In following list of resources has been developed to help ...



Governance: The governing body addresses and is fully and legally responsiblefor the operation and performance of the organization. This can be done directly or by appropriate professional delegation.The governing body must meet at least annually and keep minutes or other records as may be required for the orderly conduct of the organization.Credentialing Credentials must be verified according to the procedures established in bylaws, rules and regulations. There must be processes for expeditious processing of applications forclinical privileges.There must be a procedure for obtaining primary or secondary source information.Credentials files are maintained for each healthcare professional and include initial application, reapplications, verifications, privileges granted, and other pertinent information.In a solo practice, a peer must review the physician’s credentials file at least every three years to assure currency, accuracy, and completeness.Credentialing is a three-phase process to assess can validate qualifications to provide services.Establish minimum training, experience, and other requirements for physicians and other healthcare professionalsEstablish a process to review, assess, and validate an individual’s qualifications, including education, training, experience, certification, licensure, and any other competence-enhancing activities against the organization’s established minimum requirementsCarries out review, assessment, and validation outlined in the organization’s description of the processThe governing body must:establish and is responsible for a credentialing and reappointment process and applying criteria uniformly to all individuals who provide patient careapprove mechanisms for credentialing, reappointment, and granting of privileges, suspending or terminating clinical privileges, including provisions for appeal of such decisionseither directly or by delegation, make initial appointment, reappointment, and assignment or curtailment of clinical privileges based on peer evaluation (must be consistent with state law)have specific criteria for initial appointment and reappointment of physicians and dentistsmake provisions for expeditious processing of clinical privileges applicationsInitial application PSVeducation, training, experience verified with primary source, experience reviewed for continuity and relevance with documentation of any interruptionspeer evaluation for current competency by an individual who can address clinical, ethical, and professional performance and, when available, by data regarding treatment outcomescurrent state licenseDEA, if applicableProof of current medical liability coverage meeting governing body requirementsNPDBCredentials Verification OrganizationThe organization must perform an assessment of the capability and quality of the CVO’s work. ReappointmentEvery 3 years unless state law requires otherwise.Must verifyCurrent state licenseDEA if applicableStatus of board certificationNPDBPeer review activitiesSolo practitioner offices will be reviewed by a peer every 3 years to assure currency, accuracy and completenessInformation the organization must require and review for both initial and reappointment:Professional liability claims historyInformation on licensure revocation, suspension, voluntary relinquishment, probationary status, or other conditions/limitationsComplaints or adverse action reports from professional society or licensure boardRefusal or cancellation of professional liability coverageDenial, suspension, limitation, termination or non-renewal of professional privileges at any clinic, hospital, health plan, or other institutionDEA and state license actionDisclosure of any Medicare or Medicaid sanctionsConviction of criminal offense (excluding minor traffic violations)Current physical, mental health, or chemical dependency problems that would interfere with the ability to provide high-quality patient care or servicesSigned release and attestation statementInformation that must be monitored on an ongoing basis (at expiration, appointment,and re-appointment, at minimum.):The organization monitors and document the currency of date sensitive information such as licensure, professional liability insurance (if required), certifications, DEA registrations, and other such items, where applicable, on an ongoing basis.PrivilegingPrivileging is a three-phase process to determine the specific procedures and treatments that may be performed. The organization must:Determine clinical procedures and treatments offered to patientsDetermine qualifications related to training and experience that are required to authorize an applicant to obtain each privilegeEstablish a process for evaluating the applicant’s qualifications using appropriate criteria and approving, modifying, any and all of the request privileges in a non-arbitrary manner.Privileges for specific procedures are granted for a specified period of time based on the applicant’s qualifications within the services provided by the organization.The organization has its own independent process of credentialing and privileging that includes review and approval by the governing body.Appointment or privileges may not be approved solely on the basis that another organization, such as a hospital, took such action, although this information can be used in consideration of the application.The governing body provides a process for the initial appointment, reappointment, assignment or curtailment of privileges and practice for allied health care professionals (based on state law and evidence of education, training, experience and competency).In following list of resources has been developed to help organizations identify primary and secondary sources for verifying credentials of health care professionals. If you have any questions regarding primary or secondary source verification, please contact the Accreditation Association at 847/853.6060 or info@.Primary Source Verification: Primary Source Verification is documented verification by an entity that issued a credential, such as a medical school or residency program, indicating that an individual's statement of possession of a credential is true. Verification can be done by mail, fax, telephone, or electronically, provided the means by which it is obtained are documented and measures are taken to demonstrate there was no interference in the communication by an outside party. Primary sources include:Certifying Boards* Chiropractic Colleges Association of Chiropractic CollegesAmerican Dental Association's (ADA)?List of Dental SchoolsDrug Enforcement Agency (DEA) databaseMedical Schools - Association of American Medical CollegesNursing Schools -?American Association of Colleges of NursingPhysician Assistant Schools - American Academy of Physician AssistantsPodiatry Schools - American Association of Colleges of Podiatric MedicineResidency and Fellowship Programs GME programs accredited by the Accreditation Council on Graduate Medical EducationState Licensing Agencies - Federation of State Medical Boards Federation of State Medical Boards *These sources are for verification of Board Certification only, not education or training. Secondary Source Verification: Acceptable secondary source verification is documented verification of a credential through obtaining a verification report from an entity listed below as acceptable on the basis of that entity having performed the primary source verification. Information received from any of these sources must meet the same transmission and documentation requirements as outlined above for primary sources. Currently acceptable secondary sources include: American Association of Nurse Anesthetists Specialty boards of the American Board of Medical Specialties Specialty boards recognized by the American Dental Association American Medical Association Physician Master Profile American Osteopathic Association Master Profile American Nurses Credentialing Center College of Nurse-Midwives Educational Commission for Foreign Medical Graduates Commission on Certification of Physician Assistants CVO is okay if you have proper assessment of capability and quality of CVO Another health care organization, such as a hospital or group practice, that has carried out primary source or acceptable secondary source verification, provided it supplies directly, without transmission or involvement by the applicant or other third party, original documents or photocopies of the verification reports it has relied upon. A statement that it has performed verification is not sufficient.Documents, diplomas, certificates or transcripts provided directly by the applicant rather than by the primary or secondary source are not acceptable. ................
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