Credentialing and Privileging

Credentialing and privileging are processes of formal recognition and attestation that a physician is both qualified

and competent. Credentialing verifies that a physician meets standards as determined by an organization by reviewing

such items as the individual’s license, experience, certification, education, training, malpractice and adverse clinical

occurrences, clinical judgment, and character by investigation and observation. Privileging defines a physician’s scope of

practice and the clinical services he or she may provide. Privileging is based on demonstrated competence and is a data

driven process.

Credentialing and privileging must be products of qualified and objective physician-controlled peer review, utilizing

criteria that have been established through common legal, professional and administrative practices, endorsed by a

formal consensus process, and that are publicly available. These criteria must be directly related to quality of patient care,

and documented physician performance should be measured against these criteria. Peer review decisions must be fair,

performed in good faith, not unreasonable, capricious or arbitrary, have dated detailed documentation, and be justifiable

and equally applied to all without bias. Peer review decisions should be confidential and protected . In cases of adverse

peer review decisions, avenues of appeals utilizing due process and the inclusion of fair hearings must be available to the

physician being credentialed.

Patient mix or referrals to outpatient clinics or physician specialists must never be a factor in the credentialing

process.

The percentage or number of negative or positive determinations of medical necessity by a physician reviewer

during the medical review process must never be used to evaluate a physician reviewer.
 
 
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