Spectrum Health Credentials Verification Office (SHCVO ...€¦ · Other Certifications (ACLS, BLS,...

SHCVO Operating Manual | Last updated September, 2016 1

Spectrum Health Credentials Verification Office (SHCVO)

Operating Manual

Evidence OO11-3, Spectrum Health Credentials Verification Operating Manual, pgs. 6-24


Table of Contents Item Page Number Table of Contents ......................................................................................................................... 2

Definitions .................................................................................................................................... 4

Purpose and Scope ...................................................................................................................... 6

Background ............................................................................................................................... 6

Purpose .................................................................................................................................... 6

Scope ....................................................................................................................................... 6

SHCVO Structure and Contact Information .................................................................................. 9

Structure ................................................................................................................................... 9

Contact Information ................................................................................................................... 9

Initial Application Procedures ..................................................................................................... 10

Initial Application Request ....................................................................................................... 10

Online Initial Application Process – Applicant Responsibilities ................................................ 10

Application Fee ....................................................................................................................... 11

Review of Initial Application for Return and Completeness...................................................... 11

Initial Application Tracking....................................................................................................... 12

Credentials Verification Procedures ........................................................................................... 14

Verification Process Overview ................................................................................................. 14

Verification Procedures ........................................................................................................... 15

Processing Online Query Requests ........................................................................................ 15

Primary Source Verification Requests ..................................................................................... 16

Adverse Information Definition ................................................................................................ 17

Evaluation Procedures ............................................................................................................ 17

PMSO Initial Appointment Responsibilities .............................................................................. 17

Expirables .................................................................................................................................. 18

State License .......................................................................................................................... 18

Controlled Substance License (CSL) ...................................................................................... 19

Drug Enforcement Administration Registration (DEA) ............................................................. 19

Malpractice Insurance ............................................................................................................. 20

Board Certification .................................................................................................................. 21

Other Certifications (ACLS, BLS, PALS, NRP) ........................................................................ 21

National Practitioner Data Bank (NPDB) ................................................................................. 22

Health Information ................................................................................................................... 22



Recredentialing Procedures ....................................................................................................... 24

Reappointment Schedule ........................................................................................................ 24

Reappointment Process .......................................................................................................... 24

PMSO Reappointment Responsibilities ................................................................................... 26

Database Management .............................................................................................................. 27

Access to Electronic Files .......................................................................................................... 29

Hospital Affiliation Verification Requests .................................................................................... 30

References ................................................................................................................................. 31

Review and Revision of this Manual ........................................................................................... 32

Review Process ...................................................................................................................... 32

Revision Process .................................................................................................................... 32

Approval Process .................................................................................................................... 32

Approval History ...................................................................................................................... 32

Exhibit List .................................................................................................................................. 33

A: Overview Routine Processing of Applications ..................................................................... 33

B: Practitioner Application Request Form ................................................................................ 33

C: Sample Application ............................................................................................................. 33

D: Credentials Verification Methods and Requirements .......................................................... 33

E: Document Grid ................................................................................................................... 33

F: Sample Audit Summary Report ........................................................................................... 33

G: Morrisey Downtime Log ...................................................................................................... 33

H: Practitioner Demographic Update Form .............................................................................. 33

I: Joint Commission CVO Standards ...................................................................................... 33

J: Sample Practitioner Profile Report ...................................................................................... 33

K: Designated Equivalent Sources .......................................................................................... 33



Definitions Apogee Morrisey’s Apogee module automates and streamlines provider enrollment and management for managed care organizations, health plans, independent practice associations, physician health organizations and group practices. The Provider Support and Enrollment (PSES) Department will use Apogee for enrollment of employed and other providers for which Spectrum Health is responsible for billing professional services. Provider data entered in MSOW is shared with Apogee for the providers that are within the billing responsibility of the PSES Department. Application The term ‘application’ refers to the completed practitioner online form and any specific attachments required to contribute to a completed application. It does not include the documentation of verification information. See Exibit C. See “File” below.

Credentials Verification Organization (CVO) By broad definition, a CVO is any organization that provides information on an individual’s professional credentials. The Joint Commission provides ten principles that a Medical Staff Office can use to gain confidence in the information obtained by a CVO. See Exhibit I

Designated Equivalent Sources Selected agencies that have been determined to maintain a specific item(s) of credential(s) information that is identical to the information at the primary source. See Exhibit K

File The term ‘file’ refers to the completed application and all returned verification documents supporting the information in the application.

Focused Professional Practice Evaluation (FPPE) The time-limited evaluation of practitioner competence in performing a specific privilege. This process is implemented for all initially requested privileges and whenever a question arises regarding a practitioner’s ability to provide safe, high-quality patient care.

MSOW MSOW is the web-based credentialing database used for credentialing and privileging at Spectrum Health. Often called “Morrisey”, the name of the company, MSOW is one of many Morrisey applications used in healthcare administration.

National Committee for Quality Assurance (NCQA) The National Committee for Quality Assurance is a private, 501(c)(3) not-for-profit organization dedicated to improving health care quality. Since its founding in 1990, NCQA has been a central figure in driving improvement throughout the health care system, helping to elevate the issue of health care quality to the top of the national agenda.



NCQA’s Credentials Verification Organization (CVO) Certification Program evaluates credentials verification operations and the processes that the SHCVO uses to continuously improve the services it provides to its clients. CVO certification is available to organizations that conduct credentials verification, report the credentialing information to clients and have systems in place to protect the confidentiality and integrity of the information.

Participating Medical Staff Offices (PMSOs) This term refers to all Medical Staff Office (MSO) personnel and its organized medical staff that collectively represent an affiliated hospital facility who have committed to using the Spectrum Health CVO for the services outlined in this manual.

Privilege Criteria and Content Builder (PCCB) PCCB is the name of the privileging application that is integrated with MSOW.

Peer Recommendation Information submitted by a practitioner(s) with the same professional credential as the applicant reflecting the practitioner’s perception of the applicant’s clinical practice, ability to work as part of a team, and ethical behavior or the documented peer evaluation of practitioner-specific data collected from various sources for the purpose of evaluating current competence.

Practitioner Home Page (PHP) Practitioner home page is the online portal through which practitioners can access their online applications, request privileges, upload images, and view progress of their entire application process. The SHCVO will grant practitioners access to this page, as well as facilitate the issuance of passwords used for access.

Primary Source A primary source is the original source or an approved agent of the source of a specific credential that can verify the accuracy of a qualification reported by an individual practitioner. Examples include medical schools, nursing schools, graduate education, state medical boards, federal and state licensing boards, universities, colleges, and community colleges.

Primary Source Verification (PSV) Verification of an individual practitioner’s reported qualifications by the original source or an approved agent of that source. Methods for conducting primary source verification of credentials include direct correspondence, documented telephone verification, or secure electronic verification from the original qualification source, or reports from CVOs that meet the 10 Joint Commission requirements.

Static Credentials Credentials that once completed do not change over a practitioner’s career. Additional credentials in these areas may be added, but those already completed are considered static credentials. Examples include: evidence of medical school graduation, evidence of residency completion, past hospital verifications, past work history. Per NCQA requirements, an organization only needs to verify static credentials once and may provide this information to numerous clients.



Purpose and Scope

Background

Prior to July, 2011, each individual Spectrum Health Hospital credentialed its providers separately. This resulted in duplication of effort for the health care organization as well as the practitioners who had affiliations with more than one hospital in the system. The formation of the Spectrum Health Credentials Verification Office (SHCVO) provides a single point of service for application management, credentials verification, expirable confirmation, and database management and support.

Purpose

Spectrum Health has designed and implemented a comprehensive Credentials Verification Office (CVO) in order to:

Provide data and information to Participating Medical Staff Offices (PMSO) toassure that healthcare practitioners possess the credentials, including training andexperience, to provide patients the quality of care consistent with the mission ofSpectrum Health

Eliminate duplication of effort between multiple hospital facilities Promote efficiency and cost savings through single repository of primary source

verifications Promote consistency in credentials verification processes across the Spectrum

Health Delivery System Assure requirements of regulatory and licensing agencies are met

Scope

Facilities

All Spectrum Health Hospital facilities are eligible to participate with the SHCVO. Spectrum Health Grand Rapids (SHGR) Spectrum Health United (SHUH) Spectrum Health Kelsey (SHKEL) Spectrum Health Reed City (SHREED) Spectrum Health Gerber Memorial (SHGERBER) Spectrum Health Zeeland Community (SHZCH) Spectrum Health Continuing Care Special Care Hospital (SHCCSH) Spectrum Health Big Rapids (SHBR) Spectrum Health Ludington (SHLH) Spectrum Health Pennock (SHP)



Practitioner Types

The following licensed independent practitioners are eligible for inclusion: Physician (MD or DO) Dentist (DDS/DMD) Podiatrist (DPM)

The following Advanced Practice Professionals (APP) are eligible for inclusion: Anesthesia Assistant (AA) Certified Nurse Midwife (CNM) Certified Registered Nurse Anesthetist (CRNA) Clinical Nurse Specialists (when holding H&P or prescribing privileges) Doctor of Optometry (OD) Licensed Clinical Social Worker Licensed Professional Counselor (LPC) Nurse Practitioner (NP) Physician’s Assistant (PA) Psychologist

Credentialing Items

The following list is representative of the credentialing information that will be verified by the SHCVO:

Application with attestation Education Training Specialty certification References Work History Hospital Affiliations License to practice in the State of Michigan DEA CSL Professional liability insurance Professional liability claims settlement history Sanctions, restrictions or limitations in license or scope of practice Medicare or Medicaid sanctions

Database Access

All applicable staff of the Participating Medical Staff Office (PMSO) will be given access in MSOW to the providers linked to their specific facility. The PMSO staff will have access to Facility Specific fields including:

Peer Review Committees CME



Societies Leadership Collaborators Images User Defined Fields Facility Status and Department

No PMSO staff will have the ability to add practitioners to the database. No PMSO staff will have the ability to make changes at the SHCVO Facility level or at the Individual Practitioner Level. This data must be maintained by the SHCVO to ensure data integrity across all organizations.



SHCVO Structure and Contact Information

Structure

The Spectrum Health CVO structure is separate from the SHGR Medical Staff Structure. Specific roles such as the Database Specialist may have time dedicated to the SHCVO as well as the SHGR MSO.

Organizational Structure:

Contact Information

Email Address: [email protected]

Department Phone: 616.391.1609

Department Fax: 616.391.3115

Mailing Address: Credentials Verification Office, MC233 Spectrum Health Hospitals 100 Michigan Street NE Grand Rapids, MI 49503


mailto:[email protected]


Initial Application Procedures Initial Application Request

A practitioner can request an application via two methods: The applicant contacts the PMSO to request an initial application via phone or

email. The applicant completes an Application Request Form and submits to the PMSO

via email or fax. The PMSO personnel will advise the practitioner that they use the Spectrum Health Credentials Verification Office (SHCVO) for application management and verification functions. Processing of their application will be conducted through the SHCVO.

The PMSO personnel will interview the practitioner or representative by telephone to determine the practitioner specialty, necessary privileges, and whether the practitioner meets minimal criteria for initiating the application process for their facility. Only the PMSO has the authority to initiate the application process through the SHCVO. The PMSO personnel faxes or emails the Practitioner Application Request Form (Exhibit B) to the SHCVO with the applicable privilege request form. If the SHCVO receives an application request directly from a practitioner or their representative, the SHCVO will email the request to the applicable PMSO for authentication and approval to initiate the application process.

When the SHCVO receives the verified Application Request Form, the SHCVO Intake Coordinator will determine if the provider is already entered in MSOW. If so, they will link the provider to the new facility and assign the status of “Applicant”. If the provider is not in MSOW, they will enter the provider data into MSOW and assign a community physician ID number and link the provider to appropriate facilities. The SHCVO will initiate the application process in MSOW using the online integrated application process through a secure Practitioner Home Page (PHP).

Online Initial Application Process – Applicant Responsibilities

The SHCVO will initiate the application process by emailing the applicant a link to the Provider Home Page (PHP). A second email will contain the system-generated password needed to access the PHP.



The PHP site contains links to documents and important information to assist the provider with the credentialing process such as:

Instructions for testing computer compatibility with the online application Checklist of items required to complete the credentialing process Application form and other Mandatory Credentialing Documents Privilege delineation forms (as applicable and/or sent via separate email to the

practitioner) Instructions for mailing the application fee and uploading documents via the Transfer

Files tool Contact information for help with the application process The link Application Status which provides real-time information on status of the

application process

The applicant completes the online application, electronically signs all relevant pages using e-signature, and submits/attaches all additional documents via the PHP.

The applicant sends the application fee directly to the SHCVO.

The above phase of processing will be managed in conformance with the general processing overview described in Exhibit A of this manual which is imbedded into the SHCVO software’s process management.

Application Fee

A non-refundable application fee of $200.00 is due at the time of submission of the application.

Practitioners already credentialed by the SHCVO may apply to additional Spectrum Health Hospitals within 90 days of submitting their most recent initial application without incurring an additional application fee. If the practitioner’s most recent application is greater than 90 days old, but less than 120 days old, the SHCVO will contact the Medical Staff Office at the hospital where the practitioner is seeking membership and/or privileges to determine if the application and respective primary source verifications are acceptable as available in MSOW. If the SHCVO may pass the file without re-verifying any portions of the file, no additional fee will be required. If the practitioner’s most recent application is greater than 120 days old, the application fee will be $200.00.

A Spectrum Health Department may pay the fee on behalf of an applicant, but may not waive the fee.

Review of Initial Application for Return and Completeness

When an initial application is activated for an applicant via the Practitioner Home Page (PHP), the SHCVO Intake Coordinator will track submission of the application through MSOnet and follow-up on non-responses.



