CREDENTIALING PROCESS, POLICY AND … · Web viewThe purpose of U.C. Davis Student Health and Counseling Services (SHCS) credentialing program is to ensure that all Licensed Independent

U.C. DAVIS STUDENT HEALTH AND COUNSELING SERVICESCREDENTIALING PLAN 09/2013

I. SCOPE AND PURPOSE

The purpose of U.C. Davis Student Health and Counseling Services (SHCS) credentialing program is to ensure that all Licensed Independent Practitioners, Allied Health Professionals, and Other Healthcare Professionals who provide services to students are appropriately licensed/certified, and/or credentialed and privileged in accordance with the requirements of the University of California, the Accreditation Association for Ambulatory Health Care (“AAAHC”), and federal and state laws and regulations.

The credentialing process includes 1) establishing minimum training, experience, and other requirements (i.e., credentials) for physicians and other health care professionals; 2) establishing 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 requirements; and 3) implementing the review, assessment, and validation as outlined in the organization’s description of the process.

II. POLICY

The Governing Body establishes and is responsible for the credentialing and reappointment process, applying criteria in a uniform manner to appoint individuals to provide health care services for the organization. The Governing Body approves mechanisms for credentialing, reappointment, and the granting of privileges, and suspending or terminating clinical privileges, including provisions for appeal of such decisions.

Licensed Independent Practitioners (LIPs), Allied Health Professions (AHPs), and Other Healthcare Professionals (OHP) permitted by law and U.C. Davis SHCS to provide health care services, must complete the credentialing process prior to initial appointment or reappointment and patient contact. Credentials are updated and reviewed at least once every three (3) years.

Licensed Independent Practitioners (LIP) subject to credentialing include: Medical Doctors (MD) Doctors of Osteopathy (DO) Doctors of Podiatric Medicine (DPM) Psychologists (PhD, PsyD)

Allied Health Professions (AHP) subject to credentialing include: Advance Practice Nurses (Nurse Practitioners) Physician Assistants Licensed Clinical Social Workers Marriage and Family Therapists Optometrists Pharmacists practicing in expanded role (e.g., providing injections)

Other Healthcare Professionals (OHP) subject to credentialing include: Alcohol and Drug Counselor; licensed or unlicensed Clinical Lab Specialist, technologist or technician Clinical Medical Assistants Certified Phlebotomy Technician Clinical Social Worker, professional counselor; unlicensed Massage Therapists

Occupational Therapists Pharmacy Assistant/Technician Physical Therapists/Physical Therapist Assistants Registered Nurse or LVN Registered Dieticians Certified Radiology Technicians Opticians/ Optometrist Assistants

The SHCS Credentials Committee, on an annual basis, reviews the credentialing plan, policies and procedures, with recommendation for any change or approval forwarded to the Governing Body. The SHCS Credentials Committee through delegation to the contractor Credentialing Verification Organization (CVO) shall monitor and document: current licensure; professional liability insurance, if required; certifications; OIG; and DEA and other registrations, where applicable, on an ongoing basis with oversight by the SHCS Credentialing Office

III. DEFINITIONS

Allied Health Professions (AHP). Allied Health Professions are defined as those licensed health care practitioners, other than physicians, podiatrists, and psychologists, who are authorized to make independent patient care treatment decisions by virtue of their appointment or professional licensure. At SHCS these providers include: advanced practice nurses (nurse practitioners), licensed clinical social workers, marriage and family therapists, optometrists, and any pharmacist practicing in an expanded role.

Credentials Verification Organization (CVO). This term refers to the organization contracted to perform credentials verification or, if no contracted CVO exists, to designated staff.

Governing Body. Under Article IX, Section 9 of the California Constitution the Regents of the University of California are responsible for the governance of the University of California. For the purpose of general administration, the Regents have delegated their authority to the President who has, in turn, delegated this authority to the Chancellor of each campus. Under Standing Order 100.6, authority and responsibility for campus operations are delegated to the Chancellor on each campus, who then delegates authority to the appropriate Vice Chancellor. On the Davis campus, this authority is given to the Vice Chancellor for Student Affairs, who then delegates authority through the Associate Vice Chancellor for Student Affairs to the Executive Director of Health and Wellness. The Associate Vice Chancellor serves as the chair of the Governing Body for SHCS, which consists of four members: the Associate Vice Chancellor for Student Affairs, the Executive Director of Health and Wellness who serves as the Program Director of SHCS, the Medical Director of SHCS, and the Counseling and Psychological Services (CAPS) Director.

Licensed Independent Practitioner (LIP) “Licensed Independent Practitioner” means a practitioner category that by licensure is deemed to provide patient care independently.

Mental Health Staff Includes Psychiatrists, Psychologists, Marriage and Family Therapists (MFT), and Licensed Clinical Social Workers (LCSW).

Masters Level Therapists Those individuals who possess a qualifying degree of either Masters of Science or Masters of Arts in Counseling or Psychology, or Licensed Clinical Social Worker (LCSW) or Marriage and Family Therapists (MFT). Masters Level Therapists are licensed and regulated by the California Board of Behavioral Sciences (BBS).

Psychologist Those individuals possessing a doctoral degree in psychology, educational psychology, or in education with a field of specialization in counseling psychology or educational psychology from a regionally accredited institution. Psychologists may practice independently in

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Latest Revision: 9/20/2013 Replaces: 6/28/2012

any private or public setting. Psychologists are licensed and regulated by the California Board of Psychology.

Privileges. “Privileges” means the permission granted to Licensed Independent Practitioners and Allied Health Professionals as identified herein to provide patient/client care and includes access to those SHCS resources including equipment, facilities, and personnel which are necessary to effectively exercise those privileges.

Other Healthcare Professionals (OHP): Those individuals who are licensed or certified (except those not required to be licensed/certified by law or the University) in a health care profession other than those specified in the Licensed Independent Practitioners and Allied Health Professions category. OHPs practice under Human Resources Policies and Procedures and/or defined by a Scope of Practice.

