The Credentialing and Privileges Manual, 4th Edition, is a 426-page tool box of credentialing policies, procedures, competency criteria and core privileges with delineated privilege checklists for all physician specialties, plus all licensed allied health professionals or non-physician clinicians.

Health systems, health plans, hospitals and medical groups use the Credentialing and Privileges Manual, 4th Edition, to design and implement exemplary credentialing and privileging programs for physician and non-physician clinical practitioners. This manual is focused on criteria for the granting of core and delineated privileges for primary and specialty physicians and non-physician clinicians (often called physician extenders, allied health professionals or midlevel practitioners) such as Nurse Practitioners, Nurse Anesthetists, Nurse Midwives, Surgical Assistants, Psychologists, Therapists and Podiatrists. Extensive and detailed example privileges are listed for each specialty in an easy-to-use core privileging and a checklist format. Resources include extensive references, joint commission and web links. The manual is continuously updated as new recommendations become available from specialty societies and other authoritative resources.

The Credentialing and Privileges Manual, 4th Edition, is a unique and important resource designed to assist hospitals, health plans and medical groups in the design and implementation of exemplary credentialing and privileging programs for physician and non-physician clinical practitioners. It was developed as a tool for Credentialing Committee members and credentialing staff who must perform this critical function in an organized, timely and objective manner on behalf of the medical staff and governance body.

The Credentialing and Privileges Manual, 4th Edition, is focused on credentialing issues, forms, and criteria for credentialing, recredentialing and the granting of privileges for primary and specialty physicians plus non-physician clinicians (often called physician extenders, allied health professionals or midlevel practitioners). Extensive and detailed example lists of privileges for each specialty or clinician are included in an easy to use check-list format. References and resources related to appropriate granting of privileges for each physician specialty or clinician are listed. Resident competency guidelines by year of training resource links are included for most specialties.

Table of Contents

• Preface
  
  
• Introduction: Procedure credentialing vs. core credentialing; Joint Commission bylaws and other credentialing requirements; Standard of care for credentialing and privileging processes; Document handling



• Credentials: Why credential?; Credentials committee, procedure credentialing vs. core credentialing; JCAHO medical staff by-laws requirements; Peer review; Negligent credentialing; Economic credentialing; Bylaws and credentials, Provider credentials and privileges policy and procedures, Credentialing processes, Recredentialing, request for provider application response letter, request for application, application and related documents, provider release/consent form, release of insurance information form, addendum to provider legal history form, applicant references; Identifying appropriate peers; Evaluation form/letter to send to applicants references; Application process
  
  
  • Working document for coordinators use: Letters/forms to verify internship/residency training, provider application credentialing form check lists, provider letter re: required documents between credentialing cycles, providers, DEA certification form, ADA implications for medical staff privileges, release of appointment application to hospital medical staff for use by PHO or another external organization, monthly hot sheet review recommendation; High risk providers, Provider sanctions, criminal background checks, public law title IV (HCQIA), national practitioner data bank (NPDB); Practitioner health status request letter, primary verification by state medical and dental boards, criminal background checks by state (FSMB chart);
    
    
  • Web Sites for Online Verification by State and Specialty Boards
    
    
  • Voluntary resignation/Leave of Absence Policy: Adverse re-credentialing or privileges determinations fair hearing; Suspension notes; Licensure Examination Scores relation to quality of practice.
    
    
  • Interns residents, preceptorships, other trainees
  
  
  
• Peer (physician/physician and physician/staff) Evaluations: Physician Physician evaluation procedures and forms, physician/physician, self-evaluation and physician/staff forms



• Privileges: Introduction to privileging, requirements for the granting of privileges, staffing plan, limited privileges, temporary Privileges, emergency/disaster privileges, aging practitioners; Proctoring, board certification, competency, core privileges, request for privileges to perform a new procedure; Privileges signature sheet & form; Medical executive committee (MEC), clinical privileges review and recommendations & form; Form to record granting privileges by board; Volume considerations as a privileging criteria for procedures; Focused professional practice evaluation (FPPE)
  