If any applications are submitted incomplete, the Intake Coordinator will inform the practitioner via email and reactivate the online application which will send it back to the applicant with notification of the missing items. Definition of a completed application:

The application form has all requested data elements addressed or marked as “N/A” and is electronically signed when the applicant ‘Submits’ the application. NOTE: A Curriculum Vitae WILL NOT be accepted in lieu of completely filling out the application form.

If an incomplete application is submitted and reactivated and submitted back to the applicant, the final submission date will be considered the date the application was submitted complete.

Any gaps in work history since medical school or within the last 10 years (whichever is shorter), of 90 days or more must be explained.

Evidence of current medical malpractice insurance coverage through submission of a

certificate of insurance. If medical malpractice insurance is pending, the applicant must provide the date the certificate will be provided to the SHCVO.

Payment of the non-refundable credentialing application fee. Additional documents required based upon privileges requested (e.g. ACLS

certificate, procedure logs, etc.).

Initial Application Tracking

Failure to Return an Application Applicants have 45 days to submit a completed application online; failure to do so will result in the application being deemed an “Expired Application”. Reminder emails are sent by the SHCVO to the practitioner on the 14th day, the 28th day and the 42nd day. If the applicant fails to submit a completed application within 45 days of the date the application was sent, the application request process will be considered an exhausted effort by the SHCVO. The SHCVO Intake Coordinator will notify the PMSO(s) on the 42nd day to determine the need to reactivate the application. If a completed application has not been submitted or reactivated after the 45th day, the SHCVO and all applicable facilities will be changed to “Inactive” and the status category will be changed to “Application Expired”.



Failure to Return a Complete Application When an incomplete application is received from a practitioner, they are informed via email to complete the application. The application is reactivated and the status is reset on the PHP web site. When an incomplete application is returned to an applicant, an appropriate notation is made in the comments field of the MSOW process to indicate what information is missing.

If the applicant fails to return a complete application within 14 days, the SHCVO Intake Coordinator will send an additional email reminder to the applicant with an appropriate notation in the comments field.

If no application is returned within a total of 45 days, the element will be considered an exhausted effort. The SHCVO intake coordinator will review the incomplete application and assess reactivation with the relevant PMSO(s).

Complete Application Received When a complete application is received from the practitioner, the data is verified and imported by SHCVO Intake Coordinator within three (3) working days of application being submitted via the PHP web site.

Once data entry of the application is complete, the SHCVO Intake Coordinator will scan any relevant documentation into the database as detailed in the next section entitled Credentials Verification Procedures.



Credentials Verification Procedures Verification Process Overview

The SHCVO utilizes Morrisey’s MSOW software (credentialing database) to automate tracking of work-in-process and make available the most recent/current items delivered to each PMSO on a given practitioner. Past electronic documents are archived in the database based on archiving rules defined in the Document Grid (Exhibit E). The SHCVO is responsible for verifying all credentialing items outlined in the Purpose and Scope and the Credentials Verification Methods and Requirements (Exhibit D) of this manual. The work product returned from the verification process (application, letters, references, web-based verifications, etc.) is data entered and/or scanned into the database. The work-in-process (requests for information, phone calls, data collection steps, etc.) will be noted in the system PROCESS/JOB/TASK utilizing comments, dates and notes sections as necessary to communicate the status of the credentials verification process to customers. Documents or images are scanned or saved into the database under the proper document category key. This is very important for paperless file review and approval. A specific Document Grid (Exhibit E) identifies all document names and types. Documents include, but are not limited to:

Application forms Privilege forms State license and controlled substance license DEA Medical malpractice insurance face sheet Exclusion reports NPDB query results Hospital affiliation letters Education and training verification letters Board certification AMA or AOA profiles (when applicable) Professional references (peer and authoritative) Results of background checks Other information that may have a bearing on competency is scanned into the

appropriate document name



A PMSO has the ability to scan facility specific information into the database. Data and images can be entered at the facility level (via blue buttons) or directly into Images using a facility assignment to limit access by other PMSOs.

Key practitioner correspondence (i.e., critical correspondence with healthcare practitioners that medical staff leadership would consider in evaluating competency or any correspondence to the practitioner sent via certified mail) will be scanned into MSOW as “Correspondence” or “Note to MS Leadership – HOSPITAL NAME” with a notation referencing the person or issue in the Comment section.

Verification Procedures

Authority The SHCVO acts as the agent of the PMSO to provide services as outlined in this manual. Additionally, the SHCVO may have an agency relationship with a subcontractor to provide a portion of these services.

The SHCVO performs selected verifications in accordance with Credentials Verification Methods and Requirements (Exhibit D).

Source Items to be verified, sources to be utilized, and methods of verification are specified in Exhibit D.

Primary source verification of all data elements will be attempted a minimum of three times on a set schedule. As each query is initiated, SHCVO staff members will data enter the date the query was performed (or if web crawl was utilized the software will auto update).

Primary source information may be requested from any of the “Designated Equivalent Sources” identified in Exhibit K.

Processing Online Query Requests

Upon data entry of the completed application, online primary source verifications (e.g. web crawls or internet grabbers) are initiated. Images are attached to each record either automatically or via scanning. As each query is completed, the SHCVO staff verifies the legitimacy of each item, notes any specific circumstances or concerns and ensures that the credentialing checklist in the database is updated through the use of the MSOW processes.

When all required items are received or SHCVO efforts to obtain required items are exhausted, the file will be forwarded to the PMSO(s) for review.



Primary Source Verification Requests

Initial Request The first request for primary source verification is sent within 0-3 business days of a completed application being assigned to a verification coordinator.

Second Request If no response is received within 14 days of the initial request, the SHCVO staff initiates a follow-up request.

Third Request If no response is received within 21 days of the first request, the SHCVO Verification Coordinator attempts to reach the verifying organization by telephone or other means. The applicant and their credentialing contact (if applicable) are notified by sending a missing items report so that they can assist in facilitating a response.

Final Request If no response is received within 28 days of the first request, the SHCVO Verification Coordinator sends the final request for information. The applicant and their credentialing contact (if applicable) are notified by sending a missing items report so that they can assist in facilitating a response.

Exhausted Effort If no response is received within 45 days of the date of the initial request, the applicant and their credentialing contact (if applicable) is informed that the SHCVO has exhausted its effort to obtain the item, and it is now the applicant’s responsibility to facilitate a response by the reference source.

The SHCVO verification coordinator consults the CVO Manager and/or relevant medical staff office when contemplating exhausted effort. Expiration of an application will be considered when the application reaches 120 days. Application will be expired when it reaches 180 days without any medical staff or PMSO action. Data Entry Responses to queries received will be reviewed and data entered by SHCVO Verification Coordinator within three (3) working days of receipt. Management will periodically monitor the inbound email inbox to assure there are no items present exceeding the three (3) day standard indicating a data entry backlog is evolving. Approximately 90% of documents are received electronically (via email or Right Fax) and saved electronically in the Morrisey system. The remaining 10% of documents are received in hard copy form, are scanned into the system, reviewed by a Coordinator to ensure scanned copy quality and then shredded.



Adverse Information Definition

The verification coordinator will note the presence of potentially adverse information in MSOW in the Comments tab which will populate on the profile report, and select the appropriate yellow/red flag in the Last Verification tab, as well as provide explanatory information in the comments section of that tab. Examples of adverse information include, but are not limited to:

Non-response to query Incomplete response to query Rating of “Below Average” on reference forms Variance between information verified and what was represented on the application Unexplained gap of greater than 90 days Insufficient information Excessive malpractice claims NPDB reports Licensure complaints or sanctions Criminal history on a background check

Evaluation Procedures

Each SHCVO verification coordinator is responsible for assuring file accuracy and completeness in accordance with the standards established. When the review is complete, the verification coordinator notifies the PMSO, the CVO manager and evaluation coordinator that the file is ready for review. The SHCVO manager or evaluation coordinator reviews a minimum of 10% of all initial applications to assure compliance with service standards established in this manual. The evaluation coordinator may initiate additional follow-up on any file item not pursued in accordance with specified procedures.

PMSO Initial Appointment Responsibilities

Upon receipt of email notification from the SHCVO that verifications are complete and ready for review, the PMSO will review all file documentation in MSOW and prepare the file for medical staff review and board approval.

If temporary privileges are granted, the PMSO is responsible for updating facility specific dates, status, category, department assignment, and privileging codes (HBOC) in MSOW. The PMSO is also responsible for scanning images of the temporary privileges documentation into MSOW.

The PMSO is responsible for providing a list of all board credentialing decisions to the SHCVO within one week of the board decision.



The PMSO is responsible for providing written notification to the practitioner affected by a board decision within ten (10) days of the board’s decision. The PMSO is responsible for updating facility specific dates, status, category, department assignment, privileging codes (HBOC), and provider orientation documentation in MSOW. The PMSO is responsible for scanning images of board letters for initial appointment, along with signed/approved privileges into MSOW. The PMSO is responsible for instituting an FPPE plan for all practitioners during their first initial appointment cycle per their bylaws.

Expirables The practitioner is responsible for remaining current on licensure, DEA certification, malpractice insurance coverage, board/specialty certification and life-saving certifications (ACLS, BLS, etc.), as applicable. The SHCVO is responsible for initiating the process to obtain updated credentials information through PSV and the practitioner. The SHCVO will inform the PMSO(s) of the impending expiration at specific intervals depending on the credential. The SHCVO will notify the PMSO when administrative suspension should be considered for a practitioner whose Michigan license to practice is expired, and there is no documentation from the State that the practitioner falls under a grace period because the renewal is in process. Additionally, if a practitioner fails to provide documentation of professional liability insurance, the SHCVO will notify the PMSO and director level management that an administrative suspension should be implemented. For all other expiring credentials (DEA, CSL, board certification, ACLS/BLS/ATLS/PALS/NRP), each PMSO is responsible for taking action (i.e., revoking privileges due to expired documents) in accordance with organization-specific standards, state statutes, and accreditation requirements. State License

Source Michigan State Medical License is verified via the Michigan Department of Licensing and Regulatory Affairs (LARA) web site.

Method Online web crawl.

Process MSOW is set to automatically run a web crawl to capture current license status 34 days prior to expiration. If the license is expired, email notification is sent to the practitioner. Another web crawl will run at 15 and 8 days prior to expiration. At 7 days prior to expiration, email notification will be sent to the practitioner and a task will post to the work queue for SHCVO Expirables Coordinator. One day prior to expiration, MSOW will automatically run the web crawl and post a task to the work queue for the SHCVO Expirables Coordinator. If the license is not renewed by the expiration date, the Expirables Coordinator will inform the PMSO that administrative



suspension is to be implemented on the day after expiration and steps should be taken to facilitate continuity of care for any of the practitioner’s hospitalized patients

On the day after expiration, the SHCVO Expirables Coordinator will run a web crawl and if the license remains expired, an administrative suspension letter will be sent to the practitioner via email, fax and certified mail. The SHCVO will change the practitioner’s category and HBOC codes in MSOW to reflect the administrative suspension which will suspend the practitioner’s access to computer applications across the System. The administrative suspension will be lifted once documentation of a current license is obtained or there is indication from the State that renewal is in process and a grace period enables the practitioner to continue practicing under that license. If the practitioner fails to respond within 30 days of delivery of the certified letter, the SHCVO will consider the lack of response as a request for voluntary resignation and forward the matter to the PMSO(s) for further action by the Hospital Board. The PMSO will inform SHCVO of any decisions made by Board regarding provider status changes and dates.

Controlled Substance License (CSL)

Source Michigan State Controlled Substance License (CSL) is verified via the Michigan Department of Licensing and Regulatory Affairs (LARA) web site.


Process MSOW is set to automatically run a web crawl to capture current license status 34 days prior to expiration. If the license is expired, email notification is sent to the practitioner. Another web crawl will run at 15 and 8 days prior to expiration. At 7 days prior to expiration, email notification will be sent to the practitioner and a task will post to the work queue for the SHCVO Expirables Coordinator. On the date prior to expiration, MSOW will automatically run the web crawl and post a task to the work queue for the SHCVO Expirables Coordinator. If the license is not renewed by the expiration date, the Expirables Coordinator will notify the practitioner and all PMSO(s) where the practitioner has privileges.

The PMSO will follow their procedures for sending certified letters and communications, suspensions processes and committee support of those actions per their own Medical Staff Bylaws. The PMSO will inform SHCVO of any decisions made by Board regarding provider status changes and dates (e.g. voluntary resignations, suspensions).

Drug Enforcement Administration Registration (DEA)

Source DEA registration is verified via the National Technical Information Service (NTIS) web site.




Process MSOW is set to automatically run a web crawl to capture DEA status 30 days prior to the DEA expiration date. If the license is expired, email notification is sent to the practitioner. At 8 days prior to expiration, MSOW will run a web crawl to capture DEA status. If expired, email notification is sent to the practitioner and a task posts to the work queue of the SHCVO Expirables Coordinator who will attempt any available method to contact the provider to obtain verification of a current, effective DEA registration. If the DEA remains expired on the expiration date, the SHCVO Expirables Coordinator will notify the practitioner, the PMSO and CVO manager by email that the DEA registration is expired and prescribing privileges cannot be exercised until the DEA is renewed. The PMSO will then follow their own procedures for sending certified letters and communications, suspension processes and committee support of those actions per their own Medical Staff Bylaws. The PMSO will inform SHCVO of any decisions made by Board regarding practitioner status changes and dates (e.g. voluntary resignations, suspensions). Malpractice Insurance

Source Copy of the certificate of insurance (facesheet).

Method US Mail, email, interoffice mail, fax, or hand delivery.