Scope of Practice. A statement describing practitioners’ care services authorized by the Governing Body to be provided at UC Davis SHCS

IV. AUTHORITY AND RESPONSIBILITIES

A. Credentials Committee

The Governing Body has the authority to delegate roles and responsibilities for the credentialing process and the SHCS Credentials Committee. The responsibilities of the respective delegated bodies are as follows:

a. The SHCS Executive Director has been delegated authority by the Governing Body and responsibilities include:

i. Identifying Credentials Committee membership;ii. Assuring a complete and accurate report of Credentials Committee

activities to the Governing Body;iii. Final approval of appointments, reappointments and the overall

credentialing verification process of LIP,AHP and OHP applicants after Credentials Committee recommendation;

iv. Participating in Credentials Committee meetings as an ex-officio member;

v. Reviewing Credentialing Plan, Policies and Procedures and Privileging Forms at least annually.

b. The Medical Director (or designee) responsibilities include:i. Acting in compliance with SHCS credentialing standards, protocols,

policies, and provisions;ii. Recommending approval/denial of requested privileges in collaboration

with the Peer Review Committee Chair; iii. Maintaining oversight and review of the Credentialing Plan and related

policies;iv. As deemed appropriate, previewing credential files to ensure accuracy

and completeness prior to the Credentials Committee meetings;v. Reviewing clinical quality of care summaries which are presented in the

re-credentialing decision making process;vi. Reviewing credential files with potential issues or problems prior to hire,

new appointment or re-appointmentvii. Participating in Credentials Committee meetings as Chair.

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c. The Credentials Committee reviews and evaluates the qualifications of each applicant. The Credentials Committee responsibilities include:

i. Reviewing and objectively evaluate applicants against pre-established criteria;

ii. Recommend approving credentials of applicants for staff appointment/reappointment and provide recommendation to Governing Body;

iii. Providing a summary report of approved practitioners to the Governing Body at least annually;

iv. Referring applicants not meeting criteria that are not recommended for staff appointment to the Medical Director or CAPS Director for review;

v. Monitoring the credentialing policies and procedural activities and make recommendations to the Governing Body for changes to these policies;

vi. Reviewing the findings resulting from contractor CVO, credentialing and quality monitoring and recommendations from the credentialing coordinator;

d. The Quality Improvement Manager (or designee) responsibilities include:i. Ensuring compliance with SHCS’ credentialing standards, protocols,

policies, and specified provisions;ii. Maintaining oversight of the Credentialing Plan and related policy to

ensure compliance with current requirements of the appropriate regulatory bodies and SHCS’ standards and policies;

iii. Previewing of verification and credentials files to ensure accuracy and completeness prior to the Credentials Committee meetings

iv. Coordinating Credentials Committee meetings in regards to the time, place, member attendance, agenda, and minutes of each meeting; or authorizes file reviews by voting members outside formal meetings if necessary.

v. Assuring verification of qualifications and credentials is in accordance with policy;

vi. Assuring a completed credential file summary for each applicant is presented for review;

vii. Maintaining the confidentiality of credentials files;viii. Reporting the Credentialing activities to the Governing Body.ix. Participating in Credentials Committee meetings as an ex-officio

member.x. Performing annual random audits of credentialing files.

e. Credentials Committee Membershipi. The functions of the Credentials Committee are performed by three (3)

licensed health care practitioners including the Medical Director, CAPS Director, and one AHP, credentialed by SHCS, who are the only voting members.

ii. The three (3) practitioners shall represent the various specialties at SHCS. When credentialing practitioners with a specialty not represented on the Committee, the Committee may designate an Auxiliary Member (with that specialty) and request that the Auxiliary Member review the application. After the Auxiliary Member advises the Committee on the application, the appointed members of the Committee will make the recommendation regarding the application. Auxiliary Members must be practitioners on staff at SHCS whose credentialing applications have been approved by the Credentials Committee.

iii. The Credentials Committee chair will be the Medical Director.

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iv. Ex-officio, non-voting members of the Committee include Executive Director of Health and Wellness and Quality Improvement Manager / designee.

f. Credentials Committee Members Responsibilities:i. Each member of the Credentials Committee will be responsible for

maintaining an objective view of credentials review activities.ii. Each member will be required to sign a Confidentiality Agreement, which

includes a statement regarding conflict of interest, wherein the committee member agrees to maintain the confidentiality of credentialing activities and to refrain from participating in activities that may represent a conflict of interest.

B. Practitioners (LIPs, AHPs, and OHPs)

All applicants seeking appointment or reappointment to practice at SHCS must complete an online credentialing application provided through the contractor CVO. Applicants are required to provide information including all demographic information, practice locations, current licensure and/or certifications, DEA (if applicable), current professional liability coverage (if applicable), current hospital affiliation(s), Board certification (if applicable), education, training, and employment history.

The applicant has the burden of obtaining and producing all needed information for a proper evaluation of professional competence, character, ethics and other qualifications in a timely manner. The information must be complete and verifiable. The applicant has the responsibility for furnishing information that will help resolve any questions concerning these qualifications. Failure to provide information in a reasonable time may serve as a basis for declaring application incomplete (see V.E. Incomplete Application) or denial of SHCS staff appointment, reappointment, privileges and employment.

V. CREDENTIALING PROCESS

Applicants for health care staff appointment must complete the credentialing process. SHCS does not grant temporary or provisional status, and practitioners are not granted staff appointment until the process is completed in accordance with SHCS credentialing policy and related procedures. Employment at SHCS shall be based on successful completion of the credentialing process and all required Human Resources processes such as reference checks, background checks, pre-employment physical and medical clearances.

