10.07.01.24

.24 Physician Credentialing Process.

A. General. In accordance with this regulation, a hospital shall have in effect a credentialing process.

B. Scope of Credentialing Process. The credentialing process shall apply to any physician who shall admit or treat patients in the hospital.

C. Specific Standard — Appointment and Employment Process.

(1) In accordance with this section, a hospital shall establish a formal written process for the appointment or employment of a physician by the hospital.

(2) The term of an appointment shall be 2 years or less.

(3) The formal written appointment or employment process shall provide for a probationary period that shall be successfully completed before the finalization of the appointment or employment of the physician.

(4) As part of the formal written appointment and employment process, the hospital shall collect, verify, review, and document the following information about the physician:

(a) The physician's education;

(b) The clinical expertise of the physician;

(c) The professional experience of the physician including:

(i) Any board certification or specialty training of the physician;

(ii) The internship of the physician; and

(iii) The residencies of the physician;

(d) Any license or registration to practice a health occupation ever held by the physician, including:

(i) A license to practice medicine; and

(ii) DEA registration;

(e) Whether any license or registration to practice a health occupation ever held by the physician has been:

(i) Suspended;

(ii) Revoked;

(iii) Voluntarily surrendered or not renewed;

(f) Concerning any hospital where the physician was appointed or employed:

(i) The name of the hospital;

(ii) The term of appointment or employment;

(iii) Privileges held and any disciplinary action taken on the privileges, including suspension, revocation, limitation, or voluntary surrender;

(g) Concerning the physician's professional liability insurance:

(i) The physician's present carrier;

(ii) The physician's current limits of coverage;

(iii) The physician's current types of coverage;

(iv) Restrictions on the physician's coverage; and

(v) Whether or not the physician has maintained continuous malpractice coverage since first obtaining professional insurance;

(h) Any claim that has been made against the physician in the practice of any health occupation and the status of the claim;

(i) The physician's medical history including the physician's current mental and physical health status;

(j) A complaint or report filed with:

(i) The Board of Physicians or any other state medical discipline agency;

(ii) A state medical society;

(iii) A state disciplinary body; or

(iv) A professional or specialty association.

(5) The formal written process shall provide for the documentation of any action taken by the hospital regarding the appointment or employment of the physician.

(6) Uniform Standard Credentialing Form.

(a) A hospital shall use the uniform standard credentialing form approved by the Department for the initial credentialing of a physician seeking appointment or employment.

(b) Use of the uniform standard credentialing form does not preclude a hospital from requiring additional information, attestations, or supplemental documentation as required by that hospital's credentialing process.

(c) A physician seeking hospital privileges shall submit an updated and complete uniform standard credentialing form at the time of application to each hospital.

D. Specific Standard—Granting of Delineated Clinical Privileges.

(1) In accordance with this section, a hospital shall establish a formal written process for the granting of delineated clinical privileges.

(2) The formal written process shall include:

(a) Criteria for determining whether a physician shall be granted privileges by the hospital to provide specific services;

(b) Criteria for ongoing evaluation of the performance of the services for which privileges have been granted;

(c) Procedures for altering, suspending, or revoking the delineated privileges.

(3) The formal written process shall provide for documentation of any actions taken regarding delineated privileges.

E. Specific Standard—Reappointment.

(1) In accordance with this section, a hospital shall establish a formal written process for the reappointment of a physician who has been appointed to the hospital.

(2) The term of reappointment shall be 2 years or less.

(3) As part of the formal written appointment process, a hospital shall collect, verify, review, and document the following information about the physician:

(a) An update of the information regarding appointment under §C of this regulation;

(b) Concerning the physician's pattern of performance based on an analysis of the following:

(i) Claims filed against the physician;

(ii) Utilization, quality and risk data;

(iii) A review of clinical skills;

(iv) Adherence to hospital bylaws, policies, and procedures;

(v) Compliance with continuing medical education requirements;

(vi) An assessment of current mental and physical health status;

(vii) Attitudes, cooperation, and the ability to work with others; and

(viii) The results of the Practitioner Performance Evaluation process as described in Health-General Article, §§19-3B-01—19-3B-09, Annotated Code of Maryland.

