University Hospital

UNIVERSITY HOSPITAL

Medical Staff
Policy & Procedure
Title: / Policy #: / Approval:
Verifications and Primary Sources / MS-16 / 01/05
Approved by: / Pages:
5 / Revised/Reviewed Date:
______
Chief Medical Officer Date / 03/07

POLICY:

It is the policy of University Hospital to authenticate the credentials listed in applications submitted by practitioners desiring Medical Staff membership or affiliation. The validation process will be conducted in compliance with current JCAHO standards. Verifications may be via oral report, telephonic communications, visual inspection, electronic database interface or in writing.

PROCEDURE:

University Hospital will perform the following minimum verifications:

Note: The verification methods and requirements document lists verification elements that apply to all practitioners . There may be additional items to verify, depending on the privileges that an applicant has requested. These verifications should be incorporated into the process at the appropriate time.

180-day rule means that the item must have been received and verified within 180 days of making the final credentialing decision. This is typically applied to information that is subject to change

Credentialing Item

/ Method of Verification /
Initial Appointment / Reappointment / Update as Expires / New Privilege(s) /

State license to practice

Verify current license, expiration date, and sanctions/limitations. / Primary Source via Web site
180-day rule applies / X / X / X / X
Licenses to practice in other states (all current and past)
Verify current license, expiration date, and sanctions/limitations. / Primary source via
·  In writing/mail
·  By phone/fax
·  By Web site, if an approved Web site
180-day rule applies / X / X / X / X

DEA registration

Verify DEA registration number, expiration date, schedules. / Obtain copy from practitioner / X / X / X
Medical school (domestic graduates)
Or other professional schooling relevant to privileges requested (nonphysician applicants).
Verify institution, completion date, and degree received. / Primary Source via:
·  Confirm directly with medical school/professional school in writing or orally
·  AMA profile / X
ECFMG (foreign graduates)
Graduation from a foreign medical school (does not cover internships and fellowships).
Verify ECFMG number and date issued. / Contact information:
Educational Commission for Foreign Medical Graduates
3624 Market Street, 4th Floor
Philadelphia, PA 19104-2685
Tel: 215/386-5900
www.ecfmg.org / X

Internship/Other professional training

Completed after medical school graduation OR post receipt of ECFMG.
Verify institution, begin/end dates, type of internship, and successful completion. / Primary Source via:
·  Confirm directly with internship program in writing or orally
·  AMA profile / X

Residency/Other professional training

Completed after medical school graduation OR post receipt of ECFMG.
Verify institution, begin/end dates, type of residency, and successful completion. / Primary Source via:
·  Confirm directly with residency program in writing or orally
·  AMA profile / X / X
Verify any new education or professional training that may be required for the privilege(s) requested or that may provide information about the applicant’s competency to perform the requested new privilege(s).

Fellowship/Other professional training

Completed after medical school graduation OR post receipt of ECFMG.
Verify institution, begin/end dates, type of fellowship, and successful completion. / Primary Source via:
·  Confirm directly with fellowship program in writing or orally
·  AMA profile / X / X
Verify any new education or professional training that may be required for the privilege(s) requested or that may provide information about the applicant’s competency to perform the requested new privilege(s).
Board certification or other professional certification or registration
All specialty board certifications (may be multiple) that are American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA)-approved (for physicians).
Verify certifying board, specialty of certification, date certified/recertified, and expiration date, if applicable. / Primary Source via:
·  Confirm directly with certifying board (or the ABMS or AOA) in writing, orally, or electronically (via an authorized Web site). Any other authorized ABMS source, must be designated as an “Official ABMS Display Agent” by the ABMS.
·  CertiFax (has been designated as an Official ABMS Display Agent)
180-day rule applies / X / X
If applicant received any new certifications during the previous appointment period / X / X
If any new certifications have been obtained since the previous appointment period that would qualify the applicant for the new privilege(s).

