Policy: Credentialing and Privileging
Date: December 6, 2011
CREDENTIALING: BEFORE HIRE
1.
All provider applicants will submit the necessary
documents for credentialing. Original Source Verification
will be required of all essential documents. Every effort
will be made to have all paperwork in order at every
step in the process.
2.
The following documents will be required and
incorporated into the credentialing process:
a. Curriculum Vitae
b. Application
c. EEOC
d. Professional References
e. Release of Information
f.
Credentialing Statement & Attestation as to
Correctness and Completeness of the Application
g. Professional license and certification numbers
h. Pre-Screening and Interview Notes
i. Criminal/Education Background Form
j. Google Search
k. Physician Profile -AMA, ECFMG (For MDs/DOs/PAs or
NCCPA -Not for NPs)
l.
American Nurses Credentialing Center (ANCC) or
American Academy of Nurse Practitioners (AANP) for
NPs
m. NCCPA –Physician Assistant Verification
n. American Dental Association (For Dentists Only)
o. License to Practice or NURSYS Nurse Practitioners
Out-of-State –For NPs there are two (RN and NP)
p. Minnesota Controlled Substance
q. DEA Registration
r.
Sanctions or Limitations on Licensure or Previous
Sanctions by Medicare/Medicaid
s. National Practitioner Data Bank Healthcare Integrity
& Protection Data Bank (Malpractice/Loss History)
t.
Physical capacity and/or Functional capacity
assessment, as determined by job description


CREDENTIALING: AFTER OFFER/HIRE

1.
2.
An Employment Agreement will be reviewed with and
signed by the provider applicant prior to commencing
employment and clinical work.
The following documents will be assembled, organized
and again verified:
a. Collaborative Agreement (Non-Physician Providers)
as Appropriate
b. Verification of Picture Identification -Must obtain
copy of state issued picture ID plus copy of one of
the following federal government issued
identification –social security card, passport, birth
certificate, certificate of U.S. citizenship, certificate
of naturalization, permanent resident card,
unexpired temporary resident card.
c. Copy of Original Diplomas
d. Copy of Original Specialty License
e. Copy of Original Verified Training (i.e. residency or
NP program)
f. Documentation of Continuing Professional Education
(as applicable)
g. Life Support Training (BLS, ACLS, ATLS, CPR, PALS,
etc. as applicable)
h. Copy of Original DEA Document
i.
Copy of Original Controlled Substance License
j.
Copy of Residency Certificate
k. Copy of Medical Education Certificate
l.
Copy of CPR and other position related
documentation
m. Immunization/PPD/TB status
n. Pre-Employment Health Fitness assessment
o. Copy of Car Insurance Company
p. Verified Current Competence (from last
Medical/Program Director)
PRIVILEGING
1.
All providers providing clinical care at Cedar Riverside
People’s Center will have privileges to practice and
provide clinic care granted by the Board of Directors.
2.
Recommendations for granting these privileges will be
made by the Chief Medical Officer based on his/her
review, and input from an ad hoc Professional Review
Committee that might be established, composed of
other appropriate clinicians on the medical staff.
3.
Provider applicants for privileges should submit their
credentials and allow enough time for the privileging
process to be accomplished before starting their clinical
practice at their clinical locations.
4.
All providers at Cedar Riverside People’s Center will
apply for specific procedures regarding their clinic
practice in the clinic
(see attached)
5.
Documents needed to grant privileges will include, but
not be limited to, the following documents:
a. State medical license
b. Specialty board certification
c. Curriculum vitae with past clinical experience, both
outpatient and inpatient
d. Other documentation of formal training or
certification
e. Any documentation of prior adverse findings from a
specialty board or other regulatory board regarding
the provider’s clinical practice
f. In general, the scope of practice and procedures that
are a part of standard specialty training within the
particular specialty training shall be granted to the
provider. A specific checklist of scope of practice and
procedures shall be completed as part of the
privileging process (see attached)
g. Copies of all relevant documents shall be kept in the
provider’s personnel file
h. Additional training that would permit additional
clinical privileges shall be presented to the Chief
Medical Officer as well as any credentials committee
in effect at the time, for review in order to grant
additional clinical privileges.
6.
Every effort will be made to make sure the new
provider applicant returns all paperwork to the
credentialing department and Chief Medical Officer, so
the credentialing can copy all information and issue
check if necessary.
7.
The credentialing department will review all paperwork
for accuracy and completeness.
8.
There will be ongoing follow up with the provider
regularly
ATTACHMENT:
PRIVILEGED AND CONFIDENTIAL
Proceedings and Records of the
Professional Review Committee
Cedar Riverside People’s Center
REQUEST FOR PRIVILEGES
LICENSED OR CERTIFIED HEALTH PROFESSIONALS
Position Title:
I hereby request the attached privileges/scope of practice/competencies for
which I am trained and experienced to perform, as listed on the attached forms. I
understand that it is my responsibility to demonstrate my competence to perform
the listed privileges. I understand that the privileges requested may differ from
those finally approved. I further understand that the completion of this form at
this time does not preclude me from requesting additional privileges in the
future.
Signature of Applicant
Print Name
Date
Attachment (List of privileges, scope of practice or competencies)
Note:
The requested privileges must be reasonably comprehensive (i.e., not just
specialty designation), must be based on documented education, training and/or
experience, and must be specific to the job description you are applying for at the
Center. Provide information on any special training you may have had that
qualifies you for additional services or functions.