Recommendations for initial credentials and for granting privileges shall be based upon appraisal of all information provided in the practitioner’s application, including, but not limited to, health status and written peer review recommendations regarding the practitioner’s current proficiency with respect to privileges, general competencies, as applicable, the practitioner’s training, experience, and professional performance. Recommendations from peers in a similar professional discipline as the practitioner, and who have personal knowledge of the applicant, are to be included in the evaluation of the practitioner’s qualifications.

A. Information and Materials Requested and Reviewed at Initial Credentialing

Materials requested and reviewed at time of initial credentialing include:

a. Education, training and experience: Relevant education and training are verified at the time of appointment for LIPs and AHPs; the applicant’s experience is reviewed for continuity, relevance and documentation of any interruptions in that experience.

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b. Three (3) Peer References for LIP and AHP categories: Current competence is verified and documented. (References for individuals in “OHP” category are obtained by Human Resources or the hiring supervisor.)

c. Additional references may be requested by the Medical Director.d. Board Certification, if applicable.e. Current hospital affiliation, if applicable.f. Employment history; last 5 years.g. State license(s): All active state licenses held during the past five (5) years shall be

verified and documented at the time of credentialing.h. Drug Enforcement Administration (DEA) registration, if applicable.i. Professional liability insurance information (policy name, number) for any current

policy or any policy held in the last 5 yearsj. Information obtained from the National Practitioner Data Bank (NPDB).k. Other pertinent information which includes, but need not be limited to:

i. Professional liability claims history for not less than the past five (5) year period.

ii. Information on licensure revocation, suspension, voluntary relinquishment, licensure probationary status, or other licensure conditions or limitations.

iii. Complaints or adverse action reports filed against the applicant with a local, state, or national professional society or licensure board.

iv. Refusal or cancellation of professional liability coverage.v. Denial, suspension, limitation, termination or nonrenewal of professional

privileges at any hospital, health plan, medical group, or other health care entity.

vi. DEA and state license action.vii. Disclosure of any Medicare/Medicaid sanctions.viii. Conviction of a criminal offense (other than minor traffic violations).ix. Current physical, mental health or chemical dependency problems that

would interfere with the applicant’s ability to provide high-quality patient care and professional services.

x. Signed statement releasing the organization from liability and attesting to the correctness and completeness of the submitted information.

B. Initial Application

a. Application Processi. The credentialing verification process starts when the Credentials

Verification Organization (CVO) is in receipt of a complete application.ii. The applicant has the burden of providing adequate information for

evaluation of compliance with criteria. It is the responsibility of the applicant to provide information and support the process with timely responses.

iii. Should an applicant not respond to requests in a timely manner, he/she will be informed that the application is incomplete, and the credentialing process has not been initiated. An incomplete application may be considered voluntary withdrawal of application.

iv. Once the application is found to be in compliance with the criteria for a complete application, the verification process is initiated.

b. Application

i. All applicants for health care staff appointment at SHCS shall complete, sign and submit the designated online credentialing application to the contractor CVO in a timely manner.

ii. The application includes:

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1. Reasons for any inability to perform the essential functions of the position, with or without accommodation;

2. Lack of present illegal drug use;3. History of loss of license and felony convictions;4. History of loss or limitation of privileges or disciplinary activity;5. Current malpractice insurance coverage; and6. Attestation to the correctness and completeness of the

application, signed within 180 days of the Credentials Committee decision date.

c. Collection and Verification of Information

i. The CVO will review the application for completion and accuracy according to their Standard Operating Procedures. If information or supporting documents are missing, the CVO may perform outreach to the applicant directly to collect such information and/or documents or notify credentialing contact. Once the application is deemed to be complete, information shall be verified by the CVO based on contractual agreement with UC.

ii. Upon completion of verification, the CVO will supply SHCS with the Provider Verified Profile, consisting of a verified data summary, copies of all verification images, and copies of the provider application and supporting documents.

iii. Primary Source Verification of credentials is completed for required components with acceptable sources. See Appendix A: Table of Acceptable Verification Sources.

iv. All verifications must be completed within 180 days of the date of the credentials decision.

v. Once all information is received, the credentials file is reviewed by the SHCS Credentialing Office and flagged appropriately for any issues listed in Appendix B. The applicant’s name is entered on the agenda for the next Credentials Committee meeting, or presented to Credentials Committee members individually for review.

VI. CRITERIA AND STANDARDS

Each practitioner must meet the applicable criteria. The Credentials Committee and / or the Governing Body may waive any of the criteria if it is determined that to do so would be in the best interests of SHCS (unless unlawful).

A. General Credentialing Criteria and Standards for Medical Staff:

Each medical staff applicant will meet the following criteria and standards:

a. Graduation from an accredited school of medicine, osteopath, or podiatry.b. Current, valid, unrestricted medical license issued by the state(s) in which the

applicant practices, and;c. No restriction or loss of license to practice medicine, osteopathy, or podiatry in

any state where licensed in the past five (5) years, and;d. Current Board* certification in the appropriate specialty board. (Required for new

employees subsequent to November 29, 2010.) , and;e. Acceptable explanation of any gap in work history during that is greater than 180

days in the last five (5) years and:f. Malpractice history reviewed by the Credentials Committee and considered to be

acceptable, and;

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g. History of any professional disciplinary sanctions or actions by a medical organization reviewed by the Credentials Committee with determination of impact on participation status, and;

h. No history of expulsion, suspension, reprimand, or exclusion from any U.S. government sponsored programs, and;

i. No history of fraud against any U.S. government sponsored programs during past ten (10) years, and;

j. No known felony convictions, and;k. No history of denial or cancellation of liability insurance coverage by carrier

during past five (5) years, and;l. Professional liability insurance coverage if practicing outside of University of

California, and;m. Current, valid, unrestricted DEA certificate with all schedules and appropriate

address, if applicable to specialty, and;n. No known willing misrepresentation, misstatement or omission of a relevant fact

on the application or other documentation provided by the applicant, and;o. Free of any mental or physical impairment, including chemical dependency and

substance abuse, that could interfere with the performance of all or any of the requested or granted privileges, or the ability to carry out the essential functions of the applicants practice, unless reasonable accommodation can be made for such impairment consistent with the interests of sound patient care, and;

p. Three (3) letters of peer reference addressing clinical competence, moral, and ethical behavior.