Military service

Get copy of DD-214 / If military service was within past 10 years, contact hospitals where applicant provided services.
If military service was longer than 10 years ago and it is deemed necessary to verify millitary history longer than 10 years ago contact:
Military Records Center
9700 Page Boulevard
St. Louis, MO 63132
(Note: Provide Social Security number, date of birth, date of service, release of information.) / X
Healthcare organization affiliations
Hospitals, ambulatory facilities, etc. / Primary Source via:
Write directly to healthcare organization or contact via telephone inquiry.
180-day rule applies /

X

All affiliations for past 10 years / X / X
If needed to confirm exercise of requested new privilege(s) at another facility.
Work history
Obtain from applicant on application. There should be no unaccounted for gaps in time beginning with date of graduation from medical/professional school or date of receipt of ECFMG. It is not required, however, that all time be verified.
Follow up with applicant (and healthcare organizations, individuals, etc., as appropriate) and obtain explanation for any gaps in time of three month(s) or more. / Primary Source via:
Write directly to work places or contact via telephone inquiry.
180-day rule applies / X / X
Only applies if applicant has been on leave of absence since previous credentialing event.
Professional liability insurance / Primary Source via:
·  Applicant provides on application form a listing of current and past carriers.
·  Obtain certificate of insurance directly from applicant
180-day rule applies /

X

Certificate copy from current carrier(s) provided by applicant / X
If current copy is about to expire, certificate copy from
current carrier(s) provided by applicant / X
Certificate copy from current carrier(s) provided by applicant
Professional liability claims history
Settlements and judgments.
Current pending claims. / Obtain professional liability claims history through both of the following:
§  The applicant completing all portions of the application.
§  NPDB
180-day rule applies / X
NPDB / X
NPDB / X
NPDB
Continuing medical education (CME)
CME activity should relate to privileges requested/held. / Obtain listing of CME activities for the previous 24 months from applicant.
Note: If applicant completed residency or fellowship training (or other professional training for nonphysicians) within the past two-year period, waive the requirement to submit CME activities at the time of initial appointment.
180-day rule applies / X / X
More than 50% of CME activity should relate to privileges held. / X
If applicable to new privilege(s) requested. For example, CME may be a requirement for the new privilege(s) requested.
National Practitioner Data Bank (NPDB) / NPDB query
180-day rule applies / X / X / X
Medicare/Medicaid and other sanctions
includes monthly and annual monitoring / Approved method:
·  Applicant provides information and attests to accuracy and completeness.
and
·  NPDB query
·  Office of Inspector General (www.hhs.gov/oig/cumsan/index.htm)
180-day rule applies / X / X
History of criminal conduct / • Applicant provides information and attests to accuracy and completeness.
and
• Criminal background check.
180-day rule applies / X
Peer/Professional References/ Recommendations
Peer means an individual in the same professional discipline (same type of license) with essentially the same privileges. / Primary Source via:
Letter, copy of requested privileges, and questionnaire sent directly to peer/professional reference(s). Questionnaire asks for confirmation of applicant’s identify (initial appointment only—based upon enclosed picture of applicant). Letters submitted by applicant may not be used.
If telephone inquiries are made, the telephone call should be made by an official medical staff organization representative.
180-day rule applies /

X

Three letters from peers who have had contact with applicant within past two years and have personal knowledge of the applicant's competence. /

X

Two letter from peers who have had
contact with applicant within past two years and have personal knowledge of the applicant's competence / X
May be applicable and necessary, depending upon the new privilege(s) requested by the applicant
Identity of applicant / Approved method:
A current picture of the applicant must be submitted with the initial application. A copy of the picture is sent to each peer reference, and the peer reference is asked to confirm that the person for whom they are supplying a reference is the same person in the picture.
and
Before the final recommendation is made by the medical executive committee to the board, the applicant for initial appointment/initial privileges must provide his or her government-issued identification (driver’s license or U.S. passport) and a copy placed in the file. / X
Clinical activity
Includes clinical activity for the past 12 months including (when possible) numbers, types and outcomes of procedures/clinical work performed. / Physician to provide documentation from hospital/ambulatory surgery center/office setting where he/she has been practicing for the past 12 months. / X / X
For low volume practitioners / X
When applicable to demonstrate competency
PPD / Documentation of results of PPD Test or Chest X-ray / X
Documentation of PPD results completed within the past year or documentation of Chest X-Ray / X
Documentation of PPD Results or Health Questions completed on Reappointment Application pertaining to any signs/symptoms of TB / X
Annually
Fire and Safety Test
For AHPs only / Satisfactory completion of Fire and Safety Test / X / X
Drug Screen
For AHPs only / Documentation from drug screen / X

APPROVAL:

Credentials Committee: 3/12/07

MEC: 3/20/07

Board: 3/22/07

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