A primary care physician (PCP) helps patients maintain overall health by focusing on preventive care, instead of specializing in a specific area of medicine. Included in this category are a family practice or general practice. A family practitioner is qualified to care for the entire family. A family practitioner can be board-certified and have training in a variety of subjects including obstetrics and gynecology, pediatrics, internal medicine and psychiatry.

An internist in internal medicine can diagnose and treat disease with medicine. An internist is not a surgeon. There are several sub-specialties an internist can have, including: specializing in a particular organ, like the lungs or the kidneys; a particular disease, like diabetes; or a particular age group, like the elderly.

A pediatrician specializes in the overall well-being of children. Most pediatricians treat children from birth until adolescence or about 14 years old. Pediatricians can have subspecialties such as surgery or pediatric cardiology.

Non-physician primary care practitioner can be selected as PCP:

• Certified Nurse Practitioner (CNP)
• Certified Nurse Midwife (CNM)
• West Virginia Certified Physician Assistants (PA-C)

You may change your PCP no more than once per calendar month.

Specialists are physicians who have been trained to treat a specific area of the body such as the lungs, heart, brain, or teeth. For people with asthma, doctors like allergists, immunologists, and pulmonologists focus on what’s triggering the asthma symptoms. If allergies are the main trigger, for example, an allergist will identify what you’re allergic to and help you combat the allergy. He may suggest avoiding the allergen, using medications, or starting allergy shots.

When you or a family member needs health care or medical treatment, you want a highly qualified doctor dedicated to providing outstanding care. When you choose a doctor who is board-certified by one of the ABMS Member Boards, you can be confident he or she meets nationally recognized standards for education, knowledge, experience and skills to provide high quality care in a specific medical specialty. Board certification goes above and beyond basic medical licensure.

A History of High Standards

Since 1933, the ABMS Member Boards have been certifying doctors to help assure patients as well as hospitals, health plans, insurers and the government that these doctors are qualified to provide expert health care in an ever-expanding number of medical specialties and subspecialties. With the guidance and support of ABMS, each of our 24 Member Boards is responsible for developing and implementing the educational and professional standards for quality practice in a particular medical specialty or subspecialty, as well as for evaluating candidates for board certification.

A Lifetime of Learning

ABMS is nationally recognized for the high standards our Member Boards set to certify doctors in various medical specialties. To make sure board-certified doctors continuously refresh and expand their knowledge, our Member Boards have also established the ABMS Maintenance of Certification® program for career-long self-assessment, learning and improvement activities.

(www.abms.org/About_Board_Certification/means.aspx)

 

Is Your Doctor Board-Certified?

There are four ways you can find out if your doctor is certified by an ABMS Member Board.

1. Check online.
2. Call toll-free 1.866.ASK.ABMS (1.866.275.2267)
3. Contact an ABMS Member Board
   You can request written verification of Board Certification by contacting the Member Board in the doctor's specialty.
4. Look in the Book
   "The Official ABMS Directory of Board Certified Medical Specialists" provides up-to-date professional and biographical information on physicians who have met the certification requirements of their respective medical specialty boards. "The Official ABMS Directory" can be found in many medical and public libraries.

FOR DOCTORS OF OSTEOPATHIC MEDICINE OR DOs

American Osteopathic Association
www.osteopathic.org/Pages/default.aspx

 

What is a DO?

You have been going to a physician ever since you were born. But did you know that some or all of them could have been osteopathic physicians, or DOs? Both DOs and MDs are fully qualified physicians licensed to perscribe medication and perform surgery.

DOs and MDs are alike in many ways

• Students entering both DO and MD medical colleges typically have already completed four-year bachelor's degrees with an emphasis on scientific courses.
• Both DOs and MDs complete four years of basic medical education.
• After medical school, both DOs and MDs obtain graduate medical education through internships, residencies and fellowships. This training lasts three to eight years and prepares DOs and MDs to practice a specialty.
• Both DOs and MDs can choose to practice in any specialty of medicine?such as pediatrics, family medicine, psychiatry, surgery or ophthalmology.
• DOs and MDs must pass comparable examinations to obtain state licenses.
• DOs and MDs both practice in accredited and licensed health care facilities .
• Together, DOs and MDs enhance the state of health care available in the U.S.

(www.osteopathic.org/osteopathic-health/about-dos/what-is-a-do/Pages/default.aspx)

 

Find a Doctor of Osteopathic Medicine

www.osteopathic.org/osteopathic-health/find-a-do/Pages/default.aspx

All practitioners wishing to participate with The Health Plan must be credentialed. Our Provider Relations Department has formulated a descriptive credentialing policy and procedure that are reviewed annually to assure compliance with NCQA (http://www.ncqa.gov), Medicare/Medicaid (http://www.cms.hhs.gov), and any state or regulatory agency requirements.

