PIEDMONT HEALTH SERVICES, INC



Credentialing Procedure

Purpose:

-------uses the credentialing process to obtain, verify and assess the qualifications of health care practitioners that will provide patient care services in and for our clinics. The determination is based on evaluation of the individual’s education, training, experience, competence, current licensure, and professional judgment. Credentials and qualifications used by are designed to be consistent with Federal Tort Claims Act a requirements for professional credentialing. The review process is used to make formal appointments to the staff.

Applicability and Scope:

The credentialing review process applies to all -------, owned and operated locations where clinical services are provided. The process includes all health care providers employed and/or contracted to provide clinical services in ----------facilities. This process applies to applicants for employment and current employees for the purposes of periodic re-credentialing.

All information acquired during the credentialing/re-credentialing process will be treated in a confidential manner.

____________________________________________________________________________

Initial Credentialing Procedures for Licensed Health Care Practitioners:

Prior to appointment on the ----------staff, the applicant will be asked to complete a series of documents that meet the core criteria for the credentialing process. The criterion includes but is not limited to, a curriculum vitae, Provider Credentialing Application, a signed Release Statement, current licensure; relevant education, training or experience; current competence; and ability to perform requested privileges. Each criterion must be applied uniformly and verified by primary sources. An applicant interested in employment with ----------will be provided the documents necessary.

Current Licensure - This information will be supplied by the applicant and verified by the Human Resources Department prior to the time of hire. The appropriate state licensing board will be contacted to verify online or in writing the information regarding the license submitted. Verification should be documented and signed off by the Copies of the license will be kept in the applicant’s credentialing file.

Relevant Training and Experience – The applicant will supply the name and address of the professional schools (medical, dental, etc.), residency and/or postdoctoral programs that he/she attended. ------will verify and document attendance dates and completion of the program(s) prior to hire. Applicants that have just completed training in an applied residency or postdoctoral program may obtain a letter from the Program Director to submit as proof of attendance. The ------will also verify board certification in medical specialties by the listings in the official ABMS Directory of Board Certified Medical Specialists.

Current Competence – The applicant will be given recommendation forms to be completed by individuals personally acquainted with their professional and/or clinical performance. Letters should contain informed opinions about the applicant’s scope and level of performance. These letters will be returned to the Human Resources Department and will be a part of the credentialing file.

Ability to Perform Requested Privileges – Applicants ability to safely perform the essential functions of the job by a provider in the same or similar profession or specialty with or without accommodation. The Medical Director along will determine if privileges should be extended to the provider who has applied for the position. The applicant/current employee will also complete the Delineation of Clinical Privileges form that will be submitted for approval by the Credentialing Committee.

The applicant will also be asked to complete a health statement that states that no health problems exist or existed that could affect his/her practice. The Medical Director and herd staff or current health care provider of Piedmont Health Services, Inc. will verify the document submitted.

Malpractice Insurance – The applicant will be asked to provide a copy of the policy as proof of malpractice insurance coverage.

The Human Resources Department will verify and document all dates and credentialing information. Information will also be obtained from the National Practitioner Data Bank Query. The information obtained from the NPDB query includes any adverse actions and/or outcomes pertaining to the applicant’s medical license, practice, etc.

Once all verification and documentation is completed, the applicant will be presented and recommended by the PHS, Inc.’s Credentialing Review Committee to the PHS, Inc.’s Board of Directors for favorable appointment and/or re-appointment to the PHS, Inc.’s staff.

Re-credentialing Procedure for Licensed Health Care Providers:

PHS, Inc. uses the re-credentialing process for reappraising the professional performance, judgment and clinical competence of individual practitioners/providers. The process is conducted on a bi-annual basis.

The following information will be requested as applicable:

1. NC Board Certification

2. DEA Certification

3. License

4. Hospital privileges (obtained from the appropriate hospital)

5. Malpractice Coverage and History (FTCA)

6. CME activities for the past 2 years

7. Disclosure Questions - Information requested pertains to, but is not limited to, professional disciplinary actions, hospital privileges, license suspension or chemical dependency and substance abuse history.

8. Peer Review Form. Peer Review will also be conducted to ensure that the practitioner/provider is clinically competent to perform the essential functions of the job. All updated information will be forwarded to the Human Resources Director or designee for verification and reviewed by the Credentialing Review Committee.

9. New Delineation of Privileges Form

Current practitioners/providers will be presented and recommended to the Board of Directors on a bi-annual basis. Primary verification of license, however, will occur annually and be maintained by the________. The Committee will notify the Board of Directors of any staff credentialing changes. The -------- will prepare documentation to present to the Board to approve bi-annually. Once approved, the practitioner will be granted privileges to continue work with the organization.

-----------------will re-credential practitioners bi-annually.

Appeals Process:

Should a practitioner/provider not be extended privileges and/or not meet the credentialing criteria, he/she has the right to appeal the decision by using the Grievance process as outlined and explained in Section 704 of the Personnel Policies and Procedures Manual. The practitioner/provider will be allowed to appeal the decision by doing the following:

1. Request and arrange a mediation meeting with the Credentialing Review Committee.

2. Within three (3) working days, the Committee will meet and discuss the appeal.

3. Within one week after the meeting, the Committee will put their decision in writing and communicate the decision to the practitioner/provider.

4. If the practitioner/provider is still dissatisfied, he/she may file the appeal with the Board Personnel Grievance Committee. A written request for a hearing with the Committee should be submitted to the Executive Director within five (5) days of the Committee’s decision.

5. All material associated with the appeal, along with a recommendation, will be submitted to the Board Personnel Grievance Committee. The Committee will be made up of the Board Personnel Committee Members and three staff members.

6. The appeal will be presented to the Board Personnel Grievance Committee in a closed hearing.

7. The Board Personnel Grievance Committee will follow the guidelines as stated in the Grievance Policy, Appendix VI-C, in the Personnel Policies and Procedures Manual.

Temporary Credentialing of New Providers:

In the case of an emergency when a practitioner has to be employed to provide continuous coverage in the clinic due to the abrupt absence or termination of another practitioner, PHS will credential the practitioner on an temporary basis. The provider is credentialed except for the formal presentation to the Board of Directors who meet monthly. A current license, DEA if possible and completion of the application packet will be completed before any provider begins working for PHS, Inc. There will be a 30 day maximum time frame for the Board approval or inclusion. A temporary credentialing form will be completed and signed by the ____________and Medical or Dental Director and placed in the provider credentialing folder. The provider will be presented to The Board of Directors at the next regularly scheduled or within 30 days.

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download