441 E. 8th St.
Lima, OH 45804 / DATE: January 26, 2005
SUBJECT: Credentialing / Page 1 of 3
Policy: ACHP’s CEO will be responsible for implementing and maintaining a system whereby physicians, dentists, and other licensed or certified health care professionals are appropriately credentialed.
Procedure: The Medical or Dental Director, and CEO will be responsible for reviewing all credentialing information and must approve the credentialing and privileging of each practitioner. Specific elements of this process must be on file in the office of ACHP’s CEO or their designee and include:
1. Incoming physician, dentist, or mid-level practitioner.
a. Completed “Request for Privileges” application.
b. Current Curriculum Vitae
c. Signed release to obtain background information.
d. National Practitioner Data Bank Inquiry.
e. Validation of Education Degrees.
f. Current Ohio Medical License Certification.
g. Three letters of recommendation.
h. Copy of current DEA Registration.
i. Board Certification or Board Eligibility.
j. Documentation of hospital privileges.
k. State of health fitness for work.
l. Review of history of liability claims and adverse actions.
m. Photo ID
n. TB Test Results
o. CPR Certification
2. Re-credentialing of providers shall occur every two years and will include the following:
a. Review to assure current State of Ohio License is on file.
b. Review to assure current DEA Registration is on file.
c. Review that hospital privileges are current when appropriate.
d. Inquiry to National Practitioner Data Bank.
e. Documentation of Continuing Medical Education (CME) appropriate with licensure.
f. Review for current Board re-certification when appropriate.
g. Annual performance review completed jointly by the Medical or Dental Director and the Practitioner.
h. Review for annual statement of health fitness for work.
Allen County Health Partners441 E. 8th St.
Lima, OH 45804 / DATE: January 26, 2005
SUBJECT: Credentialing / Page 2 of 3
3. Original source verification of credentials including medical education, certification, and licensure shall be performed through the American Medical Association (AMA), the American Osteopathic Association (AOA), or the American Dental Association (ADA) with the requirements of the Joint Commission for Accreditation of the Health Care Organizations (JCAHO).
4. Per this policy, the ACHP Board shall delegate the responsibility of approving the appointment and subsequent renewal of privileges of each physician, dentist, or nurse practitioner providing patient care at ACHP to the CEO and Medical or Dental Director. In the case of privileging either the Medical or Dental Director the responsibility will be that of the ACHP CEO.
5. The credentialing process should be completed prior to the first day of employment. However, there are two circumstances for which temporary privileges would be acceptable.
a. To fulfill an important patient care need, as determined by the ACHP CEO.
b. When an applicant with a complete, clean application is awaiting review and approval of the medical or dental executive committee. The granting of temporary privileges is not to exceed 120 days.
The appropriate ACHP department director will be responsible for reviewing all credentialing information and must approve the credentialing of other LICENSED OR CERTIFIED HEALTH CARE PROFESSIONALS. Specific elements of the credentialing process must be on file with the appropriate department director and include:
1. Incoming nurse, medical assistant, dental hygienist, dental assistant, social worker, or other licensed or certified health care professional.
a. Current resume.
b. Current Ohio license or certification with Original Source Verification.
2. Re-credentialing of licensed or certified health care professionals shall occur every two years and include the following:
a. Review to assure current license or certification.
b. Review to assure appropriate Continuing Education Units (CEU’s) have been met.
c. Proof of current CPR certification when appropriate.
Allen County Health Partners441 E. 8th St.
Lima, OH 45804 / DATE: January 26, 2005
SUBJECT: Credentialing / Page 3 of 3
All such information will be maintained in the practitioner’s file held at ACHP, located at 441 E. 8th St., Lima, Ohio 45804.
This information cannot be released without written permission of the practitioner. ACHP CEO may gather the above information or contract with a reputable company specializing in obtaining credentialing information to satisfy the requirements of this procedure.
APPROVAL:
______
Janis Sunderhaus Date
CEO
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Gene Wright, MD Date
Board President