* Board Certification with the American Board of Medical Specialties (ABMS), the American Osteopathic Association (AOA), the American Board of Podiatric Medical Specialties (ABPMS), or American Board of Podiatric Surgery (ABPS)

B. General Credentialing Criteria and Standards for Psychologists and Allied Health Professions:

Each psychologist and Allied Health Practitioner applicant will meet the following criteria and standards:

a. Graduate of accredited program in area of practice, and;b. Current certification or clinical experience in the practice of specialty such that

the applicant is able to provide patient care services at an acceptable level of quality and efficiency, and;

c. Current, valid, unrestricted license issued by the applicable state Board, in the state(s) in which the applicant practices, and;

d. No restriction or loss of license in any state, and;e. Current valid DEA certificate to include appropriate schedules and appropriate

address, if applicable to practice, and;f. Malpractice history and history of any professional disciplinary sanctions or

actions by a professional organization reviewed by the Credentials Committee with determination of impact on participation status, and;

g. Acceptable explanation of any gap in work history that is greater than 180 days in the last five (5) years and:

h. No history of denial or cancellation of liability insurance coverage by carrier during past five (5) years, and;

i. No history of expulsion, exclusion, or finding of fraud from any U.S. government sponsored programs, and;

j. Three (3) peer reference letters addressing clinical competence, moral and ethical behavior, and;

k. No known willing misrepresentation, misstatement or omission of a relevant fact on the application or other documentation provided by the applicant, and;

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l. Free of any mental or physical impairment, including chemical dependency and substance abuse, that could interfere with the performance of all or any of the requested or granted privileges, or the ability to carry out the essential functions of the applicants practice, unless reasonable accommodation can be made for such impairment consistent with the interests of sound patient care and;

m. Professional liability insurance coverage if practicing outside of the University of California.

C. General Credentialing Criteria and Standards for “Other Healthcare Professionals”:

Each applicant in this category will meet the following criteria and standards:

a. Current, valid, unrestricted license or certificate issued by the applicable professional board in the state(s) in which the applicant practices (except those professions not required by law such as massage therapist), and;

b. Standards as listed above in VI.B. f, g, h, i, k, l, and m, if appropriate; and;c. References may be obtained by Human Resources or the hiring supervisor.

Additional references may be requested at the discretion of the Medical Director or CAPS Director, as appropriate.

D. Criteria for Complete Application

A completed application shall include, at a minimum, the following:a. Detailed information concerning the applicant's qualifications, including

education, training, and clinical experience, current licensure or certification, continuing education that is relevant to the privileges requested, current health status as it relates to the applicant's clinical activities, and other information in satisfaction of the basic qualifications for employment and of any additional qualifications established by SHCS which the applicant seeks appointment such as five (5) years of past employment history.

b. The specific practitioner category for which the applicant wishes to be considered (as listed on the application).

c. The applicant’s specialty training program, and, as applicable, the names, provider types and addresses of a minimum of three (3) peers who have known the applicant for at least one year, worked with the applicant and observed the applicant’s professional performance and who can provide information regarding the applicant’s clinical ability, ethical character, and ability to work with others so as not to adversely affect patient care for LIP and AHP. For “OHP” category, references may be obtained by Human Resources or the hiring supervisor. The Medical Director or CAPS Director may request additional references for any applicant.

d. Information requested in the “Attestation Disclosure Questions” section on the application form regarding professional sanctions and health status. If any items in this section apply, the details thereof shall be included and reviewed.

e. Professional liability insurance information sufficient to verify any claims experience during the past five (5) years, if applicable, including a consent to release information by the applicant’s present and past malpractice carriers, as applicable. The applicant has the burden to provide sufficient information on any claims if requested by SHCS. (If applicant has no claims, the disclosure and signed attestation on the application is acceptable and does not require verification.)

f. Information on any other professional liability insurance policies currently in effect such as certificates of self-insurance from the University of California Office of the President (UCOP) or the California State University Risk Management Authority (CSURMA)

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g. Information regarding receipt of written notice of any adverse action against the applicant under the Medicare or Medicaid programs, including, but not limited to, fraud and abuse proceedings or convictions, as applicable.

E. Incomplete Application

A practitioner whose application is not fully completed as defined above shall not be processed and will be returned to SHCS after an agreed upon outreach campaign has been completed by the CVO to contact the provider for collection of missing elements. If the practitioner fails to complete the application within thirty (30) days it shall be deemed withdrawn by the applicant. The applicant may apply again and any information gathered during the initial process may be used if still valid and timely.

VII. REVIEW AND APPROVAL / CREDENTIALS COMMITTEE

A. Analysis and Action

a. The Credentialing Coordinator forwards a completed credentials file to the Credentials Committee members for review flagging any issues as applicable in Appendix B.

b. The Credentials Committee assesses compliance with criteria and information related to character, professional competence, prior behavior and ethical standing provided by the applicant and other sources.

c. The Credentials Committee analyzes the credentials files of practitioners with evidence of non-compliance with criteria (see Criteria and Standard section). Non-compliance includes, but is not limited to malpractice claims, OIG report of action, NPDB / HIPDB report of action, malpractice insurance coverage below required limits, unsatisfactory reference, or loss of hospital privileges. Based on the analysis of the information and data provided, the Credentials Committee makes a recommendation to the Governing Body for appointment or non-appointment.

d. The Governing Body makes the final decision regarding appointment to practice for applicants who are either recommended or not recommended by the Credentials Committee.

e. Applicants are forwarded to the Credentials Committee no later than 120 days after receipt of a complete application.

f. The Credentials Committee may choose to pend an application to ask for additional information or clarification. If the applicant is asked for information, the request will be made in writing, and the applicant will be given thirty (30) days to respond. The new information will be included in the Credentials files and submitted for subsequent review.

g. If a recommendation by the Credentials Committee is delayed longer than 120 days, the Chair of the Credentials Committee will provide written notification to the applicant with the reason for the delay.

h. If the Credentials Committee recommends denial of appointment to practice, the applicant will be afforded appeal as described in Section XII (Appeals Process). All subsequent actions will be governed by those procedures.

i. The Credentialing Office will send a letter notifying the applicant of the credentialing decision and participation status within thirty (30) days of the decision.