Process 30 days prior to the expiration date of current malpractice insurance coverage, MSOW will send an automatic email to the provider with notification that malpractice insurance coverage is due to expire. Practitioner responses will be recorded (data entered and scanned) in the database to ensure removal from future delinquency reports. If insurance coverage remains expired at 14 days prior to the expiration date, MSOW will send a second email request to the practitioner. One week prior to the expiration date, the SHCVO Expirables Coordinator will contact the provider’s office to request coverage verification. If no documentation is provided by the expiration date, the SHCVO Expirables Coordinator will notify the PMSO and director level management that an administrative suspension should be implemented. The SHCVO, upon direction from the PMSO, or the PMSO will change the practitioner’s category and HBOC codes in MSOW to reflect the administrative suspension and notify the practitioner via email, fax and certified mail. The administrative suspension may be lifted once documentation of current malpractice insurance is provided. If the practitioner fails to respond within 30 days of delivery of the certified letter, the SHCVO/PMSO will consider the lack of response as a request for voluntary resignation and forward the matter to the PMSO for further action by the hospital board. The PMSO will inform SHCVO of any decisions made by board regarding provider status changes and dates.



Board Certification

Source Web site for the applicable board (e.g. ABMS, AOA, NCCPA, AANA, NCCAA).

Method Online web crawl, internet grabber, or copy of certificate

Process Thirty (30) days prior to expiration of board certification, MSOW will automatically run a web crawl or post a work list item depending on the procedure for the applicable board. If the web site shows an expired status, MSOW will send email notification to the practitioner. At 14 days prior to expiration MSOW will run a web crawl or post a work queue item and again at 5 days if the certification remains expired. For boards incompatible with the MSOW web crawl feature (PA, NP, CNM), the SHCVO Expirables Coordinator will conduct manual follow-up in resonse to the work queue tasks..

One the day of expiration, MSOW will run an automatic web crawl and if the applicable web site does not reflect renewal of the certification, the SHCVO will contact the practitioner to obtain the status of recertification, document the response in the blue Specialties tab of MSOW and notify the PMSO. If the practitioner has indicated that requirements for certification have been met, and the online information available from the respective board has not yet been updated, the SHCVO expirables coordinator will set a follow-up date for 30 days. Upon receipt of updated information on board certification, the SHCVO expirables coordinator will perform primary source verification and/or scan the information into the database, update the relevant database field and notify the PMSO.

The PMSO will follow their own procedures for sending certified letters and communications, suspension processes and committee support of those actions per their own Medical Staff Bylaws. The PMSO will inform SHCVO of any decisions made by Board regarding provider status changes and dates (e.g. voluntary resignations, suspensions).

Other Certifications (ACLS, BLS, PALS, NRP)

60 days prior to expiration of other certifications (ACLS, BLS, PALS, NRP) MSOW will automatically send an email to the provider notifying of the upcoming expiration date.

At 30 days prior to expiration, MSOW will automatically send a 2nd notice of the upcoming expiration.

When the SHCVO receives updated certificates from a practitioner or a PMSO, staff will scan the information into the database and update the relevant database fields.

On the day of expiration, MSOW will post a task to the work queue of the SHCVO Expirables Coordinator who will inform the PMSO(s) of the expired credentials. The PMSO will then follow



their own procedures for sending certified letters and communications, suspensions processes and committee support of those actions per their own Medical Staff Bylaws.

National Practitioner Data Bank (NPDB)

The SHCVO is registered with the NPDB as an Authorized Agent and may query and receive NPDB reports on behalf of its participating hospitals when designated. The PMSO must complete an online Authorized Agent Designation through the NPDB website to indicate that they wish the SHCVO to query, receive and review query responses on their behalf. Through this designation, the PMSO will also designate who will be notified by the NPDB when new reports are filed against a practitioner. As part of its Authorized Agent responsibilities, the SHCVO maintains facilities that are sufficiently secure to ensure the confidentiality of NPDB query responses, has a copy of the most recent NPDB Guidebook, and is aware of the sanctions that can be taken against it if it fails to maintain confidentiality of such data. The SHCVO is explicitly prohibited from using the information obtained from NPDB for any purposes other than that for which the disclosure is made. As Authorized Agent, the SHCVO will enroll, renew and dis-enroll providers in NPDB Continuous Query (CQ) based upon the status of the PMSO’s practitioners in the credentialing database. It is the responsibility of the PMSO to maintain practitioner status in the facility screen of the credentialing database and to promptly notify the SHCVO of practitioner resignations. The SHCVO will query, download and review reports on behalf of the PMSO at initial, re-credentialing and at other times as required. An image of the report will be maintained in the electronic credentials file. Any adverse/derogatory information will be flagged in accordance with SHCVO guidelines. Additionally, the NPDB will provide notification to authorized representatives of the PMSO and SHCVO when a new report is filed on a practitioner enrolled in Continuous Query. The PMSO is responsible for reviewing and analyzing all data, flagged or presented in the NPDB report. The fees charged by the NPDB to maintain CQ enrollment are the responsibility of the PMSO. The PMSO will enter on the NPDB site and provide to the SHCVO, current and valid credit card account information for the payment of any NPDB fees. Any issues with the hospital’s NPDB registration status or credit card information will be promptly addressed by the PMSO.

Health Information TB Screening Unless otherwise provided, TB screening is required on an annual basis and is tracked by the SHCVO according to the practitioner’s most recent screening date. The expiration date will be set to the last day of the month, 12 months after the previous screening. MSOW automatically emails the practitioner at 30, 15 and 5 days prior to the expiration date. On the expiration date, MSOW will post a task to the work list of the SHCVO Expirables Coordinator and email the PMSO.



Influenza Vaccine Unless otherwise provided, influenza vaccination is required on an annual basis and compliance is tracked by the SHCVO from October-December for existing practitioners and from October-April for new applicants. Practitioners attest to the date of their most recent flu vaccine by completing the Influenza Verification form or submitting documentation from the health care provider who administered the vaccine. Practitioners receiving the vaccine through Spectrum Health are tracked by Occupational Health and reported to the SHCVO as compliant, with documentation of vaccine administration being maintained in the Occupational Health Department. The SHCVO will follow-up with non-compliant practitioners beginning December 1, and provide a delinquency list to each PMSO by December 31 for further review and follow-up by the individual PMSO.



Recredentialing Procedures

Reappointment Schedule

During the transition process of integrating healthcare practitioners into the database, some schedule adjustment may be necessary to place healthcare practitioners on a single reappointment schedule for all hospitals. The Healthcare practitioners will be scheduled for reappointment every 24 months or less. The SHCVO will manage all reappointment dates as follows:

• For practitioners with no existing affiliation with a Spectrum Health Hospital, the SHCVO will set the next reappointment date as the last day of an odd month within 24 months from the initial date on staff.

• For practitioners with an existing affiliation with a Spectrum Health Hospital, the SHCVO will set the next reappointment date to match the previously established reappointment date, unless that date falls within six months of initial date on staff.

The SHCVO will utilize the official reappointment date to initiate the reappointment process. The PMSO is responsible for ensuring the file is taken to the respective hospital board of directors on or before the reappointment date.

Reappointment Process

Preparation The SHCVO credentialing coordinator will run a report of practitioners due for recredentialing and email the report to the PMSO during the even months. This report will identify all of the practitioners for which the SHCVO intends to send a reappointment packet in the upcoming month. The PMSO is responsible for reviewing the list to identify any practitioners that should not be sent a reappointment application, including those where a resignation is pending. The approved list, along with current privilege forms for the practitioners scheduled for reappointment, should be returned to the SHCVO within the timeframe requested.



Application Management

The SHCVO verification coordinators will launch the reappointment process through MSOW which will post the online application packet along with any applicable privilege forms to the PHP website for completion by the practitioner. Tracking return of the completed reappointment application will follow the process outlined under the Initial Application Tracking section.

The reappointment packet includes:

A pre-populated reappointment application Reappointment Consent and Release Privilege forms (as applicable)

Late Reappointment Applications

All completed applications must be submitted to the SHCVO within 45 days. Reappointment applications not received within 45 days are unlikely to be processed by both the SHCVO and the PMSO in time to prevent the reappointment from lapsing. It is up to the PMSO to decide how it will proceed when a practitioner submits a late application (i.e. terminate privileges/participation at the end of the reappointment term and process the individual as a new initial applicant).

If a practitioner does not return their reappointment application within the 45-day time frame, the SHCVO will not expedite processing of these files to meet required deadlines as this would divert attention away from files returned in a timely manner. All files will be processed in accordance with the procedures set forth in this manual regardless of when the applications are received.

Verification

SHCVO will initiate verification of the information provided by practitioner, including current hospital affiliations, following the process outlined in the Credentials Verification Methods and Requirements (Exhibit D).

The PMSO is responsible for obtaining competency data for practitioner reappointment based on privileging criteria, policies and bylaws.

Evaluation

Each SHCVO verification coordinator is responsible for assuring file accuracy and completeness by examining each item for potentially adverse information. Potentially adverse information is defined as any information with potential of having adverse bearing on the evaluation of the practitioner.

When the review is complete, the verification coordinator notifies the PMSO, the CVO manager and evaluation coordinator that the file is ready for review. The SHCVO manager or evaluation coordinator reviews a minimum of 10% of all recredentialing applications to assure compliance



with service standards established in this manual. The evaluation coordinator may initiate additional follow-up on any file item not pursued in accordance with specified procedures.

PMSO Reappointment Responsibilities

Upon receipt of notification from the SHCVO that verifications are complete and ready for review, the PMSO will review all file documentation in MSOW and prepare the file for medical staff review and board approval in a timeframe that is consistent with the established System reappointment date.

The PMSO is responsible to provide a list of all board credentialing decisions to the SHCVO within one week of the board decision.

The PMSO is responsible for updating facility specific dates, status, category, department assignment, and privileging codes (HBOC) in MSOW.

The PMSO is responsible for scanning images of board letters for reappointment, resignation, and change of status or privileges, along with signed/approved privileges into MSOW.



Database Management

Functional Capabilities The Morrisey database software is used to manage practitioner credentialing information and processes for both the SHCVO and all PMSOs. Additional descriptions of the functional capabilities and use of the database are located in the software vendor’s product manual kept at the SHCVO office.

Backup The contents of the database are to be backed-up nightly by TIS per Spectrum Health policy.

Data Dictionary, Auditing and Updating Practitioner Demographic Data, HL7 Under construction

Quality Control/Data Integrity Audit reports are run weekly to identify missing or incorrect information. See the SHCVO Quality Improvement Plan document for further information.

Downtime Procedures There may be numerous areas, systems or departments located at each hospital that utilize some aspect of the information housed in the database or provided to another database through an interface to support specific business requirements. It is the responsibility of each PMSO to develop downtime procedures for continuation of their own internal departmental operations.

Unplanned Downtime When an unplanned downtime occurs, users should contact the SHCVO application support staff (Technical Analyst) as soon as possible to report the problem. The Technical Analyst will investigate the problem and triage information to all PMSOs.

If the problem is software related. The SHCVO Technical Analyst will work with the

software vendor or utilize internal staff to resolve the problem. If the down time is due to hardware issues SHCVO will contact the appropriate individuals in the Spectrum Health TIS department to remedy the matter.

Planned Downtime

For any planned downtime the SHCVO will run and distribute a list of all practitioners and their status at each facility for reference by team members. If the application downtime is expected to last from 2-8 hours during normal business hours, the SHCVO will proactively print work lists and continue to perform application management and verification functions using phone/fax/Internet technology outside of the software to advance as many items as possible.



If downtime is anticipated to last between 1-3 days, the SHCVO will proactively print work lists and continue to perform application management and verification functions using phone/fax/Internet technology outside of the software to advance as many items as possible. All work products (i.e. applications, verifications, query results) will be scanned into network drives and made available to the PMSOs until they are able to access information through the Morrisey database.

All work products completed by the SHCVO during the downtime period will be scanned and data entered into the database when service is restored.

Tracking Downtime Frequency and DurationDowntime frequency and duration will be tracked via a manual log maintained at theSHCVO. As each episode occurs the application support staff member willcompletely document the parameters of the episode using all areas of the log. Theapplication support staff member will summarize monthly downtime statisticscollected from each site and forward results to the SHCVO manager on a quarterlybasis.

Review of cumulative downtime statistics, formulation and implementation ofcorrective action plans will be conducted by the SHCVO manager and applicationsupport staff member. Unresolved downtime patterns that occur with suchfrequency or duration as to critically disrupt operations at the SHCVO or a PMSOwill be forwarded to the SHCVO leadership team.



Access to Electronic Files SHCVO and PMSO staff needing complete access to the database will be assigned access codes to maintain appropriate security and confidentiality. PMSOs or other administrative departments will have access only to healthcare practitioners in their assignment and only to fields permitted via their user access code. The SHCVO manager is responsible for assuring computer database access to each staff member and PMSO is in accordance with the levels of assigned security to perform their necessary credentials file management responsibilities. Healthcare practitioners have no physical access to the credentials file, but may obtain copies of the application and other documents they provided upon payment of the established fee. Representatives of accrediting bodies may review practitioner files with the assistance of a PMSO or SHCVO staff member. The PMSO, or parties who have delegated credentialing agreements with the PMSO, may review the credentials files pertaining to that PMSOs practitioner roster. Security of electronic work products delivered to PMSOs that do not utilize the shared database are the responsibility of the PMSO, once delivery is complete. Requests for ad hoc reports from departments outside of the SHCVO are submitted for review by the SHCVO manager for response on a case by case basis.



Hospital Affiliation Verification Requests It is customary for hospitals to receive requests for verification of a healthcare practitioner’s current or previous affiliation with the individual facility. The SHCVO offers a portal through MSOW for response to such inquiries via the Spectrum Health Website (http://www.spectrumhealth.org/verificationhospitals).

