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Application Process (12/05)

When new applications or reappointment applications are received, all information on the application is reviewed to ensure:

  1. all necessary information has been provided, including complete address and telephone information.

  2. all questions are answered (explanations for any "Yes" answers are requested and documented).

  3. all necessary signatures have been obtained from applicant and are dated.

  4. all necessary signatures have been obtained on the application and privilege delineation form indicating that the department chair and chief have reviewed and approved.

  5. there is a current DEA with a Utah practice address license attached; (if applicable, i.e., pathologists and radiologists are not required to have one).

  6. there is a current license attached (verified on the Internet with the Division of Occupational Licensing.) This site is also checked for disciplinary actions, citations or pending actions against the provider. (Additionally, the Disciplinary Action Newsletter is reviewed).

  7. that a current copy of the practitioner's insurance malpractice face sheet is attached
    • Verification letters are sent to the insurance companies to verify malpractice coverage and documentation is requested if there are any malpractice claims - we go back ten (10) years on a new appointment and two (2) years on a reappointment. If there are claims, and the provider has not provided an explanation, he/she is contacted for an explanation.
    • Claims are reviewed by theRisk Manager.
  8. there is a current UH Pharmacy Signature form signed and dated attached.

  9. there is a current UH Hospital Consent form signed and dated attached.

  10. there is a current attached and provided. (Started collecting CME as of 10/05)

  11. there are no time gaps in the work history and education. (If there is a time gap, the practitioner will be contacted to provide an explanation.)

  12. Current health information has been obtained including documentation of current TB test or clear chest x-ray if positive. (We ask for MMR/Hep B.)

  13. Criminal Background Checks and Drug Testing are now required on all new applicants.
    • Community Clinic Providers - Contact Paulette Alford (587-6308)
    • Attending Physicians covered by U of U malpractice - Contact Faculty Office - Jennifer Allie (581-5705)
    • Courtesy Physicians not covered by U of U malpractice - Contact MSO - 587-6023.

  14. Verification of government issued photo ID (like a driver's license, etc.)

After the information on the application has been entered into the credentialing software CACTUS, primary source verification letters are sent out. Verifications include:

  1. verification of all affiliations from medical school forward on new applicants and two (2) years on reappointments.
  2. verification of all education from medica/professional degree forward .
  3. 3 (three) peer reference evaluations are requested on new applications and 2 (two) on reappointments.
  4. board certification is primary source verified:
    • On line with Certifacts
  5. The National Practitioner Data Bank NPDB) and Healthcare Integrity and Protection Data Bank (HIPDB) are queried on new applications and every two years on reappointments:
  6. The Federation of State Medical Boards (FSMB) is queried for any board actions on new applications and every two years on reappointments for physicians.
  7. The national sex offender registry is queried.
  8. The OIG & EPLS websites are checked for any exclusions and sanctions.
  9. Faculty Appointment is verified with the SoM Faculty Office.
  10. Malpractice coverage is verified
  11. If the provider will be providing moderate sedation, a note is sent advising that he/she needs to view the CD which is kept in the MSO office.

All applications must be completed within 180 days (NCQA requirement). The 180 day time period is from the date the application is signed to the date of the Credentials Committee approval. If the application is not completed within 180 days, an attestation must be obtained from the practitioner stating that everything in the original applications is still true and correct and verified information, i.e., malpractice, affiliations, peer reviews must be redone.

Additionally on Reappointments the following information is requested.

Ongoing professional practice profile

  1. Department Chairs & Division Chiefs are asked to review all information collected during the credentialing process.

The approval process requires review by a member of the Credentials Committee. Files are then approved by the Credentials Committe, Medical Board and Hospital Board Subcommittee. Per the Medical Staff bylaws, when necessary, an expedited process for Credentials Committee, Medical Board and Hospital Board approval may be employed.

last revised: 4/2010