The Health Plan has established participation guidelines. To ensure practitioners are qualified and meet participation standards the following information is evaluated, stored, and maintained current:

• Office Location(s)
• Accepting New Patients – Updated as needed and including every three (3) years during re-credentialing process.
• Board Certification of MDs and Dos (if not Board Certified, education and residency training.) Updated every three (3) years during re-credentialing process.
  American Board of Medical Specialties (http://www.abms.org) – verification tool for Medical Board Certification
  American Osteopathic Association (http://www.ostepathic.org) – verification tool for verification of Osteopathic specialty
• Hospital Admitting Privileges – Updated as needed but every three (3) years during re-credentialing process.
• Medical Group Affiliation – if available.
• Languages spoken in office – Self reported.

All hospitals are required to be JCAHC (http://www.jointcommission.org), DNV/NIAHO (http://www.dnv.com/industry/healthcare), American Osteopathic Association (AOA)(http://www.osteopathic.org), CARF (applicable to Rehabilitation Facilities and Mental Health Facilities)(http://www.carf.org), and HFAP (Healthcare Facilities Accreditation Program(http://www.hfap.org) accredited and in good standing with Medicare and are not followed by expiration of these certifications.

The Durable Medical Equipment (DME) providers and Infusion providers shall be JCAHO (Joint Commission Accreditation of Hospital Organizations) (http://www.jointcommission.org), CHAPS (Community Health Accreditation Program) (http://www.cdc.gov/nccdphp/dach/chaps), or HQAA (Healthcare Quality Association on Accreditation)(http://www.hqaa.org) accredited or in the process of obtaining accreditation.

To find out what network plan you are in, look at your ID card. You network plan will be printed on the card.

Sample ID Card

Below is a sample ID card. We place a red oval around the area where your network plan will be located on your ID card. (Self-funded groups will have the name of their employer)

Employer or Self Funded?

If your ID card has Employer or Self-Funded, please call customer service at 1.888.816.3096.

This information is self-reported by the practitioner and updated upon notification. It is not verified by The Health Plan. If the practitioner has a restriction, such as age limitation and/or not accepting new patients, or only accepting existing patients etc. it will be reflected in the directory. If the practitioner has no restrictions listed, that indicates the practitioner has no restrictions to his/her practice. This information is validated at least every 36 months thereafter.

This information is self-reported by the practitioner and updated upon notification. It is not verified by The Health Plan. This information is validated at least every 36 months thereafter.

The Health Plan or its designee verifies this information directly from the appropriate entity. This information is the practitioner’s self-reported field of specialty. A practitioner’s specialty listing in the directory is based on the verification of the practitioner's education, training (e.g. residency, fellowship), experience, and/or board certification/accreditation if applicable. This information is validated at least every 36 months thereafter.

This is self-reported information by the practitioner/provider and updated upon notification. It is not verified by The Health Plan. This includes the medical groups with whom the practitioner/provider has a professional relationship. This information is validated at least every 36 months thereafter.

Board certification is updated upon notification by the practitioner and verified by The Health Plan directly through CertiFACTS (an official American Board of Medical Specialties (ABMS) display agent), The American Osteopathic Association (AOA), or the pertinent board prior to adding to the directory. This information is validated at least every 36 months and quarterly upon expiration. The American Board of Medical Specialties (ABMS) website can be found at https://www.abms.org/verify-certification/ and the The American Osteopathic Association (AOA) at https://aoaprofiles.org/. If applicable, this information specifies The American Board of Medical Specialties and The American Osteopathic Association board through which the practitioner has obtained certification and the expiration date of the certification.

Admitting privileges at the practitioner primary admitting facility are verified with the facility by The Health Plan or its designee initially. If applicable, hospital affiliations specify medical facilities where the practitioner has obtained privileges. This is self-reported information by the practitioner and updated upon notification. This information is validated at least every 36 months thereafter.

The languages displayed in a provider directory are self-reported by the practitioner and updated upon notification. This information is not verified by The Health Plan. The Health Plan requests practitioners to report if the practitioner or his or her clinical office staff speak any languages other than English. This information is validated at least every 36 months thereafter.

This information is verified directly with the accrediting organization before it is displayed in this directory. Accreditation is validated at least every 36 months thereafter. Accreditation specifies whether a hospital has applied for and met particular criteria related to quality of care performance from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the DNV National Integrated Accreditation for Healthcare Organizations (NIAHO) or the Healthcare Facilities Accreditation Program (HFAP). To receive and maintain accreditation, organizations must have an extensive on-site review at least once every three years to evaluate performance in areas that effect a patient's care. Accreditation displays that an organization is dedicated to ongoing efforts to improve the quality of care provided to patients.