Online responses are available for only those healthcare practitioners designated as being “in good standing”. The SHCVO does not track whether a practitioner can be characterized as “in good standing” at each PMSO. Thus, it is the responsibility of each PMSO to appropriately identify and exclude healthcare practitioners who would not qualify for the standard response by checking the Response Letter Alert button in the facility screen of MSOW.

If the SHCVO or the hospital receives a letter or fax inquiry from an organization requesting hospital affiliation, they will direct the organization to the website. The following data elements are maintained in the credentialing database to provide the standard response to queries received via the webpage:

Practitioner Name Practitioner Birth Date To/From Dates of Affiliation Specialty/Department

When the organization making the inquiry enters the requested information (Practitioner Name and Birthdate) the software will produce a pre-populated verification letter containing the above referenced information along with the appropriate “in good standing” statement. Any healthcare practitioners who do not meet criteria for the routine response will be identified by the PMSO in the software making them unavailable for routine query and the inquiring organization will be notified the practitioner’s record could not be located with instructions to call the PMSO.



References 1. National Committee for Quality Assurance (NCQA) website

(http://www.ncqa.org/AboutNCQA.aspx), August 1, 2014.

2. The Joint Commission Comprehensive Accreditation Manual for Hospitals, July 2, 2014.



Review and Revision of this Manual Review Process

This manual will be reviewed every two years with input from the PMSOs. Recommendations for revision will be collected and reviewed by the SHCVO leadership team. Revision Process

Spectrum Health provides services to independently licensed facilities and/or affiliates (also collectively referred to as PMSOs). This manual will be reviewed every two years and revised, as necessary, on the recommendation of the SHCVO Manager with input from the PMSOs. PMSOs are responsible for assuring their internal documents (i.e., Medical Staff Bylaws and policies and procedures) complement this manual. The SHCVO Manager is responsible for day-to-day operations and compliance monitoring. The Manager works collaboratively with PMSOs to maintain procedures meeting the needs of both the PMSOs and the health system. Modifications to this manual are forwarded to the Director of Medical Staff Services, Spectrum Health for approval. Approval Process

Signed copy on file in CVO Office Signed copy on file in CVO Office CVO Manager Director, Medical Staff Services Date: 9/20/16 Date: 9/20/16 Approval History

CVO User Group Approval: 9/20/16; 9/16/14 CVO Manager Approval: 9/20/16; 9/16/14 MSS Director Approval: 9/20/16; 9/16/14; 7/1/2011; 11/9/2011;



Exhibit List A: Overview Routine Processing of Applications

B: Practitioner Application Request Form

C: Sample Application

D: Credentials Verification Methods and Requirements

E: Document Grid

F: Sample Audit Summary Report

G: Morrisey Downtime Log

H: Practitioner Demographic Update Form

I: Joint Commission CVO Standards

J: Sample Practitioner Profile Report

K: Designated Equivalent Sources


Applicant (or representative) contacts MSO to request an Application

MSO Coordinator submits completed Application Request Form, Applicant’s CV and

Privilege Request Form(s) to CVO via email

CVO Coordinator launches application via MSOnet and

notifies applicant and credentialing contact via email

Is application returned

complete?

CVO Coordinator completes application data entry

YES

3 email reminders sent until

info received or exhausted

effort (expired app)

NO

CVO Coordinator sends all verification request letters including:

medical education, internship, residency, fellowship,

hospital verifications (last 10 yrs), claims history (last 10 yrs),

background check, professional references

CVO Coordinator runs all on-line verifications including: professional license, board

certifications, dea, controlled substance, NPDB, OIG/GSA, etc.

Reminders sent until info

received or exhausted effort

(incomplete app)

Verifications returned

complete?

YES

NO

CVO Coordinator reviews all information for red or yellow flags and to

ensure file is complete and notifies MSO that file is ready for their review

MSO Coordinator reviews all red/yellow flag information and determines if

additional information is needed such as interviews, calls to references,

clarifications from candidate, etc.

MSO Coordinator compiles all information necessary to support competency

determination for the privileges requested such as clinical logs, CME information, etc.

MSO Coordinator compiles all of the information and coordinates with Division and

Departmental leadership for file review and sign off

Credentials

Committee

MEC

ApprovalBoard Approval Practitioner Boarded

MSO Coordinator prepares file for Credentials Committee agenda

to ensure that CC members can review entire file before meeting

Overview Routine Processing of Applications (Exhibit A)

Min 21

days

Avg 30

days

Max 90

days

Min 21

days

Avg 30

days

Max 90

days

Forw

ard

privile

ge info

to M

SO

CVO Form 6/20/14


CVO form revised: 1/10/2017 Page 1

REQUEST FOR APPLICATION FOR MEDICAL STAFF MEMBERSHIP/PRIVILEGES

Applicant Name / Degree: Date of Request:

Alias Name:

Anticipated start date for the hospitals checked below: The credentialing process typically takes 45-90 days

Check all Spectrum Health Hospital(s) to which you are applying:

Big Rapids Hospital Pennock Hospital

Gerber Memorial Hospital Reed City Hospital Grand Rapids (Blodgett, Butterworth & Helen DeVos Children’s Hospitals) Special Care Hospital

Kelsey Hospital United Hospital

Ludington Hospital Zeeland Community Hospital

Contact information: Applicant’s Personal Information

(all fields are required) Office Credentialing Contact

(if applicable)

Address Name

Address Phone

Cell Phone Phone

Email Fax

DOB Email

Pre-application questions:

Yes No

Is the applicant excluded from participating in any Federal or State program or otherwise prohibited from providing services under a government payment program?

Does the applicant have an unrestricted Michigan state medical license?

If NO, provide date of licensing application:

Has the applicant practiced and/or been in training for at least three (3) out of the last five (5) years?

Is the provider board certified?

If NO, provide expected date of board exam:

Specialty and subspecialty:

Do you require robotics, sedation, laser or any other special privileges?

Describe any special procedures you perform or privileges required:

Advanced Practice Professionals (APP) provide name of supervising/collaborating physician(s):


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Practitioner Application Request Form (Exhibit B)

CVO form revised: 1/10/2017 Page 2

Intent to practice:

Identify the hospital where the majority of your patients will be admitted or seen by you:

Spectrum Health Non-Spectrum Health

Big Rapids Borgess

Blodgett/Butterworth/Meijer Heart Center Bronson

Gerber Memorial Hospital Holland Hospital

Helen DeVos Children’s Hospital Mercy Health Muskegon

Kelsey Hospital Metro Health

Ludington Hospital Mercy Health Saint Mary’s

Pennock Hospital Others:

Reed City Hospital

Special Care Hospital

United Hospital

Zeeland Community Hospital

Your practice will include the care of:

Adults Only Children Only Adults and Children

If you reside more than 30 minutes from the primary hospital listed above, what is your plan for coverage of urgent Patient care needs or consults?

Not applicable, I can respond to urgent care needs within 30 minutes.

Not applicable; I am a telemedicine provider.

I do not reside within 30 minutes of primary facility, my plan for coverage is:

E-mail this form and a current CV to all hospital(s) where you are applying:

Spectrum Health Hospital Medical Staff

Office Contact Phone Fax Email Address

Big Rapids Hospital Billie Fedewa 231.592.4433 231.592.1079 [email protected]

Gerber Hospital Michon Blain 231.924.1141 231.924.1390 [email protected]

Grand Rapids Hospitals

Julie Trumpie Wendy Justema Mary Rich Brandy Tarrant

616.391.1609 616.391.2911 [email protected]

Ludington Hospital Connie VanLoon 231.845.2297 231.845.3607 [email protected]

United & Kelsey Hospitals Jamie Lindeman 616.225.6410 616.225.0809 [email protected]

Pennock Hospital Jacklyn Main 269.945.1212 x1453 269.945.0825 [email protected]

Reed City Hospital Charlene Keysor 231.832.8511 231.832.0228 [email protected]

Special Care Hospital Angel Schuch 616.486.2414 616.486.2419 [email protected]

Zeeland Community Hospital Brenna Osborn 616.748.3624 616.748.2828 [email protected]


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-

INITIAL MEMBERSHIP APPLICATION FOR PHYSICIANSI am seeking medical staff membership and/or privileges at the hospital(s) below where my Current Status is designated asapplicant. Please email [email protected] if there are errors or additions.

Status Hospital Name Status Hospital Name

INSTRUCTIONS: You must fill out this application in its entirety and include all required documentation. All areas must be completed even if the response is “Not Applicable (NA)” or “Unknown (UNK). Failure to do so will result in the return of the application and will delay processing. In no area of the form does the statement “See CV” meet the requirements for a completed application.

DEMOGRAPHIC INFORMATION

Personal InformationLast Name First Name Middle Name

Other Names you may have used Date of Birth Sex

Male Female

Home Address Ciy State Zip Code

Home Phone Number Cell Pager (Beeper #)

Degrees Social Security Number Your E-mail address

Birth City State Country Languages spoken fluently in addition to English Driver License Number Issuing State

Primary Office/Practice Site Check if also your Mailing AddressOffice/Practice Name Anticipated Start Date

Office Street Address Line 1 Office City

Address Line 2 Office State Zip

Office Phone 1 Office Phone 2 Office Fax

Office Contact/Office ManagerFirst Name Last Name

Office Contact E-mail Address

Credentialing Contact Name Credentialing Contact E-mail Address

Office Website

Secondary Office/Practice Site Check if also your Mailing AddressOffice Practice Name Office Website



Office Phone 1 Office Phone 2 Office Fax

Office Contact/Office ManagerFirst Name Last Name

Office Contact E-mail Address

Page 1 03/01/2017

Sample Application for Physicians (Exhibit C)


EDUCATION AND TRAINING

Medical Education

Internship

Residencies

Page 2 03/01/2017


Fellowships Name of Institution Start Date (mm/dd/yyyy) Finish Date (mm/dd/yyyy)

Address Line 1 City

Address Line 2 State Zip

Program Director’s Name Specialty

Phone Number Fax Number E-Mail Address

Name of Institution Start Date (mm/dd/yyyy) Finish Date (mm/dd/yyyy)

Address Line 1 City


Program Director’s Name Specialty


Additional Formal Training or Preceptorships Name of Institution Start Date (mm/dd/yyyy) Finish Date (mm/dd/yyyy)

Address Line 1 City


Program Director’s NameDescription of Program


BOARD CERTIFICATION: Provide details requested for specialties and subspecialties in which you are certified or eligible.Please indicate which specialty represents primary practice area.PrimaryPracticeSpecialtyselect one

Specialty/Subspecialty Name Certifying Boardif applicable Specialty Status

CertificationDate

(mm/dd/yyy)

Exam Dateif not certified(mm/dd/yyyy)

Have you ever failed to pass any board certification examination? If yes, please explain: Yes No

Have you applied for certification other than those listed above? If yes, please explain: Yes No

Do you participate in a specialty that does not have board certification? If yes, please explain: Yes No

Page 3 03/01/2017


INTENT TO PRACTICESelect the Hospital where the majority of your patients will be admitted or treated by you:

Spectrum HealthBlodgett/Butterworth/Meijer Heart CenterHelen DeVos Children’s HospitalBig Rapids HospitalGerber Memorial HospitalKelsey HospitalLudington HospitalPennock HospitalReed City HospitalUnited HospitalZeeland Community Hospital

Non-Spectrum HealthHolland HospitalMercy MuskegonMetro HealthSt Mary’s Medical CenterBorgess/Bronson

Others:

Your practice at Spectrum Health will include the care of:

Adults Children Adults and Children

What is your plan for coverage of urgent patient care needs or consults at the Spectrum Health Hospitals where you are applying:

I am part of a group practice and my partners will cover my patient care responsibilities when I am unavailable.

I am in solo practice and have made arrangements with the provider(s) listed below to cover my practice when I am unavailable:

LICENSES, REGISTRATION AND OTHER CERTIFICATIONS

Type NumberApplication orCourse Date(if pending)

Issue Date(mm/dd/yyyy)

Expiration Date(mm/dd/yyyy)

Michigan License

MI Controlled Substance (CS-3)

DEA Registration

NPI Number

ECFMG

ACLS eCard Code:

ATLS eCard Code:

BLS eCard Code:

NRP eCard Code:

PALS eCard Code:

Other

OTHER STATE LICENSES: Report information for all states where you have ever held a license.

State Number Issue Date Expiration Date

Page 4 03/01/2017


HOSPITAL AFFILIATIONS:

HOSPITAL APPLICATIONS IN PROCESS:

Page 5 03/01/2017


MILITARY EXPERIENCE: List all military experience you have had during the last ten (10) years or since your highest level ofeducation (whichever is shorter).Name of Institution Start Date (mm/dd/yyyy) End Date (mm/dd/yyyy)

Address Line 1 Address Line 2 Job Title

City State Zip Reason for Leaving

Supervisor’s Name Phone Number Fax Number E-Mail Address

Name of Institution Start Date (mm/dd/yyyy) End Date (mm/dd/yyyy)




CLINICAL TEACHING APPOINTMENTS: List current and previous clinical teaching appointments you have had during the lastten (10) years or since your highest level of education (whichever is shorter).Name of Institution Start Date (mm/dd/yyyy) End Date (mm/dd/yyyy)








WORK HISTORY: List clinical employment for the last ten (10) years or since residency (whichever is shorter). Begin with yourcurrent position and list in reverse chronological order. Explain gaps in work history on next page.Name of Institution Start Date (mm/dd/yyyy) End Date (mm/dd/yyyy)


City State Zip Brief Description of Primary Job Responsibilities

Supervisor’s Name Phone Number Fax Number Reason for Leaving

E-Mail Address



City State Zip Brief Description of Primary Job Responsibilities

Supervisor’s Name Phone Number Fax Number Reason for Leaving

E-Mail Address

Page 6 03/01/2017


GAPS IN CLINICAL WORK HISTORY: Please explain any gaps of three (3) months or more in your clinical work history during the last ten (10) years or since highest level of education (whichever is shorter). Include the reason for the gap along with your activity during the gap to maintain clinical competency or expertise such as continuing education.