F. Specific Standard—Record Maintenance.

(1) In accordance with this section, a hospital shall maintain a separate credentialing file for each physician.

(2) The credentialing file for each physician shall contain documentation relating to the credentialing process required under this regulation.

G. Disaster Privileges.

(1) During an emergency or disaster in which the hospital's disaster or emergency management plan has been activated, when the Governor has declared that a state of emergency exists, or when the Secretary has issued an order pursuant to Health-General Article, §18-905, Annotated Code of Maryland, the chief executive officer, medical staff president, or designee may grant temporary disaster privileges to licensed physicians who have not been appointed to the hospital's medical staff.

(2) The hospital shall develop a medical staff plan for the granting of disaster privileges that identifies:

(a) The individual responsible for granting disaster privileges;

(b) The responsibilities of that individual;

(c) A system to manage, assign, and supervise the physicians who have been granted disaster privileges; and

(d) The process by which credentials and privileges are verified as soon as the situation allows, ensuring that the process complies with §C of this regulation.

(3) Physicians granted disaster privileges by a hospital shall:

(a) Be registered and trained by the Department as part of the Department's Maryland Physician Volunteer Corps and possess the Department issued photo identification; or

(b) Comply with the hospital's medical staff plan for granting privileges in a disaster, which shall require at least one of the following:

(i) Presentation of a current Maryland license to practice medicine and a valid identification picture (ID) issued by a state, federal, or regulatory agency;

(ii) Presentation of a license to practice medicine from another state if a state of emergency has been declared by the Governor and the assistance of the physician has been requested by Maryland pursuant to the Emergency Management Assistance Compact, Public Safety Article, §14-702, Annotated Code of Maryland;

(iii) Presentation of a current photo identification card from another Maryland hospital where the physician is a member of the medical staff; or

(iv) Verification by a current member of the hospital's medical staff who has personal knowledge regarding the practitioner's identity and current Maryland medical licensure.

(4) Disaster privileges shall be discontinued when the hospital's chief executive officer, medical staff president, or designee determines that the emergency condition no longer exists and that the hospital has adequate resources to meet the patient's needs.

(5) The hospital shall maintain records that include:

(a) The number of hours worked by each physician;

(b) The type of service provided by each physician;

(c) The location where these services were provided; and

(d) Any additional information required by the Department for federal and State reimbursement.

H. Telemedicine.Notwithstanding any other provision of COMAR 10.07.01.24, in its credentialing and privileging process for a physician who provides medical services to the patients at the hospital only through telemedicine from a distant-site hospital or distant-site telemedicine entity, a hospital may rely on the credentialing and privileging decisions made for the physician by the distant-site hospital or distant-site telemedicine entity as authorized under 42 C.F.R. Part 482, if:

(1) The physician who provides medical services through telemedicine holds a license to practice medicine in the State under Health Occupations Article, Title 14, Annotated Code of Maryland; and

(2) The credentialing and privileging decisions with respect to the physician who provides medical services through telemedicine are:

(a) Approved by the medical staff of the hospital; and

(b) Recommended by the medical staff of the hospital to the hospitalís governing body.

I. Request for Documentation by Department. On request from the Department, a hospital shall provide documentation that before:

(1) Appointment or employment of a physician or granting delineated privileges, the hospital has complied with the requirements of this regulation; and

(2) Reappointment or renewing of employment or specific privileges, the hospital has complied with the requirements of this regulation.

J. Penalties. If a hospital fails to have in effect a credentialing process in accordance with these regulations, the Secretary may impose upon the hospital the following penalties:

(1) Delicensure of the hospital; or

(2) A fine of $500 for each day that the hospital is in violation of these regulations.