  
  • Setting or location for the exercise of surgical or invasive procedure privileges; Monitoring procedures performed that require specific privileges; Cross-department privileges by procedure (ECG interpretation, Swan-Ganz catheter insertion, vasectomy, sigmoidoscopy, hyperbaric oxygen therapy, amniocentesis, thoracotomy tube insertion and management, tympanocentesis, C-sections, endoscopies)
  • Procedure scheduled by a staff physician who does not have privileges for a specific non-core procedure/procter assignment;
  • On-call cross-departmental privileges, processing privileges, Privileges Signature Sheet, Signature and Record Sheet for Granting Privileges, Loss of privileges due to inactivity; Privilege requests for new technology, devices or procedures; Radiofrequency tumor ablation; Cryotherapy procedures
  • Volume considerations as a privileging criteria for procedures; Setting or location for exercise of surgical or invasive procedure privileges
  
  
  
• Delineation of Privileges: Core and detailed privileges lists and criteria for each specialty or subspecialty
• Anesthesiology: Core; Checklist + detailed privileging criteria for: Conscious sedation, Resident competency by year of training link; Pain management; Anesthesiology proctor assessment form; Anesthesiology web links
• Cardiovascular/thoracic surgery: Core criteria; Privileges checklist and resources
• Critical Care: Core criteria; Privileges checklist and resources
• Cross-departmental privileges: Core criteria
• Dentistry and Oral Surgery: Core criteria; Privileges checklist and resources plus detailed privileging criteria for: arthroscopy of the temperomandibular joint
• Dermatology: Core criteria; Privileges checklist and resource links
• Disaster Medicine: Core criteria
• Emergency Medicine; Disaster medicine: Core criteria; Privileges checklist and resource links
• Family Practice: Core criteria; Checklist
• Cross-departmental privileges: Conscious sedation, electrocardiogram interpretation, Swan Ganz catheter insertion, Vasectomy, flexible sigmoidoscopy, hyperbaric oxygen (HBO) therapy, Amniocentesis, thoracotomy tube insertions and management, Cesarean section, endoscopy procedures diagnostic, therapeutic to include colonoscopy, snare polypectomy, variceal hemastasis, EGD, ERCP, esophageal dilation/stent placement, laparoscopy; On call; Electrodiagnostic tests; Integrative or complementary/alternative medicine; Plasma exchange/Plasmapheresis
• Hospitalists: General information; Credentialing and privileges based on specialty and current competence
• Internal Medicine: Core criteria for privilege levels I, II, III, IV; Checklist and detailed privileging criteria for: core criteria for allergy and immunology subspecialty III/IV privileges; Core criteria for endocrinology and metabolism subspecialty III/IV privileges; Core criteria for infectious disease subspecialty III/IV privileges; Core criteria for HIV privileges; Core criteria for nephrology subspecialty III/IV privileges; Core criteria for rheumatology subspecialty III/IV privileges; Core criteria for pulmonary disease subspecialty III/IV privileges; Example delineation of privileges forms online; Resident competency requirements
• Cardiology/cardiovascular surgery: subspecialty III/IV procedure privileges criteria: checklist + detailed privileging criteria for: carotid endarterectomy; Cardiac computed tomography and computed tomography coronary angiography (CCTA); Direct current cardioversion, elective; Exercise treadmill test (stress test) privileges; Echocardiography, stress echocardiography privileges, references; Permanent pacemaker placement privileges; Impedance cardiography; Percutaneous transluminal coronary angioplasty (PTCA) privileges; Cardiac catheterization; Intracoronary stent implant privileges; References for angioplasty, stents, cardiac catheterization; Percutaneous balloon valvuloplasty (PTV); Electrophysiology (EP), references; Cardiology/cardiovascular procedure privileges general references; Internal medicine web sites useful for credentialing;
• Hematology/oncology: Core criteria; Privileges checklist and resource links
• Neurology: Core criteria; Checklist and detailed privileging criteria for: electrodiagnostic testing privileges with resource links
• Neurosurgery: Core criteria; Privileges checklist and resource links
• Nuclear Medicine: Core criteria; Checklist and detailed privileging criteria for: nuclear cardiology, I-131 therapy with resource links
• Obstetrics/gynecology: Core criteria; Checklist plus detailed privileging criteria for high-risk privileges; Obstetrical and gynecological ultrasound examination privileges; Laparoscopically assisted vaginal hysterectomy, colposcopy
• Occupational medicine: Core criteria; Privileges checklist and resource links
• Ophthalmology: Core criteria; Privileges checklist and resource links
• Orthopedic surgery: Core criteria; Privileges checklist and resource links and pediatric orthopedic surgery privileges
• Otolaryngology/head and neck surgery (ENT): Core criteria; privileges checklist and resource links
• Pathology: Core criteria; Privileges checklist and resource links
• Pediatrics: Core criteria, pediatrics, I, II, III, IV, V; Privileges checklist and resource links
• Physical medicine and rehabilitation: Core criteria; Privileges checklist and resource links
• Plastic and reconstructive surgery: Core criteria; Privileges checklist and resource linkss
• Podiatry: Core criteria; Privileges checklist and resource links
• Preventive medicine/public health: Core criteria; Privileges checklist and resource links
• Psychiatry: Core criteria; Privileges checklist and resource links
• Behavioral health care clinicians: Core criteria; Credentialing & privileges: checklists and detailed privileging criteria for: Psychiatry, psychology, psychotherapist, psychology associate or assistant; Psychiatric nurse specialist (advanced practice nurse); Medical social work; Medical hypnosis/hypnotherapy privileges, addiction specialist core criteria and checklist; Biofeedback privileges, neuropsychological testing privileges, therapy: family and/or marital privileges for psychology,
• Radiology; Therapeutic radiology: Privileges checklist and detailed privileging criteria for diagnostic and interventional radiology (criteria for ultrasound imaging, cardiac computed tomography and computed tomography coronary angiography (CCTA); discography, core-cut breast biopsy privileges, MRI, neuroradiologic procedures, neuroradiology facility, renal and visceral transluminal angioplasty and vascular stenting, peripheral and visceral arteriography, arteriography/angioplasty facility, kyphoplasty and vertebroplasty; Percutaneous Nephrostomy,
• Radiation Oncology: Core criteria; Privileges checklist and detailed privileging criteria with resource links
• Surgery: Core criteria; general: checklist and detailed privileging criteria for bariatric surgery criteria; Criteria for endoscopic cholecystectomy, laser procedures (all specialties); Laparoscopic gastric bypass and pediatric general, transplant surgery privileges
• Urology: Core criteria; Privileges; Privileges checklist; Laparoscopic nephrectomy; Tension-free vaginal tape (TVT) procedure; Percutaneous nephrostomy; Robotic assisted radical prostatectomy (RAP) and laser radical prostatectomy (LRP) procedures and resource links
• Other: Detailed privileging criteria for: pain management; Telemedicine services; Ventilator management; High frequency oscillatory ventilation (HFOV) and other procedures; Long-term care (LTC/SNF) medical directors and physicians