From Date(mm/dd/yyyy)

To Date (mm/dd/yyyy) Explanation of Gap

Page 7 03/01/2017


PROFESSIONAL REFERENCES:* E-mail address is required for all references

Authoritative Reference who meets the following criteria:

Authoritative Reference Name and Degree

Peers who meet the following criteria:

Peer Reference Name and Degree

Peer Reference Name and Degree

Page 8 03/01/2017


MALPRACTICE COVERAGE:

Check the response applicable to your situation:

(providing coverage at Spectrum Health):

List all other medical malpractice carriers within the past ten (10) years

Page 9 03/01/2017


Attestation Questions: Please answer the following questions. If you answer YES to questions A.1 – A.12,please provide full details and note appropriate question number with your response on the Attestation Response Form ADDENDUM A

A.1

Has your license, certification, or registration to practice your profession, your Drug Enforcement Administration (DEA) registration or any applicable narcotic registration in any jurisdiction ever been denied, limited, restricted, suspended, revoked, not renewed, or subject to probationary conditions, or have you been fined or received a letter of reprimand or is such action pending in any jurisdiction?

Yes No

A.2 Have you voluntarily relinquished any license or registration in any jurisdiction for any reason other than an actual or anticipated relocation? Yes No

A.3Have you ever been denied participation in, suspended, fined, disciplined, or otherwise sanctioned, restricted or excluded by or from Medicare, Medicaid, or any other federal or state healthcare program(s) or is any such action pending or under review?

Yes No

A.4

Have you ever been denied clinical privileges, membership, contractual participation or employment by any medical organization (e.g., hospital medical staff, medical group, health plan, medical society, professional association, medical school faculty position or other health delivery entity or system) or have your clinical privileges, membership participation or employment at such organization ever been suspended, restricted, reduced/limited, subject to probationary conditions, placed in abeyance (military), revoked, not renewed, or challenged for possible incompetence, professional conduct or breach of contract, or is any such action pending or under review?

Yes No

A.5

Have you ever surrendered, allowed to expire, or voluntarily withdrawn a request for clinical privileges, membership, contractual or employment by any medical organization (e.g., hospital medical staff, medical group, health plan, medical society, professional association, medical school faculty position or other health delivery entity or system) while under investigation or Focused Professional Practice Evaluation (FPPE) for possible incompetence or improper professional conduct, or breach of contract, or in return for such an investigation not being conducted, or is any such action pending or under review?

Yes No

A.6Have you ever surrendered, voluntarily withdrawn, or been requested or compelled to relinquish your status as a student in good standing in any internship, residency, fellowship, preceptorship, or other clinical education program?

Yes No

A.7Has your membership or fellowship in any local, county, state, regional, national, or international professional organization ever been revoked, denied, reduced, limited, subjected to probationary conditions, or is any such action pending or under review?

Yes No

A.8 Have you ever been denied certification/recertification by a specialty board, or has your eligibility, certification or recertification status changed or lapsed (other than changing from eligible to certified)? Yes No

A.9

Have you ever been charged by any local, state or federal authority, official or agency, pled guilty to or been convicted of any crimes or offenses related to:

1. Medicare, Medicaid or other federal or state healthcare program(s)? Yes No2. Abuse or neglect of patients? Yes No3. Fraud, theft, embezzlement, breach of fiduciary responsibility or other financial misconduct? Yes No4. Obstruction of justice? Yes No5. Manufacture, distribution, prescription, or dispensing of any controlled substance? Yes No6. The use of alcohol or controlled substances? Yes No7. Any other crimes or offenses, with the exception of minor traffic infractions or parking tickets? Yes No

A.10

Has your professional liability insurance ever been terminated, not renewed, restricted, or modified (e.g. reduced limits, restricted coverage, surcharged), or have you ever been denied professional liability insurance, or has any professional liability carrier provided you with written notice of any intent to deny, cancel, not renew, or limit your professional liability insurance or its coverage of any procedures?

Yes No

A.11

Has any Focused Professional Practice Evaluation (FPPE), monitoring, or proctoring requirement ever been imposed on your practice at any hospital or health facility (other than routine proctoring in conjunction with a new application for privileges) or have your ever been suspended/removed from the emergency room rotational (call) schedule?

Yes No

A.12

Have you ever been an officer, director, or employee of a hospital, corporation, professional corporation, limitedliability company, partnership or joint venture which has been suspended, fined, disciplined, sanctioned restricted or temporarily or permanently excluded from participation in Medicare, Medicaid or other federal or state healthcare program? (If you answer “yes” to the above question, please use ADDENDUM A to provide the following details: the name of the entity, the date(s) you served as an officer or director, and/or the date(s) of your employment, the date(s) of exclusion, your title, and a description of your duties and responsibilities.)

Yes No

If you answer YES to question A.13 please provide full details on the Professional Liability Action Explanation Form, ADDENDUM B

A.13 During the past seven (7) years, have there been any arbitration proceedings, judgments, or settlements against you in professional liability cases, or are there currently any arbitration proceedings, notices of intent, or lawsuits filed against you regarding your professional practice?

Yes No

Page 10 03/01/2017


Health Status Verification: If you answer YES to questions H.1 – H.6, please provide full details on the Confidential Health Status Response Form ADDENDUM C

H.1Are you currently using or consuming illegal drugs, or are you using or consuming prescription drugs in amanner contrary to law? If yes, please give a full explanation, including, without limitation, frequency and amount of use, the time period in which you engaged in such use, and the date last used on Addendum C.

Yes No

H.2Are you currently engaged in the illegal use of controlled substances of any kind? If yes, please give a fullexplanation including, without limitation, frequency and amount of use, the time period in which you engagedin such use, and the date last used on Addendum C.

Yes No

H.3

Have you ever been enrolled in a drug or alcohol rehabilitation program?

Name of Program/Institution:

Yes No

Address:

Dates of hospitalization(s) or treatment program(s):

From to

From to

From to

H.4

Have you ever been under investigation or has your license, medical staff membership, clinical privileges,employment or contractual relationship ever been voluntarily or involuntarily limited, suspended, restricted, revoked, terminated, or are there any such investigations or actions pending related to or involving your use of drugs, controlled substances, or alcohol?

Yes No

H.5

Have you ever had, or do you currently have any physical or mental impairment or condition which wouldmake you unable, with or without reasonable accommodation, to perform the essential mental and physical functions related to the clinical privileges you are requesting, or unable to perform these essential functions with reasonable skill and safety?

Yes No

H.6Have you ever been advised by your treating physician that you have a mental, physical, or emotionalcondition, which, if untreated, would be likely to impair your ability to practice medicine with reasonable skill and safety?

Yes No

If you answer NO to the questions below, please provide full details on the Confidential Health Status Response Form ADDENDUM C.H.7 Are you able to meet all the obligations and attendance requirements (e.g. on-call, surgical scheduling) of the

category of medical staff membership or clinical privileges you seek, with or without accommodation? Yes No

H.8

Are you able to perform all the services required by your agreement with the Healthcare Organization, including the professional medical staff bylaw, to which you are applying, with or without reasonable accommodation, according to accepted standards of professional performance and without posing a direct threat to the safety of patients?

Yes No

By signing below, I attest that the information submitted in connection with my application for appointment and clinical credentialing status at Spectrum Health is true, correct and complete to the best of my knowledge and belief. I fully understand that any misleading statement or omission in connection with my application, whether discovered now or later, may constitute grounds for denial of my application or cause immediate termination of my hospital staff appointment.

I further acknowledge and agree that I will promptly and fully report all information to the respective Spectrum Health Hospitals Medical Staff Office(s) in the event any of the above answers change, or if any situation arises which affects my ability to treat patients, while my application is pending, and, if I am granted membership and/or clinical privileges, while I maintain membership and/or clinical privileges.

Printed Name

Signature and Date

Reminder: If you have not already signed and submitted privilege request forms, please take a moment to do so now. Your application will not be processed until we receive your privilege request forms.

Page 11 03/01/2017


ATTESTATION RESPONSE FORM

ADDENDUM AComplete this page if you answered Yes to Attestation Question A.1 through A.12

Description/Details Date of Incident




If you need additional space, please send the details in a word document and uploadas Correspondence using the transfer file function on your Practitioner Home Page (PHP).

Page 12 03/01/2017


PROFESSIONAL LIABILITY ACTION EXPLANATION FORM

ADDENDUM BComplete this page if you answered Yes to Attestation Question A.

NPDB report will NOT be accepted in lieu of written explanation of claims

Plaintiff’s Name: Date of Alleged Incident /Injury:

Date of Notice of Intent / Complaint: Allegations

Your Response (Please give a full response to the allegations.)

StatusNotice of Intent Dismissed without Prejudice Trial Verdict for Plaintiff

Pending Dismissed with Prejudice Trial Verdict for Defendant

Settlement/JudgmentSettlement Total $

Amount Paid on your behalf $
















Page 12 03/01/2017


CONFIDENTIAL HEALTH STATUS RESPONSE FORM

ADDENDUM CComplete this page if you answered Yes to Attestation Question H.1 through H.6

Complete this page if you answered No to Question H.7 or H.8

Health Status Question Number: Treating Provider Name:

Description/Details:






Page 14 03/01/2017


ADDITIONAL HOSPITAL AFFILIATIONS:

Page 15 03/01/2017



Address Line 1 Address Line 2 Work History Type

City State Zip Job Title

Supervisor’s Name Phone Number Fax Number Brief Description of Primary Job Responsibilities

E-Mail Address Reason for Leaving


























Page 16 03/01/2017


ADDITIONAL MEDICAL MALPRACTICE CARRIERS List all carriers within the past ten (10) years

Carrier Name Coverage Start (mm/dd/yyyy) Coverage End (mm/dd/yyyy)

Address Line 1 Policy Number

Address Line 2 Phone Number

City State Zip Fax Number





















Page 17 03/01/2017


OTHER STATE LICENSES:


Page 18 03/01/2017


INITIAL APPLICATION FOR ADVANCED PRACTICE PROFESSIONALS (APP)ADVANCED PRACTICE PROFESSIONALS (APP)

Status Hospital Name Status Hospital Name

INSTRUCTIONS:

DEMOGRAPHIC INFORMATION

Personal Information

Primary Office/Practice Site Check if also your Mailing Address

Page 1 03/01/2017

Exhibit C - APP Initial ApplicationEvidence OO11-3, Spectrum Health Credentials Verification Operating Manual, pgs. 6-24

Secondary Office/Practice Site Check if also your Mailing Address

Office Practice Name



Office Phone 1 Office Phone 2

Office Contact/Office Manager

First Name Last Name

Office Fax

Office Contact E-mail Address Office Website

EDUCATION AND TRAINING: Enter highest level that is applicable to your practice specialty

Graduate and Post GraduateName of Institution Start Date (mm/dd/yyyy) Finish Date (mm/dd/yyyy)

Address Line 1 City


Program Director or Contact Name Degree Obtained



Address Line 1 City


Program Director or Contact Name Degree Obtained


Internship/Fellowship, if applicableName of Institution Start Date (mm/dd/yyyy) Finish Date (mm/dd/yyyy)

Address Line 1 Program Type (Internship, Fellowship, Other)

Address Line 2 Specialty

City State Zip Program Director’s Name



Address Line 1 Program Type (Internship, Fellowship, Other)

Address Line 2 Specialty

City State Zip Program Director’s Name


Page 2 03/01/2017


SPECIALTY CERTIFICATION:

if not certified

Have you ever failed to pass any Board Certification examination? If yes, please explain:

Have you applied for certification other than those listed above? If yes, please explain:

Do you participate in a specialty that does not have board certification? If yes, please explain:

LICENSES, REGISTRATION AND OTHER CERTIFICATIONS

Type NumberApplication orCourse Date Issue Date Expiration Date

OTHER STATE LICENSES:


Page 3 03/01/2017


HOSPITAL AFFILIATIONS:

HOSPITAL APPLICATIONS IN PROCESS:

Page 4 03/01/2017


MILITARY EXPERIENCE:

CLINICAL TEACHING APPOINTMENTS:

WORK HISTORY:

Page 5 03/01/2017


GAPS IN CLINICAL WORK HISTORY:

From Date(mm/dd/yyyy)

To Date (mm/dd/yyyy) Explanation of Gap

Page 6 03/01/2017


PROFESSIONAL REFERENCES:Three (3) references are required of which at least one (1) must be an authoritative and two (2) may be peers. * E-mail address is required for all references

Authoritative Reference who meets the following criteria:If you have completed formal training within the past two (2) years, your Authoritative Reference must be your ProgramDirector, Training Director or Program Instructor.

ORIf you have completed formal training more than two (2) years ago, your Authoritative Reference must be your current ormost recent supervising physician.

Authoritative Reference Name and DegreeProgram Director

Department Chair/Chief

Supervising Physician

Medical Director

Other

Address Line 1



Has this reference had exposure to your clinical practice within the

past two (2) years? Yes No

*E-mail Address

Peers who meet the following criteria:Must have the same type of clinical license/certification as you.Must have had exposure to your clinical practice within the past two (2) years, and be able to attest to your current clinicalcompetence and professional performance.Must NOT be a relative, family member, fellow student or subordinate.