VIII. INITIAL APPOINTMENT

A. Medical Staff

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a. Upon approval by the Credentials Committee and the Governing Body and completion of all required Human Resources processes, the applicant is appointed to the Associate Medical Staff, granted privileges based on training and experience, and assigned a proctor from the active Medical Staff.

b. Following completion of the proctoring (reference SHCS Policy and Procedure CPR-003) and prior to completion of the six (6) months of Associate Staff Membership, the Medical Director reviews recent performance, proctoring and any applicable risk management and quality of care issues and determines appropriate recommendation for appointment to the Active or Consulting Medical Staff. The recommendation is forwarded to the Peer Review Committee (PRC) for review. For contracted employees, privileges may be granted for a period not to exceed the initial contract period (1 year maximum) if approved by the Medical Director.

c. The PRC recommendations are subsequently reviewed by the Medical Director and forwarded to the Executive Director for review. Final approval or denial of the appointment to the Active or Consulting Medical Staff is the responsibility of the Executive Director (designee of the Governing Body).

d. If the Executive Director disapproves the applicant for appointment to the Active or Consulting Medical Staff, the file is referred back to the Medical Director for follow-up.

e. If the Executive Director approves the applicant for appointment to the Active or Consulting Medical Staff, the applicant is notified within 30 days and provided a copy of their approved privileges. The appointment is approved for three (3) years. The CVO is notified of the appointment dates.

B. Mental Health Staffa. Upon approval by the Credentials Committee and the Governing Body and

completion of all required Human Resources processes such as reference checks, background checks, pre-employment physical and medical clearances, the applicant is granted privileges based on licensure or doctorate or masters level education for a probationary period of six (6) months. For contracted employees, privileges may be granted for a period not to exceed the initial contract period (1 year maximum) if approved by the CAPS Director.

b. Following completion of the proctoring and prior to completion of the six (6) months probationary period, the CAPS Quality Assurance Committee (QAC) reviews the applicant’s performance, proctoring, and risk management and quality of care issues. The QAC determines appropriate recommendation for appointment to the CAPS Staff.

c. The QAC recommendations are forwarded to the CAPS Director for review. The CAPS Director’s recommendations are forwarded to the Executive Director for review. Final approval of the appointment to the CAPS Staff is the responsibility of the Executive Director (designee of the Governing Body).

d. If the Executive Director disapproves the applicant for appointment, the file is referred back to the CAPS Director for follow-up.

e. If the Executive Director approves the applicant for appointment, the applicant is notified within 30 days. The appointment is approved for three (3) years. The CVO is notified of the appointment dates.

C. Nurse Practitioners (NPs)a. Upon approval by the Credentials Committee and the Governing Body, the

applicant is recommended for a 6-month probationary appointment to the AHP staff, granted privileges based on training and experience and scope of practice, and assigned a proctor from the active Medical Staff.

b. Following completion of the proctoring (reference SHCS Policy and Procedure CPR-003) and prior to completion of the six (6) months probationary appointment, the Medical Director reviews recent performance and any

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applicable risk management and quality of care issues and forwards his/her recommendations to the PRC. For contracted employees, privileges may be granted for a period not to exceed the initial contract period (1 year maximum) if approved by the CAPS Director.

c. The PRC recommendations are subsequently reviewed by the Medical Director and forwarded to the Executive Director for review. Final approval of the appointment to the Active AHP Provider Staff is the responsibility of the Executive Director (designee of the Governing Body).

d. If the Executive Director disapproves the applicant for advancement to the Active AHP Provider Staff, the file is referred back to the Medical Director for follow-up.

e. If the Executive Director approves the applicant for advancement to the Active AHP Provider Staff, the applicant is notified within 30 days and provided a copy of the privilege list. The appointment is approved for three (3) years. The CVO is notified of the appointment dates.

f. Clinical privileges are requested and granted in accordance with the NP Standardized Procedures and Protocols.

D. AHP (Other than NPs) (Optometrists and Pharmacists in Expanded Roles)a. Upon approval by the Credentials Committee and the Governing Body and

completion of all required Human Resources processes such as reference checks, background checks, pre-employment physical and medical clearances, the applicant is granted employment and applicable privileges based on scope of practice for a probationary period of six (6) months (may be extended to 1 year at the discretion of the Medical Director).

b. Prior to completion of the probationary period, the Medical Director reviews recent performance, risk management and quality of care issues and makes a recommendation to the Executive Director.

c. Final approval of the appointment to practice is the responsibility of the Executive Director (designee of the Governing Body).

d. If the Executive Director disapproves the applicant for appointment to practice, the file is referred back to the Medical Director for follow-up.

e. If the Executive Director approves the applicant for appointment to practice, the applicant is notified within 30 days. The appointment is approved for three (3) years. The CVO is notified of the appointment dates.

E. Other Healthcare Professionalsa. Upon approval by the Credentials Committee and the Governing Body, the

Human Resources manager and the hiring supervisor are notified that the applicant has successfully completed the credentialing process. The applicant is notified within 30 days of approval.

b. If the applicant is not recommended by the Credentials Committee and the Governing Body, the file is referred to the Human Resources manager and/or hiring supervisor for follow up.

IX. CONTINUED PARTICIPATION / RE-CREDENTIALING

LIP and AHP practitioners are re-credentialed every three (3) years. Approximately four (4) months prior to the end of the three (3) year appointment period, the provider is directed to update their online contractor CVO application. Information changed since last credentialing decision is corrected in the online credential application and re-attested by the practitioner. The CVO re-verifies applicable elements of the application per contract and returns a completed, verified profile within 30 days.