• Non-physician Clinicians or Allied Health Professionals: Credentials and Privileges: Introduction; Allied health professionals staff application form; Credentialing criteria for allied health professionals; Authorization/monitoring of external agency or physician employees who provide healthcare services; Allied health professional privileges approval sheet; Certification statement by supervising physicians
  
  
• Credentialing and Delineation of Privileges for Non-physician Clinicians by Area of Practice: Supervision of AHPs, Physician responsibilities; Allied health behavioral health competency assessment; Core criteria; Checklists and detailed privileging criteria for Audiologists; Blood bank technologist; Nurse Practitioners, Standardized procedures for nurse practitioners (immediate/urgent care); Verification of critical care nurse competencies (form); SNF patient management options by NPs, CNS and PAs; Chiropractors; Doulas; Optometry; Pharmacist, clinical; Podiatrists; Behavioral health providers; Physicians assistant's (PA, hospital-related services, PA, Ambulatory care privileges, PA, notification of privileges form); Medical assistant; Surgical assistant; Certified registered nurse anesthetists (CRNA); Certified nurse midwives (CNM); CNM job description; Licensed vocational nurse (LVN/LPN), scope of practice; Registered nurse, scope of practice; Case manager employed by another organization; Nurse/physician assistant endoscopy; Case manager (CM); Nutritionists; Physical therapists; Occupational therapists; Speech-language pathologists; Respiratory therapy; Ultrasound technicians; Safety officers; Cardiology technicians/assistants; Electrodiagnostic technicians; Volunteers; Therapeutic yoga; Acupuncturists; Provider relations and credentialing: coordinator position description; NCQA credentials verification services certification criteria list
  
  
• Addenda: Community health medical staff credentialing; Guidelines for credentialing in long-term care; Credentialing software and services with lists of vendors and contact information; Site visit or survey credentialing tool in a check-list format for physician offices and facilities plus an authorization and release form for medical office site visits; Joint Commission office-based surgery standards sampler; Case law references for credentialing
  
  
• Web links: Related to medical staff bylaws, credentialing and the granting of privileges, performance appraisal, and peer review
  
  
• References: Resources in addition to references and resources related to credentialing and privileges