Peer Reference Name and DegreeDepartment Chair/Chief Program Director

Medical Director Partner

Clinical Instructor Professional Colleague

Other:

Address Line 1





*E-mail Address

Peer Reference Name and DegreeDepartment Chair/Chief Program Director

Medical Director Partner

Clinical Instructor Professional Colleague

Other:

Address Line 1





*E-mail Address

Page 7 03/01/2017


MALPRACTICE COVERAGE:

Check the response applicable to your situation:

(providing coverage at Spectrum Health):

List all other medical malpractice carriers within the past five (5) years

Page 8 03/01/2017


Attestation Questions: Please answer the following questions. If you answer YES to questions A.1 – A.12,please provide full details and note appropriate question number with your response on the Attestation Response Form ADDENDUM A

A.1

Has your license, certification, or registration to practice your profession, your Drug Enforcement Administration (DEA) registration or any applicable narcotic registration in any jurisdiction ever been denied, limited, restricted, suspended, revoked, not renewed, or subject to probationary conditions, or have you been fined or received a letter of reprimand or is such action pending in any jurisdiction?

Yes No

A.2 Have you voluntarily relinquished any license or registration in any jurisdiction for any reason other than an actual or anticipated relocation? Yes No

A.3Have you ever been denied participation in, suspended, fined, disciplined, or otherwise sanctioned, restricted or excluded by or from Medicare, Medicaid, or any other federal or state healthcare program(s) or is any such action pending or under review?

Yes No

A.4

Have you ever been denied clinical privileges, membership, contractual participation or employment by any medical organization (e.g., hospital medical staff, medical group, health plan, medical society, professional association, medical school faculty position or other health delivery entity or system) or have your clinical privileges, membership participation or employment at such organization ever been suspended, restricted, reduced/limited, subject to probationary conditions, placed in abeyance (military), revoked, not renewed, or challenged for possible incompetence, professional conduct or breach of contract, or is any such action pending or under review?

Yes No

A.5

Have you ever surrendered, allowed to expire, or voluntarily withdrawn a request for clinical privileges, membership, contractual or employment by any medical organization (e.g., hospital medical staff, medical group, health plan, medical society, professional association, medical school faculty position or other health delivery entity or system) while under investigation or Focused Professional Practice Evaluation (FPPE) for possible incompetence or improper professional conduct, or breach of contract, or in return for such an investigation not being conducted, or is any such action pending or under review?

Yes No

A.6Have you ever surrendered, voluntarily withdrawn, or been requested or compelled to relinquish your status as a student in good standing in any internship, residency, fellowship, preceptorship, or other clinical education program?

Yes No

A.7Has your membership or fellowship in any local, county, state, regional, national, or international professional organization ever been revoked, denied, reduced, limited, subjected to probationary conditions, or is any such action pending or under review?

Yes No

A.8 Have you ever been denied certification/recertification by a specialty board, or has your eligibility, certification or recertification status changed or lapsed (other than changing from eligible to certified)? Yes No

A.9

Have you ever been charged by any local, state or federal authority, official or agency, pled guilty to or been convicted of any crimes or offenses related to:

1. Medicare, Medicaid or other federal or state healthcare program(s)? Yes No2. Abuse or neglect of patients? Yes No3. Fraud, theft, embezzlement, breach of fiduciary responsibility or other financial misconduct? Yes No4. Obstruction of justice? Yes No5. Manufacture, distribution, prescription, or dispensing of any controlled substance? Yes No6. The use of alcohol or controlled substances? Yes No7. Any other crimes or offenses, with the exception of minor traffic infractions or parking tickets? Yes No

A.10

Has your professional liability insurance ever been terminated, not renewed, restricted, or modified (e.g. reduced limits, restricted coverage, surcharged), or have you ever been denied professional liability insurance, or has any professional liability carrier provided you with written notice of any intent to deny, cancel, not renew, or limit your professional liability insurance or its coverage of any procedures?

Yes No

A.11

Has any Focused Professional Practice Evaluation (FPPE), monitoring, or proctoring requirement ever been imposed on your practice at any hospital or health facility (other than routine proctoring in conjunction with a new application for privileges) or have your ever been suspended/removed from the emergency room rotational (call) schedule?

Yes No

A.12

Have you ever been an officer, director, or employee of a hospital, corporation, professional corporation, limitedliability company, partnership or joint venture which has been suspended, fined, disciplined, sanctioned restricted or temporarily or permanently excluded from participation in Medicare, Medicaid or other federal or state healthcare program? (If you answer “yes” to the above question, please use ADDENDUM A to provide the following details: the name of the entity, the date(s) you served as an officer or director, and/or the date(s) of your employment, the date(s) of exclusion, your title, and a description of your duties and responsibilities.)

Yes No

If you answer YES to question A.13 please provide full details on the Professional Liability Action Explanation Form, ADDENDUM B

A.13During the past seven (7) years, have there been any arbitration proceedings, judgments, or settlements against you in professional liability cases, or are there currently any arbitration proceedings, notices of intent, or lawsuits filed against you regarding your professional practice?

Yes No

Page 9 03/01/2017


Health Status Verification: If you answer YES to questions H.1 – H.6, please provide full details on the Confidential Health Status Response Form ADDENDUM C

If you answer NO to questions , please provide full details on the Confidential Health Status Response Form ADDENDUM C.

Printed Name

Signature and Date

Reminder:

Page 10 03/01/2017


ATTESTATION RESPONSE FORM

ADDENDUM AComplete this page if you answered Yes to Attestation Question A.1 through A.12






Page 11 03/01/2017


PROFESSIONAL LIABILITY ACTION EXPLANATION FORM

ADDENDUM BComplete this page if you answered Yes to Attestation Question A.

NPDB report will NOT be accepted in lieu of written explanation of claims























Page 12 03/01/2017


CONFIDENTIAL HEALTH STATUS RESPONSE FORM

ADDENDUM CComplete this page if you answered Yes to Attestation Question H.1 through H.6

Complete this page if you answered No to Question H.7 or H.8








Page 13 03/01/2017


ADDITIONAL HOSPITAL AFFILIATIONS:

Page 14 03/01/2017


ADDITIONAL WORK HISTORY: List clinical employment for the last five (5) years. Begin with your current position and list inreverse chronological order. Explain gaps in work history on page 6.Name of Institution Start Date (mm/dd/yyyy) End Date (mm/dd/yyyy)






























Page 15 03/01/2017


ADDITIONAL MEDICAL MALPRACTICE CARRIERS

Page 16 03/01/2017


OTHER STATE LICENSES: Report information for all states where you have ever held a license.

State Number Issue Date ExpirationDate

Page 17 03/01/2017


Credentials Verification Office Credentials Verification Methods and Requirements

CREDENTIALING ITEM

METHOD OFVERIFICATION

PROCESS &DOCUMENTATION

ACCREDITATION &CVO SCOPE In

itial

A

pplic

atio

n

Rea

ppoi

ntm

ent

Ong

oing

/Ann

ual

Req

uire

men

ts

Licenses LICENSES TO PRACTICE IN STATE OF MICHIGAN

Verify current license(s), expiration date and sanctions, challenges and/or limitations

Online webcrawl to the appropriate Michigan State Licensing Board

Documented phone call with licensing board when web access or verification system is down

Web verification image is saved automatically or scanned as a response image into the ‘State License’ document of the ID Numbers tab of the electronic file

EXPIRABLE: Ongoing Verification upon Expiration

It is required by The Joint Commission to be verified via primary source (MS.06.01.03, EP 6 and MS.06.01.05, EP 2)

It is required by NCQA to verify license in the states where the practitioner provides care to members and information on sanctions or limitations for the past five-year period

The SHCVO provides license verification at initial application, reappointment and upon expiration, and initiates FOIA request to obtain details of licensure challenges, sanctions or limitations from the State of Michigan

Y Y E

CONTROLLED SUBSTANCE LICENSES FOR MICHIGAN

Verify current license(s), expiration date and sanctions challenges and/or limitations

Online web crawl to the appropriate Michigan State Licensing Board

Documented phone call with licensing board when web access or verification system is down

Web verification image is saved automatically or scanned as a response image into the ‘Controlled Substance” document of the ID Numbers tab of the electronic file


It is required by The Joint Commission to be verified via primary source (MS.06.01.03, EP 6 and MS.06.01.05, EP 2)

It is required by NCQA to verify license in the states where the practitioner provides care to members and information on sanctions or limitations for the past five-year period

The SHCVO provides license

Y Y E


jud84067

Typewritten Text

jud84067

Typewritten Text

jud84067

Typewritten Text

jud84067

Typewritten Text

Exhibit D: Credentials Verification Methods and Requirements


verification at initial application, reappointment and upon expiration Some medical staff members may not be required to have a Controlled Substance license based on their specialty

LICENSES TO PRACTICE IN OTHER STATES – CURRENT AND PREVIOUS PROFESSIONAL LICENSES

Verify current and previous license(s), expiration date and sanctions challenges and/or limitations

Online web crawl to the appropriate State Licensing Board

Online webcrawl to the FSMB website when practitioner has practiced in three or more states

Web verification image is saved automatically or scanned as a response image into the ‘State License’ document of the ID Numbers tab of the electronic file

It is not required by The Joint Commission, NCQA or CMS to verify out-of-state licenses

The SHCVO considers this best practice and will verify current and previous licenses in other states on initial application only

Y N N

DEA REGISTRATION

Obtain DEA Registration number; verify expiration date, schedules, and sanctions, challenges and/or limitations

Online web crawl to www.deanumber.com

Web verification image is saved automatically or certificate copy is scanned into the “DEA Number” document of the ID Number tab of electronic file


Community standard is to verify DEA registration and schedules

Some medical staff members may not be required to have a DEA based on their specialty

Copies of certificates will only be accepted in a temporary, urgent situation where the website has not yet updated data

Y E E

Education and Training HIGH SCHOOL EDUCATION N N N UNDER GRADUATE EDUCATION N N N PROFESSIONAL EDUCATION (GRADUATE, NON-MEDICAL)

Professional, graduate level education (excluding medical school) that is relevant to privileges requested

In writing, or confirmed via telephone by a Coordinator from the school directly as primary source

Designated equivalent source such

Copy of letter, documented phone verification, or online web image is saved into the “Research – GME and/or Research – Work History” document as a response image under the Credentials Tab of the

The Joint Commission requires all levels of the applicant’s “relevant’ training to be verified via primary source (MS.06.01.03, EP 6 and MS.06.01.05, EP 2)

Y N N


http://www.deanumber.com/


as an association of schools of the health profession that obtains its verification from the primary source (e.g. National Student Clearinghouse)

electronic file

The verification of Professional Education is a static document. The existing file copy will be reused to support future initial applications

NCQA requires only the highest level of education to be verified via primary source

The SHCVO will provide verification of Professional Education at initial application only

ADVANCED PRACTICE PROFESSIONAL (APP) EDUCATION

Verify institution, start date, completion date, and degree received

In writing or confirmed via telephone by a Coordinator from the professional school directly as primary source or a designated equivalent source (e.g. National Student Clearinghouse)

Copy of letter, documented phone verification, or online web image is saved as a response image into the “APP Education” document under the Credentials Tab of the electronic file

The verification of APP Education is a static document. The existing file copy will be reused to support future initial applications

The Joint Commission requires all levels of the applicant’s “relevant” training to be verified via primary source (MS.06.01.03, EP6 and MS.06.01.05, EP 2)


The SHCVO will provide verification of professional school at initial application only

Y N N

MEDICAL SCHOOL (DOMESTIC GRADUATES)

Verify institution, start date, completion date, and degree received

In writing, or confirmed via telephone by a Coordinator from the medical school directly as primary source

Designated equivalent source including: web verification via AMA or AOA

Copy of letter, documented phone verification, or online web image is saved as a response image into the “Medical education” document under the Credentials Tab of the electronic file

The verification of Medical School is a static document. The existing file copy will be reused to support future initial applications



The SHCVO will provide verification of Medical School at initial application only

Y N N

MEDICAL SCHOOL (FOREIGN GRADUATES)

Graduation from a foreign medical school

This section does not cover foreign internships or fellowships.

Online queries obtained from the Educational Commission for Foreign Medical Graduates (ECFMG) via the www.ecfmg.org website

Web verification image is saved as a response image into the “Medical education” document under the Credentials Tab of the electronic file

The verification of Foreign Medical

*Only completed for applicants thathave graduated from a foreignmedical school

The SHCVO will provide verification of Foreign Medical School at initial application only

IA* N N


http://www.ecfmg.org/


School is a static document. The existing file copy will be reused to support future initial applications

INTERNSHIP, RESIDENCY AND FELLOWSHIP (DOMESTIC PROGRAMS)

All training completed after medical school graduation , OR, post receipt of ECFMG

Verify institution, start date, end date, type of program and successful completion

In writing, or confirmed via telephone by a Coordinator from the graduate medical education program directly as primary source

Designated equivalent source including: web verification via AMA or AOA profile

Copy of letter, documented phone verification, or online web image is saved as a response image into the “Internship, Residency and/or Fellowship” document under the Credentials Tab of the electronic file

The verification of Internship, Residency and Fellowship is a static document. The existing file copy will be reused to support future initial applications



The SHCVO will provide verification of Internship, Residency and Fellowship at initial application

*Only performed at reappointmentif a new fellowship program wascompleted since application or lastreappointment

Y IA* N

INTERNSHIP, RESIDENCY AND FELLOWSHIP (FOREIGN PROGRAMS)

When the highest level of training is ACGME approved training, only that level will be verified.

In the absence of any ACGME verified training, best efforts to obtain primary source verification will be completed

Verify institution, start date, end date, type of program and successful completion

In writing, or confirmed via telephone by a Coordinator from the graduate medical education program directly as primary source

Utilize an international equivalent site such as the Royal Colleges or through a Specialist Registrar

Copy of letter, documented phone verification, or online web image is saved as a response image into the “Internship, Residency and/or Fellowship” document under the Credentials Tab of the electronic file

The verification of Internship, Residency and Fellowship is a static document. The existing file copy will be reused to support future initial applications


NCQA requires only the highest level of education to be verified via primary source.