A. Compliance with General Criteria

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It is the responsibility of each practitioner to maintain compliance with general criteria and to inform Administration of changes in the status of any information normally maintained in the credentials file.

B. Clinical Performance Evaluation

a. Information related to clinical performance is maintained in the Provider Performance Summary File (Blue File) for LIPs and AHPs. As appropriate, information is reviewed with an individual practitioner by the Medical Director or CAPS Director.

b. Information documented in the Provider Performance Summary file is reviewed and taken into consideration as part of the continued participation and/or recredentialing determination and / or recommendation.

c. Other healthcare providers’ (OHP) performance is reviewed annually through the Human Resources process.

C. Information and Materials Requested and Reviewed at time of Recredentialing

Materials requested and reviewed at time of recredentialing include:

a. Updated online contractor CVO applicationb. Current California state license or certification is verified and documented at the

time of reappointment.c. Board Certification, if applicable.d. Current hospital affiliation, if applicable.e. Drug Enforcement Administration (DEA) registration, if applicable.f. Proof of current medical liability coverage if applicable per SHCS policy.

(Certificates of liability coverage renew annually on June 30th for practitioners who practice for the University of California.)

g. Information obtained from the National Practitioner Data Bank (NPDB) and primary source verification with insurance carriers.

h. Other pertinent information which includes, but need not be limited to:o Professional liability claims history if applicable.o Information on licensure revocation, suspension, voluntary

relinquishment, licensure probationary status, or other licensure conditions or limitations.

o Complaints or adverse action reports filed against the applicant with a local, state, or national professional society or licensure board.

o Refusal or cancellation of professional liability coverage.o Denial, suspension, limitation, termination or nonrenewal of professional

privileges at any hospital, health plan, medical group, or other health care entity.

o DEA and state license action.o Disclosure of any Medicare/Medicaid sanctions.o Conviction of a criminal offense (other than minor traffic violations).o Current physical, mental health or chemical dependency problems that

would interfere with Applicant’s ability to provide high-quality patient care and professional services.

o Signed statement releasing the organization from liability and attesting to the correctness and completeness of the submitted information.

D. Primary Source Verification

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Current licensure, status of hospital affiliations, and changes related to Board Certification are primary source verified. All other information is verified in accordance with methodology identified in Appendix A.

The CVO shall perform verification services in accordance with the contracted verification scope, expeditiously seeking to verify the practitioner's qualifications, National Practitioner Data Bank status, professional liability status, current licensure, current Drug Enforcement Agency registration, and other information in satisfaction of the basic qualifications in writing and from the primary source whenever feasible.

E. Recommendation

a. The Medical Director or CAPS Director shall, upon receiving a completed reappointment Provider Verified Profile for LIPs or AHPs, add practitioner-specific performance improvement and patient quality, risk, and safety management data, and then evaluate the professional performance, judgment, patterns of patient care, and when appropriate, technical skill based on this information.

b. The credentials file and summary of Medical Director or CAPS Director’s review are sent to Peer Review Committee or Quality Assurance Committee (QAC) as appropriate.

c. The PRC or QAC reviews the completed credentials file with summary of performance. and determines appropriate recommendation for reappointment to the Medical Staff or CAPS Staff.

d. The PRC or QAC recommendations are subsequently reviewed by the Medical Director or CAPS director and forwarded to the Credentials Committee for review.

e. Within thirty (30) days of receipt of recommendations from the Medical Director or CAPS Director, the Credentials Committee shall review the file and provide their recommendation to the Governing Body.

f. The Governing Body completes the review of all credentials data and determines whether the applicant will be reappointed.

g. If the Executive Director approves the applicant for reappointment, the applicant is notified within 30 days and provided a copy of the privilege list. The appointment is approved for three (3) years. The CVO is notified of the reappointment dates.

h. If the Executive Director disapproves the applicant for reappointment, procedures in the Medical Staff Bylaws are followed, as appropriate, and/or Human Resource Policies and Procedures.

F. Failure to Complete Reappointment

The non-submission of a complete reappointment application or the submission of an incomplete application by the reappointment due date shall result in an automatic suspension of the practitioner’s clinical privileges to practice at SHCS. Should this occur, the matter shall be referred to the SHCS Executive Director and Human Resources department for further action in accordance with University of California personnel policies and procedures and Medical Staff Bylaws, as appropriate.

If it is determined that the practitioner will be allowed to continue to work at SHCS, the practitioner will be required to reapply for and obtain clinical privileges subject to terms and conditions set forth below.

a. Practitioners suspended from clinical practice due to failure to return a complete reappointment application or supporting documentation by the reappointment

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due date may apply for reappointment if the application or required documents are submitted to SHCS within thirty (30) days of suspension.

b. If more than thirty (30) days have elapsed since the practitioner was suspended, the practitioner must submit an application for initial appointment.

X. MONITORING

SHCS through delegation to the Contractor CVO shall monitor and document: current licensure; professional liability insurance, if required; certifications; OIG; and DEA and other registrations, where applicable, on an ongoing basis with oversight by the SHCS Credentialing Office. XI. PRACTITIONER RIGHTS AND RESPONSIBILITIES

A. Non discrimination

No practitioner will be denied appointment to practice, be subject to corrective actions, have his/her ability to practice be suspended or terminated solely on the basis of sex, creed, race, color, age, national origin, physical or mental disability, sexual orientation, or the types of procedures or patients in which the practitioner specializes.

