The department chair
The CEO or his/her designee on the recommendation of the medical staff president or department chair
The department chair and the president of the medical staff.
The American Board of Medical Specialties
Education Commission on Foreign Medical Graduates Profile
Federation of State Medical Boards
Letter from the State licensing Agency
Surgical and medical floors
Medical staff office
Surgical Suite and Wherever Surgical procedures are scheduled.
State Licensure and DEA
State Licensure and Highest level of Education
Malpractice claims history and highest level of education
Board Certification and DEA
Annually unless state law provides otherwise
At least every two years, unless state law provides otherwise
At least every three years, unless state law provides otherwise
AAAHC does not require re-credentialing unless practitioner competence is in question.
Medicare Conditions of Participation
Medical Staff Bylaws
Joint Commission on Accreditation of Healthcare Organizations Standards
National Committee for Quality Assurance Standards and Guidelines
Health Integrity Portability and Accountability Act
Health Insurance Private and Accountability Act
Health Insurance Portability and Accountability Act
Health Insurance Portabili8ty and Accuracy Act
A generic statement of the scope of privileges
A listing of each individual procedure the applicant is approved to perform
Any limitations on an individual’s privileges to admit and treat patients or direct the course of treatment for the conditions for which the patients were admitted
A generic statement of privileges combined with a listing of individual procedures the applicant is approved to perform.
To query the NPDB at the time of initial credentialing and monthly
To query the NPDB at the time of initial credentialing and once yearly
To query the NPDB at the time of initial credentialing and at least every two years
To query the NPDB at the time of initial credentialing, every two years, and whenever the physician changes staff categories.
Chart review by an RN
The process of evaluating the necessity, appropriateness and efficiency of healthcare services
The process of evaluating the cost of healthcare delivery on a concurrent basis
The review of discharge protocols
Agreement that identifies rights and obligations
Amicus – brief filed by an interested party giving information or an opinion about a case
“Let the Master Answer/Speak”
Have an effective, hospital-wide QI program
Provide a certain amount of charitable care
Participate in managed care plans
Have over 25 licensed beds
Have an Executive Committee of the Medical staff that can act for the Medical Staff
Keep copies of credentials files for practitioners no longer on staff for a period of at least 5 years
Inform patients/beneficiaries of their business practices concerning release of information
Provide a repository of care information
The physician is afforded notice and fair hearing procedures
The action is being taken with the belief that it will further quality health care
Facts were obtained through investigation and review
All of the above
The practitioner can’t bill federal healthcare programs for care rendered.
Neither the practitioner nor facility providing services to patients at practitioner’s request can bill federal healthcare programs for care rendered.
The facility providing services to patients at practitioners request can’t bill federal healthcare programs for care.
None of the above, the exclusion is informational.
American Medical Association
American College of Surgeons
Healthcare Financing Administration
Joint Commission on Accreditation of Hospitals
2/3 of number of members must be present for business to be transacted
51% of number of members must be present for business to be transacted
Minimum number of members who must be present for business to be transacted
None of the above
Human Resources Department
Medical Staff credentialing/reappointment process
Both a & b
None of the above
Medical Executive Committee
Physician Wellbeing Committee
Both a & b