There are often difficulties in verifying foreign graduate medical education program information. When the applicant has not had any ACGME approved training, the CVO will make 2 attempts to gather this information and then consider it an exhausted effort and pass the information to the PMSO

Y N N



Certifications BOARD CERTIFICATION (ALLOPATHIC)

All specialty board certifications (there may be multiple certifications) which are ABMS, AOA, or Royal College of Physicians/Surgeons approved

Verify certifying board, specialty or certification, date certified, date recertified, expiration date, MOC or lifetime certification status

Online web crawl to CertiFacts website (designated the official ABMS Display Agent)

Confirm directly with the certifying board in writing, via phone, or electronically

AMA Profile

Web verification image is saved automatically or scanned as a response image into the “Board Specialties” document in the Specialties tab of the electronic file EXPIRABLE: Ongoing Verification upon Expiration

Eligibility: Data enter expiration date of any board eligible/qualified specialties as 3 months past the anticipated exam date at which time the Expirables Coordinator will be prompted by MSOW to follow-up. 7/1/14/jr

The Joint Commission (MS.06.01.01, MS.06.01.03), NCQA, and CMS do not require board certification but expects the medical staff to follow its own bylaws and policy

The SHCVO considers the verification of board certification best practice and will verify on initial application, reappointment and as it expires.

Y Y E

BOARD CERTIFICATION (OSTEOPATHIC)

All specialty board certifications (there may be multiple certifications) which are ABMS, AOA, or Royal College of Physicians/Surgeons approved

Verify certifying board, specialty or certification, date certified, date recertified, expiration date, MOC or lifetime certification status

Online query to the AOIA at www.doprofiles.org


Web verification image is saved automatically or scanned as a response image into the “Board Specialties” document in the Specialties tab of the electronic file


The Joint Commission (MS.06.01.01, MS.06.01.03), NCQA, and CMS do not require board certification but expects the medical staff to follow its own bylaws and policy

The SHCVO considers the verification of board certification best practice and will verify on initial application, reappointment and as it expires.

Y Y E

ADVANCED PRACTICE PROFESSIONAL (APP) CERTIFICATION

All recognized APP Certifications (AA, CRNA, CNM, NP, PA-C)

Verify certifying board, specialty or certification, date certified, date recertified, expiration date, or lifetime certification status

Online query to the respective APP certifying board


Web verification image is saved automatically or scanned as a response image into the “Board Specialties” document in the Specialties tab of the electronic file

Expirable: Ongoing Verification upon Expiration

The Joint Commission requires verification of certification if it is required by law, regulation or hospital policy (HR.01.02.05 EP 1, 2, & 7, HR.01.02.07, EP 2); NCQA, and CMS do not require APP certification but expects the medical staff to follow its own bylaws and policy

The SHCVO considers the verification of APP certification best

Y Y E


http://www.doprofiles.org/


practice and will verify on initial application, reappointment and as it expires.

OTHER PROFESSIONAL CERTIFICATIONS

ACLS, BLS, ITLA, PALS, NRP,ATLS, ETC,

Verify the date certified and the expiration date

Copy of certificate with an expiration date is provided directly to the CVO by the provider

Copy of the certificate is scanned into appropriate, corresponding document in the ID Number tab of the electronic file

EXPIRABLE: Ongoing Verification upon Expiration if required to maintain privileges

The Joint Commission does not require verification of other professional certifications but expects the medical staff to follow its own bylaws and policy

The SHCVO will only request documentation for certifications that are required based on the privileges requested

Y E E

Professional Liability InsurancePROOF OF CURRENT COVERAGE

Verify carrier, policy number, effective date of coverage, expiration date of coverage, individual coverage limits and aggregate coverage limits

Copy of the policy (“deck page”, “policy binder”, “declaration page”, “coverage description page” “facesheet”, etc.) which can be received directly from the applicant, the applicant’s practice, or the malpractice carrier

Coverage must be applicable to the institution where the applicant is requesting privileges

Copy of verification page is scanned as a document image into the “Insurance – Current Malpractice” document in the Insurance tab of the electronic file


The Joint Commission, NCQA and CMS do not require primary source verification of medical malpractice coverage. The Joint Commission expects the Medical Staff to follow its own Bylaws and Policies

The SHCVO considers the verification of medical malpractice to be imperative in protecting the organization from risk and is a requirement in almost all medical staff bylaws

Y E E

MALPRACTICE CLAIMS HISTORY

Verify the date of alleged incident or injury, the allegations and the status of the complaint (pending, dismissed, settlement, verdict, amount paid)

The applicant is required to report any closed or pending arbitration proceedings, judgments, or settlements filed against them in professional liability cases during the past seven (7) years.

Judgments, verdicts and settlements that result in payment are available on the NPDB report

The Application and Addendum B (Professional Liability Action Explanation Form) is saved in images in the electronic file

NPDB reports saved as noted above

Claims History reports are scanned as a response image into the

The Joint Commission and NCQA require organizations to evaluate evidence of an unusual pattern or excessive number of professional liability actions resulting in final judgment against the applicant. (MS.06.01.05, EP 9)

Y N N



Primary source verification will be performed with all carriers that covered the physician (MD/DO/DPM/DDS) applicant during the past seven (7) years, except where the applicant was participating in an accredited post-graduate training program (internship, residency or fellowship)

“Insurance – Claims History” document in the Insurance tab of the electronic file

The scope of the SHCVO is to provide information on filed claims only. If the applicant reports a Notice of Intent (NOI), no further information will be obtained from the carrier as they are not required to report NOIs. If the PMSO requires additional information about an NOI, they can pursue additional information from the applicant

Current Competence HEALTHCARE ORGANIZATION AFFILIATION

Hospital, ambulatory facilities, surgical centers, etc.

Verify current status, begin/end dates of affiliation, adverse actions, performance or behavior problems, and whether the applicant was/is in good standing.

In writing by Online Primary Source Verification (PSV) letter, receipt of completed SH PSV form, or confirmed via telephone by a Coordinator directly with the facility as primary source

The applicant is required to list all hospitals where they had an affiliation during the last ten (10) years

Copy of letter, form, documented phone verification, or online web image is saved as a response image as “Hospital Affiliation – Current” or “Hospital Affiliation – Prior” under the Hospitals Tab of the electronic file

The Joint Commission and NCQA do not require hospitals to verify current or past hospital affiliations, but do require that organizations evaluate any voluntary or involuntary termination of medical staff membership or limitation, reduction, or loss of clinical privileges. This can be achieved through attestation questions on the application.

The SHCVO considers verification of hospital affiliations best practice and will verify affiliations held during the last ten years up to a maximum of seven; those seven always being the current and most recently held affiliations

*Reappointment – currentaffiliations only are verified up to amaximum of seven

Y *Y N

WORK HISTORY & GAP ANALYSIS

Military experience, clinical teaching appointments, and

The applicant is required to attest to work history on the application for the last ten (10) years or since highest level of education or

Explanation of gaps will be documented on the application, or through follow-up correspondence with the applicant

The Joint Commission does not use the term “work history” but requires evidence of current competence. NCQA requires the

Y N N



previous employment will be evaluated in conjunction with verified hospital affiliations to identify gaps in work history

residency, (whichever is shortest)

Any gaps in hospital affiliation or work history that occurred during the last ten (10) years and were longer than 3 months in duration must be explained by the applicant

All copies of correspondence will be scanned into images in the electronic file

applicant to provide a minimum of five years of relevant work history to allow identification of gaps in work history

The SHCVO considers it best practice to identify work history gaps within the previous 10 years

PEER REFERENCE (AUTHORITATIVE REFERENCE)

An Authoritative Reference must be the Program Director if currently in training or has completed training within the previous three years OR If the applicant has completed training more than 3 years prior, the Authoritative Reference must be the Department Chair at the hospital where the applicant has had the greatest volume during the previous year

In writing via completion by the Authoritative Reference and documented on the Spectrum Health Authoritative Reference Form.

The Spectrum Health Authoritative Reference Form can be completed by a Credentialing Coordinator via direct phone call with the Authoritative Reference.

Copy of the Authoritative Reference Form will be scanned as a “response’ image into the ‘References’ tab of the credentialing database

The Joint Commission requires that peer recommendations include written information regarding the practitioner’s current: medical/clinical knowledge, technical & clinical skills, clinical judgment, interpersonal skill, communication skills and professionalism (MS.06.01.05, EP 8)

The SHCVO will collect at least one Authoritative Reference at initial application.

Y (1) N N

PEER REFERENCE (PROFESSIONAL REFERENCE)

A peer reference must meet the following criteria: • Same type of professional

credential• Had exposure to clinical

practice for past two years• Be able to attest to current

clinical competency andprofessional performance

One peer reference may be a partner

A peer reference may not be a family member, student or

In writing via completion by the Professional Reference and documented on the Spectrum Health Professional Reference Form.

The Spectrum Health Professional Reference Form can be completed by a Credentialing Coordinator via direct phone call with the Professional Reference.

Copy of the Professional Reference Form will be scanned as a “response’ image into the ‘References’ tab of the credentialing database

The Joint Commission requires that peer recommendations include written information regarding the practitioner’s current: medical/clinical knowledge, technical & clinical skills, clinical judgment, interpersonal skill, communication skills and professionalism (MS.06.01.05, EP 8)

The SHCVO will collect at least two Professional References (one of which may be an additional Authoritative Reference) with initial application and one Professional Reference at reappointment

Y (2) Y (1) N



subordinate PROCEDURE LOGS

Requested by the SHCVO as per the requirements on privilege forms

The SHCVO will request procedure logs from the applicant. In some cases, the PMSO may have a method for gathering information from other sources.

Copy of the procedure log is scanned as a document image into the “Logs” document in the image tab of the electronic file.

The Joint Commission requires the medical staff to evaluate relevant practitioner-specific data as compared to aggregate data, and morbidity and mortality data when available (MS.06.01.05, EP 9)

The SHCVO will request and collect procedure logs and forward to the PMSO. The SHCVO will not evaluate data. Once submitted, the PMSO will follow up with the applicant for any additional information needed

Y N N

Other FEDERAL HEALTHCARE PAYER SANCTIONS

Identification of providers that are excluded from Federal Health Care program participation or any type of restriction having a bearing on an applicant’s competency or conduct

Query of the OIG/GSA websites

Note: The Spectrum Health Compliance Department has processes in place to manage excluder provider lists of those providers already employed or a member of the medical staff

Web verification image is saved automatically or scanned as a response image into the images in the electronic file

Note: Ongoing monitoring of excluded provider lists also occurs in the Spectrum Health Compliance Department

The Joint Commission does not specifically address Medicare or Medicaid sanctions. NCQA requires verification of Medicare and Medicaid sanction status by querying either the NPDB, HIPDB, FSMB, OIG, AMA Physician Masterfile, or “The Medicare/Medicaid Sanctions and Reinstatement Report” distributed to federally contracted organizations

The SHCVO will provide OIG and GSA reports at initial application only

Y N N

HEALTH STATUS AND ABILITY TO PERFORM PRIVILEGES

See application for specific health attestation questions

Applicant is required to complete the Health Status Verification section of the application

The Application and Addendum C (Confidential Health Status Response Form) is saved in images in the electronic file

The Joint Commission requires the medical staff to evaluate documentation regarding the applicant’s physical ability to perform the requested privileges

Y Y N



(MS.06.01.05, EP2)

The SHCVO monitors application for answers and explanations to the attestation questions

HISTORY OF CRIMINAL CONDUCT

Includes FACIS (fraud & Abuse), National Sex Offender Registry, and Criminal Felony and misdemeanor

A Background Check on file can be used if performed during the previous 120 days. If one is not available, or is older than 120 days, a new Background Check will be run

Copy of the Background Check is scanned as a response image into the “Background Check” document in the image tab of the electronic file.

The Joint Commission and CMS do not require verification of history of felony convictions. NCQA does require a statement from the applicant regarding his or her history of felony convictions

The SHCVO considers it best practice to perform a background check on all applicants to reduce risk to the organization

Y N N

NATIONAL PRACTITIONER DATA BANK (NPDB)

Verify medical malpractice payments, licensure disciplinary actions, adverse clinical privilege actions taken by a healthcare entity, and adverse actions affecting professional society membership

The SHCVO acts as an “Agent” for the PMSO and will enroll all providers in the NPDB Continuous Query upon receipt of application and credentialing waiver

As the Agent, the SHCVO will disenrol the provider from the NPDB Continuous Query upon notification by the PMSO that the provider no longer holds membership

Note: Submission of a ‘self-query’ from an applicant is not acceptable.

The NPDB report is automatically saved in the images of the electronic file when the enrollment process is completed

*During the reappointment process,the CVO will perform a “StatusUpdate” which automatically savesa report in the images of theelectronic file

The Joint Commission requires that NPDB is queried when clinical privileges are initially granted, at the time of renewal of privileges, and when a new privilege(s) is requested (MS.06.01.05, EP 7)

NCQA and CMS do not specifically require a NPDB query. However, query of the NPDB does satisfy some requirements for evaluating license sanctions and malpractice history

The SHCVO will seek explanation from the applicant for any discrepancies between the NPDB report and information provided on the application.

Y Y* N

LANGUAGES The SHCVO does not verify the The information the applicant The Joint Commission, CMS, or N N N



Legend: Y = Yes, this verification is performed with this process. N = No, this verification is not performed with this process. IA = If Applicable, this verification is only performed when a specific situation is present. E = The verification is performed prior to and immediately upon expiration.

Age of documents provided by SHCVO – Documents provided by SHCVO will be up to but not older than 120 days, per NQCA guideline, when submitted to each PMSO, unless the PMSO approves use of older documents.

The applicant attests to the languages spoken fluently in addition to English

accuracy of this information. provides will populate the language tab of the electronic database. Language information is not used in the credentialing process, but may be beneficial in supporting patient referrals

NCQA, do not address or require any information about languages to be collected or verified.