B. Practitioner Rightsa. Practitioners have the right to at any time inquire about their credentialing status.

A member of the Credentialing Office will respond to practitioner questions related to credentialing status within three (3) days of the request.

b. Practitioners have the right to review information submitted in support of credentialing application, however SHCS recognizes that peer review is integral to the credentialing process. Therefore, practitioners will not be provided access to references, recommendations, or other peer review protected information. In the event that through a review process, a practitioner discovers an error in the credentials files, the practitioner has the right to request a correction of the information in question.

c. SHCS will notify practitioner of any information obtained during the credentialing process that varies substantially from the information provided by the practitioner. Notification will be made in writing by the Credentialing Office within ten (10) working days of the identification of the variance. The practitioner will be provided the opportunity to clarify the variance.

d. Practitioners have the right to correct erroneous information. Following review of credentialing information or notification of a variance, the practitioner will be afforded thirty (30) days to provide written clarification or corrected information. Corrected information is not acceptable in any format other than a written statement signed by the practitioner, which is forwarded to the Credentialing Office within the allotted time frame. Upon receipt of corrected information, the Credentialing Office will be incorporated into the credentials file, verified through the appropriate primary source and placed for review on the agenda of the next scheduled Credentials Committee meeting.

XII. APPEALS PROCESS

SHCS Medical Staff members are provided Fair Hearing Rights and AHP members are provided an Appeal Process should action be taken against the provider’s privileges as a result of the provider’s quality of care or behavior. All Fair Hearing processes are outlined in the SHCS Medical Staff Bylaws, Article 6 (Hearing and Appeals).

Should a provider’s membership and/or privileges be summarily suspended and/or terminated for quality and/or behavior reasons; the Credentialing Office in collaboration with the Executive Director’s Office and the University of California Office of the President will report to the Medical

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Board of California within 15 calendar days of the decision to summarily suspend and/or terminate a provider’s membership and privileges. The National Practitioner Databank (NPDB) will be notified within 30 calendar days of the decision.

Psychologists, AHPs and OHPs are subject to corrective action processes pursuant to U.C. Davis Human Resources policies and procedures. Notwithstanding the foregoing, clinical privileges exercised by AHPs are subject to oversight by the Medical Director or CAPS Director. Performance concerns, or problems with clinical care not believed to be sufficiently resolved through the foregoing policies, procedures, and/or service contract provisions may result in clinical privileges restriction, suspension or termination by the PRC, QAC, or the SHCS Executive Director. Prior to restriction, suspension or termination of clinical privileges of a psychologist or AHP, the affected psychologist or AHP shall be given notice of the proposed action and afforded an opportunity to present written or verbal response to the Medical Director (or designee) or CAPS Director (or designee), who will make recommendation to the Executive Director for final action on behalf of SHCS.

XIII. CONFIDENTIALITY

Credentials files are treated as confidential and are kept locked in the Credentialing Office. These files are protected from discovery pursuant to Evidence Code Sections 1156 and 1157. Documents in these files may not be reproduced or distributed, except as permitted pursuant to State Law, including Sections 1156 and 1157. SHCS shall have a policy regarding access to, distribution of, addition to, and disclosure of the content of Clinical Staff credentials files. (See Appendix C.) All requests for access to these files shall be presented to the Executive Director, Medical or CAPS Director or the Quality Improvement Manager.

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Approval: (See credentialsplan.2013.pdf file for signatures; dated 9.25.13)

Quality Improvement Manager/Risk Manager Date

___________________________________ _______________________Director Patient Care Services Date

____________________________________ _______________________Director Administrative Services Date

Director Clinic Support Services Date

CAPS Director Date

Medical Director Date

Executive Director of Health and Wellness Date

Associate Vice Chancellor for Student Affairs Date

(Governing Body, Chair)

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Appendix A: Table of Acceptable Verification Sources

ELEMENTS - PHYSICIAN ACCEPTABLE VERIFICATION

License to practice medicine or osteopathy

Primary source verification with State Board of Medical Examiners for the states where the physician provides care. Verification may be completed via letter, phone, fax, or state medical board web site.

DEA Certificate Copy provided by applicant and/or NTIS table (National Technical Information Service). DOJ website (Dept of Justice):http://www.deadiversion.usdoj.gov ; Current certificate including all schedules (2, 2N, 3, 3N, 4, 5) and appropriate local address (es).

If not certified by an ABMS Board, highest level of education

- Medical School- Internship- Residency

Verification directly with program via letter, phone or fax; or AMA or AOA profile.

ECFMG if applicable verified directly with the Education Committee for Foreign Medical Graduates via Letter, fax or website electronic verification

Board Certification or obtain certification within five (5) years

Via ABMS CertiFACTS web site; AMA or AOA profile; or confirmation from the appropriate specialty Board by letter or fax. Expiration date must be present with verification.

Hospital affiliation and privileges Applicant disclosure and attestation; and verification by Hospital Medical Staff Office via phone, fax, or medical staff roster

Professional liability insurance coverage

Copy of current malpractice policy binder / insurance face sheet / declaration sheet showing dates and amounts of coverage, no more than 305 calendar days old at the time of the Credentials Committee decision

Malpractice claims history Via NPDB / HIPDB report and applicant disclosure, with explanation by applicant of current cases and cases with payment exceeding $75,000.

Sanctions and limitations on licensure State Board of Medical Examiners of any state in which the applicant held a license during the past five (5) years; NPDB / HIPDB report, and applicant disclosure with attestation.

Work history Work history for past five (5) years documented by applicant with month and year start date and month and year end date. Explanation of any gaps exceeding six (6) months documented by applicant. If the applicant has practiced less than five (5) years, the start of work history will be the date of initial medical license.

Medicare and Medicaid sanction history

Identified via NPDB / HIPDB report, and OIG sanction list, and applicant disclosure.

