Mercy Hospital Medical Staff Credentialing Manual - Mercy Health

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CREDENTIALING MANUAL REVISED AND APPROVED BY THE BOARD OF DIRECTORS JANUARY 24, 20082.2.2. Confidentiality Safeguards: The CCO must establish and enforceappropriate safeguards to ensure that credentialing information --2.2.2.1.Is protected from disclosure to persons or organizationsother than Mercy Hospitals or affiliate, except upon awritten, dated release signed by the Practitioner anddirected specifically to Mercy Health Partners (MHP)authorizing such disclosure;2.2.2.2.Is provided only to persons at such Hospitals, affiliatesinvolved in pursuit of a legitimate credentialing function;and2.2.2.3.Is provided with the express caution that such informationis confidential and may not be further disclosed.2.2.3. Incomplete Applications: The duty to file a complete, signed application,rests exclusively with the applicant. Efforts by the CCO or others to assistin the collection of documents or information do not shift theresponsibility from the applicant in any respect. The rules related totimely submission of applications contained in the System-wideCredentialing Services Operations Manual will be strictly enforced:2.2.3.1.Initial Applicants: Initial applicants who file an incompleteapplication will receive a letter from the CCO requestingcompletion within a stated deadline. If the applicant doesnot comply within the deadline it is deemed voluntarilywithdrawn as of that date. The applicant may reapply bysubmitting a new application and an additional nonrefundableprocessing fee.2.2.3.2.Applicants for Reappointment: Applicants who fail toreturn a completed application for reappointment withintimeframes approved in the System-wide CredentialingServices Operations Manual will receive a letter from theCCO requesting completion. If the application is notsubmitted or remains incomplete the application will bedeemed voluntarily withdrawn at the end of the currentappointment.2.2.4. CCO Handling: All applications must be mailed or delivered to the CCO.When an applicant has properly filled in and signed his application, theCCO will do the following:2.2.4.1.For initial and applicants for reappointment2.2.4.1.1. Verify the applicant’s current licensure, specifictraining, experience and current competencethrough primary sources. Action on an initialapplication may not proceed until all thisinformation has been collected and verified;6
CREDENTIALING MANUAL REVISED AND APPROVED BY THE BOARD OF DIRECTORS JANUARY 24, 20082.2.4.1.2.Query the National Practitioner Data Bank;2.2.4.1.3.Obtain professional malpractice claiminformation;2.2.4.1.4.Assure the presence of completed references andall other required forms and consents;2.2.4.1.5.Verify the status of privileges at other health carefacilities;2.2.4.1.6.Check for sanctions through the Office of theInspector General and the Excluded Provider ListSystem;2.2.4.2. Collection of statistical data to grant, limit or deny therequested privileges.2.2.4.2.1.Assure the presence of one peer reference and onehospital verification, if required; (reappointmentonly)2.2.5. Peer References: Recommendations from peers are obtained andevaluated for all new applicants for privileges. Upon renewal ofprivileges (reappointment), when insufficient practitioner-specific data areavailable, the medical staff obtains and evaluates peer recommendations.A recommendation from peers is defined as an appropriate practitioner inthe same professional discipline as the applicant who has personalknowledge of the applicant and the applicant’s ability to practice. Theyreflect a basis for recommending the granting of privileges. Sources forpeer recommendation may include the following:2.2.5.1.An organization performance improvement committee, the majority ofwhose members are the applicant’s peers;2.2.5.2.A reference letter(s), written documentation or documented telephoneconversation(s) about the applicant from a peer(s) who is knowledgeableabout the applicant’s professional performance and competence;2.2.5.3.A department or major clinical service chairperson who is a peer;2.2.5.4.The Medical Executive CommitteePeer recommendations include the following:2.2.5.5.Relevant training and experience2.2.5.6.Current competence2.2.5.7.Any effects of health status on privileges being requested7
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Mercy Hospital Medical Staff Credentialing Manual - Mercy Health

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