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Medical Staff Credentialing & Privileging Audit
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Audit of the medical staff credentialing and privileging process covering primary source verification, privilege delineation, peer review, and ongoing professional practice evaluation.
CMS 42 CFR 482.12(a) / 482.22TJC Medical Staff (MS)NCQA Credentialing
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Application & Primary Source Verification
- Is a complete application obtained including education, training, licensure, and work history? *
- Is licensure, board certification, and training verified through primary sources? *
- Is the National Practitioner Data Bank (NPDB) queried at appointment and reappointment? *
- Are current DEA registration and malpractice history/coverage verified? *
Privilege Delineation
- Are clinical privileges granted specific to each practitioner based on documented competence? *
- Are criteria for privileges based on education, training, experience, and demonstrated competence? *
- Is the governing body responsible for the final appointment and privileging decision? *
Reappointment & Ongoing Evaluation
- Is reappointment/reprivileging conducted at least every 24 months? *
- Is Ongoing Professional Practice Evaluation (OPPE) data collected and reviewed continuously? *
- Is Focused Professional Practice Evaluation (FPPE) performed for new privileges and for-cause concerns? *
Peer Review & Corrective Action
- Is there a peer review process to evaluate the quality and appropriateness of practitioner care? *
- Are there fair hearing and appeal procedures for adverse privileging actions in the bylaws? *
- Are professional review actions reported to the NPDB and state board as required? *
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