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http://www.deadiversion.usdoj.gov/

REQUIRED COMPONENTS –ADVANCED PRACTICE NURSE

ACCEPTABLE VERIFICATION

License to practice in appropriate specialty

State Board of Registered Nursing

Education – advanced practice Through verification of license if licensing board has primary source verified education

DEA Certificate – if applicable Copy of certificate which includes appropriate schedules and appropriate local address

Professional Liability Coverage Copy of current malpractice policy binder / insurance face sheet / declaration sheet showing dates and amounts of coverage, no more than 305 calendar days old at the time of the Credentials Committee decision

Primary Physician Supervisor Certification (for Physician Assistants)

Form completed by sponsoring or collaborative physician (copy to file)

Clinical experience, ability to work cooperatively, free of mental or physical impairment that could interfere with performance, and legible documentation skills

Reference completed by Physician Supervisor and/or applicant disclosure with attestation

Absence of felony history, license loss or restriction, or sanctions by Medicare / Medicaid

Applicant disclosure and attestation; and verification with the State Board of Registered Nursing, and query to OIG. If licensed in another state within the past 5 years, the appropriate Board or licensing entity in that state.

REQUIRED COMPONENTS –PSYCHOLOGISTS, LCSW, MFT


License to practice State Board of Psychology; Board of Behavioral Sciences, as appropriate

Education Through verification of license if licensing board primary source verified education; or National Student Clearinghouse



Malpractice history Via NPDB / HIPDB report and applicant disclosure and attestation, with explanation by applicant of current cases and cases with payment exceeding $75,000.

Sanctions and limitations on licensure

State Board of Psychology or Board of Behavioral Sciences of any state in which the applicant held a license during the past five (5) years; NPDB / HIPDB report, and applicant disclosure with attestation.

Work history Work history for past five (5) years documented by applicant

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REQUIRED COMPONENTS –PSYCHOLOGISTS, LCSW, MFT


with month and year start date and month and year end date. Explanation of any gaps exceeding six (6) months documented by applicant. If the applicant has practiced less than five (5) years, the start of work history will be date of initial license.


Identified via NPDB / HIPDB report, and OIG sanction list, and applicant disclosure and attestation.

REQUIRED COMPONENTS –OTHER AHPs (Exclude NPs)


License to practice Appropriate licensing board.

Education Through accredited program or National Student Clearinghouse





Appropriate licensing board of any state in which the applicant held a license during the past five (5) years; NPDB / HIPDB report, and applicant disclosure with attestation.

Work history Work history for past five (5) years documented by applicant with month and year start date and month and year end date. Explanation of any gaps exceeding six (6) months documented by applicant. If the applicant has practiced less than five (5) years, the start of work history will be date of initial license.


Identified via NPDB / HIPDB report, and OIG sanction list, and applicant disclosure and attestation

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REQUIRED COMPONENTS –OTHER OHPs


License/Certification in specialty Appropriate licensing board unless determined not applicable by state law

Education Through accredited program or National Student Clearinghouse; or applicant disclosure and attestation





Appropriate licensing or certifying board of any state in which the applicant held a license or certification during the past five (5) years; NPDB / HIPDB report, and applicant disclosure with attestation.

Work history Work history for past five (5) years documented by applicant with month and year start date and month and year end date. Explanation of any gaps exceeding six (6) months documented by applicant. If the applicant has practiced less than five (5) years, the start of work history will be date of initial license/certification.


Identified via NPDB / HIPDB report, and OIG sanction list, and applicant disclosure and attestation

Appendix B: File Triaging (Flagging) Categories

File Category Initial Appointment ReappointmentGreen No issues have been identified

with the provider’s appointment, and the file meets the following criteria:• Satisfactory References• No record of malpracticepayments since the lastappointment or currentpending claims• No disciplinary actions• No licensure restrictions• Current licenses• No problems verifyinginformation• No indications ofinvestigations or potentialproblems• Information is returned in atimely manner and contains

No issues have been identifiedwith the provider’sreappointment, and the filemeets the following criteria:• Satisfactory References• No record of malpracticepayments since the lastappointment or currentpending claims• No disciplinary actions• No licensure restrictions• Current licenses• No problems verifyinginformation• No indications ofinvestigations or potentialproblems• Information is returned in atimely manner and contains

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nothing that suggests thepractitioner is anything byhighly qualified

nothing that suggests thepractitioner is anything byhighly qualified• Applicant is not requestingnew privileges• Applicant is not requesting astatus change• Applicant meets all criteriafor privileges requested• Activity levels are appropriate• CME relates to privilegerequests• QA data includes no PeerReview or Quality of Careissues• No health problems identified

Yellow The provider’s file may includequestionable information, suchas:• Peer references and prioraffiliations indicate potentialor minor problems• One malpractice claim• Privileges vary from thosetypically requested by otherpractitioners in the samespecialty• Gaps in work history

The provider’s file may includequestionable information, suchas:• Peer references and prioraffiliations indicate potentialor minor problems• One malpractice claim in past3 years• Additional Privilegesrequested• Change in status requested• Low Clinical Activity• Minor Health problemidentified which will likelyhave no impact on exercise ofclinical privileges• Difficulty in obtainingmonitoring reports

Red The provider’s file showspotentially adverse information,including:• Unsatisfactory peerreferences or prior affiliations• Disciplinary actions or reportsfiled by any verificationorganization (NPDB,Federations, MBC, MedicareSanctions, AMA)• Clinical privileges revoked,diminished or altered byanother Healthcareorganization• 2 or more malpractice claims• Multiple Healthcareorganization affiliationsduring the past 5 years• Substantial number ofprofessional licenses

The provider’s file showspotentially adverse information,including:• Unsatisfactory peerreferences or prior affiliations• Disciplinary actions or reportsfiled by any verificationorganization (NPDB,Federations, MBC, MedicareSanctions, AMA)• Clinical privileges revoked,diminished or altered byanother Healthcareorganization• 2 or more malpractice claimsin past 3 years• QA information shows aquality of care issue• Monitoring reports questioncompetency• Major Health Problemsidentified

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• Any existing QA informationshows a quality of care issue• Any existing monitoringreports question competency• Any unexplained gaps in work history history.

• New privileges requestedoutside of normal scope of specialty• Substantial # of professionallicenses (greater than 3)

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