or Administering Medication
H6 Diversion of Controlled Substance
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