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Credentialing: How to Succeed

By October 1, 2020C&A Blog

Credentials are documented evidence of licensure, education, training, experience, or other qualifications. Credentials can be in the form of a certificate, letter, official identification, or experience that confirms a practitioner is qualified to perform specific procedures or services. Once credentials are submitted along with the application and all other requested paperwork, the organization needs to obtain primary source verification of the licensed independent practitioner’s education, training, certificates, and licensure from the primary source, and maintain these files of information.

The alternative to organizations doing this themselves is to have an agreement with a Credentials Verification Organization (CVO) who obtains the primary source verification information for the organization. Once credentials are verified, an organization can decide to credential (grant privileges) for a practitioner on information obtained from a CVO and should have confidence in the completeness, accuracy, and timeliness of the information.

Privileging is the process whereby a specific clinical scope and content of patient care services are requested and authorized for a healthcare practitioner by a health care organization. Privileging is based on an evaluation of the individual’s credentials and performance. A “privilege’ is defined as an advantage, right, or benefit that is not available to everyone, and is awarded to a relatively small group of people, usually as a result of education and experience.

The process of credentialing and privileging is defined in the organization’s bylaws, and assure procedures are applied uniformly for all applicants. Requests for privileges are reviewed by the medical director and governing body, and when approved a letter is sent to the practitioner informing him or her of their appointment to the medical staff and their credentialing term.

To credential licensed independent practitioners, the following documentation is required.

  • Application completed and signed
  • A valid picture ID issued by a state or federal agency (i.e., driver’s license or passport)
  • The credentialing process requires that the organization verify in writing and from the primary source or from a credentials verification organization (CVO), the following information:
    • Current licensure at the time of initial granting, renewal, and revision of privileges, and at the time of license expiration
    • Relevant education and training
    • Current competence

Additional documentation frequently requested by organizations include, by not limited to:

  • Letter of Explanation-liability or license action (if applicable)
  • Signed Authorization for Release of Information
  • Signed Pledge of Applicant / Liability Release
  • Completed Delineation of Privileges for specialty
  • Signed Confidentiality Workforce Agreement
  • Signed Compliance-Code of Conduct
  • Signature Form
  • Board Certificate(s)
  • Medical License
  • CDS License
  • DEA Certificate
  • BLS, ACLS and/or PALS Certificate(s)
  • Malpractice Insurance Certificate
  • Curriculum Vitae
  • Two (2) Peer References
  • CME/CE Credits or Attestation
  • Medical School Diploma
  • Fellowship/Internship/Residency Certificate(s)
  • ECFMG Certification (applicable to graduates from foreign medical schools)
  • Health Information Attestation
  • Current TB: two (2) Step PPD OR QuantiFERON – if positive PPD – CXR
  • Hepatitis B Titer
  • Hep B Vaccine Attestation/Declination
  • MMR Titer
  • Varicella Titer

Once additional documents are received additional primary source verifications may be required such as:

  • AMA Physician Profile
  • AOIA for Osteopaths
  • ABPM OR ABFSS OR ABPS for Podiatrist
  • AMA Physician Profile
  • Verification of Board CertificationABA (Anesthesiologist)
    • ABIM (Internal Medicine)
    • ABO (Otolaryngology)
    • ABCR (Colon/Rectal)
    • ABPS (Plastic Surgeon)
    • ABS (General)
    • ABOS (Orthopedics)
    • ABOP (Ophthalmology)
    • ABP (Pediatric)
    • ABPD (Pediatric Dentistry)
    • ABPMR (Pain)
    • ABMS (Urology)
    • ABPN (Psychiatry & Neurology)
  • OIG query
  • CDS primary source verification
  • DEA primary source verification
  • NPDB Profile
  • Verification of Hospital Privileges or Hospital Good Standing Letter

The credentialing process typically takes a few weeks, so it is important that once a practitioner requests an application for appointment to the medical staff that all required documentation be communicated to the applicant within the expected time frame for receiving that information. It is important to communicate time frames for approval to the applicant as well.

Reference
The Joint Commission Comprehensive Manuals for Hospitals, Medical Staff Chapter 2020
Ambulatory Care Program: The Who, What, When, and Where of Credentialing and Privileging – TJC (undated)

Denise E. Smith

Author Denise E. Smith

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