Please attach a delineation of privileges, scope of practice, competencies or
detailed job description. If you are requesting privileges or functions in addition
to those listed on the job description, please indicate accordingly on the
attachment.
PRIVILEGED AND CONFIDENTIAL
Proceedings and Records of the
Professional Review Committee
Cedar Riverside People’s Center
APPLICATION FOR CLINICAL PRIVILEGES
General
Granting, reviewing, and changing of clinical privileges for the staff of the Cedar
Riverside People’s Center will be accordance with Health Center policy.
Assignments of such clinical privileges are based upon education, clinical training,
experience, demonstrated current competence, documented results of patient
care, and other quality review and monitoring deemed appropriate. The principle
of “documented competency” will prevail. Primary care medicine is a dynamic
and comprehensive field. Adult medicine, pediatric care, prenatal care,
outpatient surgical care, and mental health care are integral components of
Health Center continuity of care. As a result, privileges in these areas are
identified to pertain to primary care, specialties of pediatrics, internal medicine,
family practice, general practice, midwifery and obstetrics/gynecology.
The privileges for the Center will be granted in the following three classes:
Level One
(General)
This class includes privileges for uncomplicated, basic procedures and clinical
application of cognitive skills. Physicians applying for privileges in this class will
be graduates of approved medical/osteopathic schools who are properly licensed
and demonstrate skills in appropriate general medicine practice.
Level Two
(Residency/Board Certification)
Privileges in this class include Level One privileges as well as privileges for those
procedures and cognitive skills involving more serious medical problems which
are normally taught in residency programs. This will include procedures and
clinical application of cognitive skills appropriate to the care in perinatal,
surgical, psychiatric, and critical care units. Physicians requesting privileges in
this class will have to meet criteria in Level One and have either completed
training in a residency program and/or will be Board Certified, or will have
documentation experience, demonstrated abilities and current competence in
primary care medicine.
Level Three
(Advanced Procedures)
Privileges in this category include privileges in Level One and Two. Additional
privileges may be granted to physicians who have acquired added experience
and/or training, and who have special skills and knowledge in specified areas of
medicine. As appropriate, the Medical Director will review these additional
privileges.
********
It should be noted that, even though a physician is assigned to one of the three
classes, he or she might also elect to apply for individual privileges that may be
considered to be a higher level.
PRIVILEGED AND CONFIDENTIAL
Proceedings and Records of the
Professional Review Committee
PRIVILEGE REQUEST FORM
Print Name:
Hire Date:
Primary Location:
Board Certified:
Date:
Subspecialty:
Date:
Board Eligible:
Projected Certification Date:
Write the number of the level and clinical site that applies for each privilege
Privilege Level:
1 (General)
2
(Residency/Board Certification)
3
(Advanced Procedures)
Medical
Director
Approval
Procedures
General Privileges
Management of Routine
Adolescent Care
Requeste
d
Leve
l
Site
Special
Conditions/Commen
t
Management of Routine
Adult Care
Management of Routine
Geriatric Care
Supervision of Students
Medical
Director
Approval
Procedures
Biopsy, skin
Cardiopulmonary
resuscitation (BLS)
Excision, benign lesion,
skin
Foreign body removal,
eye
Requested
Level Site
Special
Conditions/Comment
Abscess I & D
Ingrown toenail excision
Lacerations, infected
Paranychia, I & D
Suturing of simple
laceration
Privileges in Anesthesia Care
Use of local anesthetics
for wound repair
Use of topical anesthetics
Privileges in Internal Medicine
Debridement, skin
subcutaneous, tissue
Dressing/Debridement,
burn
Incision and removal of
foreign body
Laceration, simple
Privileges in Internal Medicine
Independent Care: Basic
Life Support
Basic Diagnosis &
Management
Full care of
uncomplicated cases
EKG interpretation
Needle aspiration of
subcutaneous lesion
PRIVILEGED AND CONFIDENTIAL
Proceedings and Records of the
Professional Review Committee
Medical
Director
Approval
Procedures
Requested
PFT (Pulmonary Function
Test) interpretation
Superficial
Nerve block)
Privileges in Gynecological Care
I & D Bartholin Cyst
Cervical Biopsy
Coloposcopy/Cervical
Cryotherapy
Endometrial Biopsy
Level Site
Special
Conditions/Comment
IUD insertion and
removal: Paragard
IUD insertion and
removal:
Mirena
Privileges in Orthopedic Care
Initial evaluation of
orthopedic problems
Treatment of acute back
and neck pain
Treatment of contusions,
simple lacerations,
sprains
Treatment of bursitis,
tendonitis, tennis elbow,
etc.
Casting procedures for
closed fractures requiring
no reduction
Joint aspirations
Procedures involving
destruction of nail beds
Treatment of corns,
calluses and bunions
Foot care
Treatment of closed
dislocations
Medical
Director
Approval
Procedures
Privileges in Pediatric Care
Requested
Level Site
Special
Conditions/Comment
Management of routine
pediatric care, including
full-term newborns
Special Procedures for
Level Three Privileges
Medical
Director
Approval
Requested
Level Site
Special
Conditions/Comment
I hereby request the privileges identified above. Furthermore, I am physically and
mentally capable to perform the above requested privileges.
Applicant’s Signature
Date
********
The following recommendation is made to the Center Governing Board that has
authority to grant or deny privileges.
As Chief Executive Officer and Medical Director, we recommend that:
Privileges for __________________________________ at the Center are:
Approved
Denied
Modifications:
Denial based on:
Approved with Modifications
Chief Executive Officer Signature
Medical Director Signature
Date
Date