IDENTIFICATION

The PMSO verifies that the practitioner requesting approval is the same practitioner identified in the credentialing documents.

The SHCVO defers to the PMSO to view and compare the photo ID to the credentialing documents prior to approval of membership and/or privileges.

The SHCVO matches key demographic data points as a result of the background check (SS number, driver license number, full name, etc.) but does not check identity against a photo ID.

The Joint Commission requires the hospital to verify that the practitioner requesting approval is the same practitioner identified in the credentialing documents by viewing a hospital ID card or valid picture ID issued by a state or federal agency (MS.06.01.03 EP 5)

N N N

ATTESTATION & HEALTH STATUS QUESTIONS

The applicant answers standard attestation and health status questions on the application for membership

The SHCVO reviews the answers to all questions on the application, collects explanation of adverse responses and compares the information provided by the applicant to any applicable primary source verification.

The SHCVO coordinator verifies the presence of any adverse responses to attestation or health status questions and the corresponding explanation from the applicant on the appropriate response form, which is scanned into the electronic file as part of the application form

The Joint Commission and CMS do not address attestation questions; NCQA requires an applicant attest to the following: • Lack of illegal drug use• History of loss of license

and felony convictions• History of loss or limitation

of privileges or disciplinaryactivity

• Current malpracticeinsurance coverage

• Correctness andcompleteness of application

Y Y N


Document Name List -SEPTEMBER 2016

Document Grid (Exhibit E)

CVO Reviewed 8/31/2016 1 of 13

DOCUMENT NAMES 8/2016

Cred, AHP or Apogee

Blue Tab (Link) or Image

Resp or DocUsed in

ARM packet?

DescriptionSpecial scanning instructions

Data Entry InstructionsImage screen comments

Facility Archive Rule

ACLS Cred ID Number Document YES Copy of card

When no specific issue/expiration date, use first day of month for issuance and last day for expiration

May enter expiration date of image. Helps identify current vs old documents

Open Archive if historical

AHP Annual Declaration of Status

AHP Image Application YESThe original application document for renewal of scope of services

Retain Last

AHP Appointment Letter

AHP Image DocumentLetter signed by Director of Medical Staff Service at initial appointment

Facility Never Archive

AHP Initial Application AHP Image Document YESThe original application document from the applicant

Imported via MSOnetIdentify applicable

Open Never Archive

AHP Practice Agreement AHP Image Document Archive if historical

AHP Reappointment Letter AHP Image DocumentLetter from AHP Credentialing Office at reappointment

Facility Retain Last

AHP Reference AHP References Response YESCompleted reference form from supervisor

Enter complete contact information for reference source

Identify relationship to applicant

OpenArchive if greater than 2 years

AMA Profile Cred Image Response YES Copy of AMA web document

Always scan as itself even when used as PSV for medical education or training.

Open Never Archive

Annual Competencies AHP Health Item DocumentFuture use for AHP annual competencies


AOA Profile Cred Image Response YES Copy of AOA web documentAlways scan as itself even when used as PSV for

Open Retain Last

APP Education Cred Credential Response Use for APPUse document type for copy of diploma

Open Never Archive

APP Practice Agreement Cred Image Document YESCollaborative Practice Agreement (CNM & NP) or Supervising

Identify Credentialing

Facility (if form

Never Archive

Application Cred Image Document YESThe original application document from the applicant

Initial Application-FACILITIES

Open Never Archive

Application Acceptance Test Cred Image DocumentDelete image after application submitted successfully

Open Retain Last

Application request Cred Image Document Pre-app form from MSO FACILITIES YEAR OpenArchive if greater than 2 years

Application Withdrawn Documentation

Cred Image DocumentAll documentation related to withdrawing the application

Scan correspondence and related documentation

Affected facilities should be indicated as Inactive /Application withdrawn

Include facility Open Never Archive


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Exhibit E - Document Name List





Cred, AHP or Apogee


Resp or DocUsed in

ARM packet?




ATLS Cred ID Number Document YES Copy of cardImage REQUIRED for data entry. When no specific issue/expiration date use


Audit Report Cred Image DocumentAudit report from CVO Initial or Reappt process

CVO Intake Process - FACILITIES;


Authoritative Reference Cred References Response YES Completed reference formIdentify Relationship/Role in Comments Tab


Background Check Results Cred Credentials Response YES PDF report from contracted agencyEnter adjudication in Comments Tab and flag if appropriate

Meets company standards or Flagged

Open Retain Last

BLS Cred ID Number Document YES Copy of cardWhen no specific issue/expiration date, use first day of month for


Board Letter - Initial Appointment

Cred Image DocumentCopy of Board Letter and Decision Detail Reference


Board Letter - Other Cred Image DocumentCopy of Board Letter with attachments

Status change,Additional privileges etc


Board Letter - Reappointment

Cred Image DocumentCopy of Board Letter with attachments

Effective XX/XX/XXXX


Board Specialties Cred Specialties Response YESPSV of Physician and APP board certification

AA, CNM, CRNA enter in ID Numbers Tab and Specialties


Board Specialty MOC Documentation

Cred Specialties Document YESTo be used when a provider submits a copy of the letter from their Board showing their

DO not replace the Board cert, add this as an additional document


CAQH ID Apogee ID Number ResponseUsed by PSES to enter or retrieve provider information

Enter CAQH number in number field

Open Retain Last

Certification Cred Specialties Response Internet grabber Retain Last

Clinical Assessments Cred Image Document YESAttestations to support privilege requests - sometimes is for APP with initial app


CME Cred Image Document CME EducationIdentify the specific training


Compassionate Privileges Documentation

Cred Image DocumentAll paperwork associated with compassionate privileges

Effective mm/dd/yyyy


Confidentiality Statement Cred Health Item DocumentIncluded in Mandatory Credentialing Requirements

Remove from Mandatory Cred Requirements

Enter date of electronic signature

Open Retain Last

Controlled Substance Cred ID Number Response YES Web Crawl image OpenArchive if greater than 2 years






Cred, AHP or Apogee


Resp or DocUsed in

ARM packet?




Correspondence Cred Image Document YESAny correspondence not covered by a specific document name

Describe document

Depends Never Archive

CV Cred Image Document Practitioner resume YYYY Open Retain Last

CVO Verification Documents Cred Image Document MSOs create as neededSave to network drive; delete from MSOW

FacilityArchive if greater than 2 years

DEA Number Cred ID Number Response Web Crawl image Open Retain Last

DEA-Resident Cred ID Number None GRMEP issues numberRemove once physician receives their own DEA

Retain Last

Delineation of Services AHP Image Response YES AHP scope of services SHAHP Never Archive

Driver License Cred ID Number DocumentDriver license number and image if provided by practitioner

Enter ID Number and State as last item in sequence

Identify state Open Never Archive

Drug Control Location License

Apogee ID Number Response SHMG Retain Last

Drug Treatment Program Prescriber License

Apogee Image Response SHMG Retain Last






Cred, AHP or Apogee


Resp or DocUsed in

ARM packet?




ECFMG Number Cred ID Number Response YES Copy of web pageUse document type for copy from practitioner

ID Number and date issued entered in sequence preceding driver license

Open Never Archive

Exclusion Report Cred Image Response Web Crawl image Open Retain Last

Fellowship Cred Credential Response YES Training verification form from PSV

Use document type for copy of certificate; delete certificate upon receipt of PSV

If AMA/AOA Profile is used as PSV type in Description field of Image tab "AMA/AOA Profile"

If used for certificate, identify in comments

Open Never Archive

Fingerprinting Documentation

Cred Image DocumentAble to combine images to create or add to this document name

Open Never Archive

FOIA Response Cred Image ResponseFOIA response from State licensing board

Never Archive

FPPE Documentation Cred Image Document Yes Completed proctoring form(s) etc.effective date mm/dd/yy; include initial


FPPE Forms Cred Image Document Last use was ZCH & GR 8/25/2016 Facility Never Archive

FPPE Plan Cred Image Document Last use was ZCH & GR 8/3/2016 Facility Never Archive

FPPE Quality Data Report Cred Image Document Last use was 8/18/15 by ZCHFrom date and thru date


FSMB Results Cred Image Response Copy of FSMB web image Open Retain Last

Gap Analysis Report Cred Image Document YES Gap report from MSOW Open Retain Last

Gap Explanation Cred Image DocumentAble to combine images to create or add to this document name

Retain Last

GSA - Current Cred Image ResponsePDF version of internet grabber image

Open Retain Last






Cred, AHP or Apogee


Resp or DocUsed in

ARM packet?




Health related info - MISC Cred Image Document Example, return to work clearance openArchive if greater than 2 years

High School AHP Credential ResponseUsed by AHP if highest level of education

Use document type for copy of diploma

Enter in Comments grey tab of Credentials blue tab: Verified through Background Check

If diploma, identify as such in comments

Open Never Archive

Hospital affiliation - Current Cred Hospital Response YESPSV of current active hospital affiliation

If >10 years or >7 facilities enter in Comments grey tab: Verification not required per CVO guidelines


Hospital affiliation - Prior Cred Hospital Response YES PSV of prior hospital affiliation

If >10 years or >7 facilities enter in Comments grey tab: Verification not required per CVO guidelines


ICD10 Training Cred Image DocumentDocumentation of ICD10 successful completion

Retain Last

Immunization Record AHP Health Item Document YESAttestation, titer or immunization records or exemption from requirements

Split document from AHP mandatory credentialing requirements or if actual records, combine multiple pages into a single document

Enter Completed date as date received or submitted

Open Retain Last

Influenza verification Cred Health Item DocumentIncluded in Mandatory Credentialing Requirements

Remove from Mandatory Cred Requirements

Enter date of electronic signature

Open Retain Last

Insurance - Claims History Cred Insurance Response YES

Claims History reports from Insurance Companies. All previous malpractice insurance information (for up to last 10 years) is entered under this document type so that a claims history request letter may be generated.

Scan face sheets as Document type.

Use claims history report to verify data entry of complete policy information. Check Claim Filed? field if company reports claim and flag for MSO review.

Open Never Archive






Cred, AHP or Apogee


Resp or DocUsed in

ARM packet?




Insurance - Current Malpractice

Cred Insurance Document YES

Copy of face sheet. Data entry of complete policy information drives the Expirable process and Historical should never be checked. Whenever policy truly expires or cancelled, change document to Claims History. NOTE: A provider may have two separate insurance policies in effect at the same time (ex. general practice and resident faculty).

Open Never Archive

Insurance - Prior Malpractice

Cred Insurance Document ??

Copy of face sheet. DO NOT USE GOING FORWARD. Current Malpractice changed to Claims History when policy expires. If expiration date is greater than 10 years prior mark historical.


Internship Cred Credential Response YES Training verification form from PSVUse document type for copy of certificate



Open Never Archive

ITLS Cred ID Number Document YES Copy of card



Letter - Expirables Cred Image DocumentUsed by MSO for follow-up with practitioner on expired credentials.

Identify expired credentials


Letter - Insurance Cred Image DocumentUsed by MSO for follow-up with practitioner on expired malpractice insurance.


Logs Cred Image Document YES

Procedure logs in support of privilege request. Patient identifiers redacted. Includes location, procedure names and dates performed.

File should be in PDF whenever possible.

Timeframe in years







Cred, AHP or Apogee


Resp or DocUsed in

ARM packet?




Mandatory Credentialing Documents

Cred Image Document YES

For Physicians and APPs, includes: Influenza and TB Verifications, Confidentiality Statement, Waiver - Background, Waiver - Credentialing, & Medicare Acknowledgement.For AHPs, includes: Influenza & TB Verifications, Immunization/Immune Titer Record, Confidentiality Statement, Waiver - Background, Waiver - Credentialing.

Separate and upload each document individually selecting applicable document name. Delete Mandatory Credentialing Documents to eliminate duplicate images.


Medical Education Cred Credential Response YESPSV of education for MD, DO, DDS/DMD, DPM

Use document type for copy of diploma


If used for diploma, identify in comments

Open Never Archive

Medical Visitor Documentation

Cred Image Document All paperwork for medical visitor Facility Never Archive

Medicare Acknowledgment Cred Image DocumentTo be signed prior to intial granting of privileges at any facility

Identify facilities to which it applies

Open Never Archive

Military Service CredWork History

DocumentMilitary service (not hospital affiliation)

Scan copy of DD214 if not active military

Identify if DD214 Open Never Archive

Missing Items Report Cred Image DocumentA report run by CVO to identify missing items in their processes

Comment is added to identify the process - ie Intake or verification


Non-Acute Facility Affiliation - Current

Apogee Hospital Response Retain Last

Non-Acute Facility Affiliation - Prior

Apogee Hospital Response Retain Last

Non-SH Hospital Application Apogee Hospital DocumentCopies of Applications for other non-SH hospitals

Enter information in Hospital blue tab

Name of institution


Note to MS Leadership - SHBRH

Cred Image Document YESCredentialing issues for review by medical staff leadership

TBD by MSO

Never Archive

Note to MS Leadership - SHCCSH


TBD by MSO

Never Archive

Note to MS Leadership - SHGERBER


TBD by MSO

Never Archive

Note to MS Leadership - SHGR


TBD by MSO

Never Archive

Note to MS Leadership - SHKEL


TBD by MSO

Never Archive






Cred, AHP or Apogee


Resp or DocUsed in

ARM packet?




Note to MS Leadership - SHLH


TBD by MSO

Never Archive

Note to MS Leadership - SHP Cred Image Document YESCredentialing issues for review by medical staff leadership

TBD by MSO

Never Archive

Note to MS Leadership - SHREED


TBD by MSO

Never Archive

Note to MS Leadership - SHUH


TBD by MSO

Never Archive

Note to MS Leadership - SHZCH


TBD by MSO

Never Archive

Notice of Licensure Sanction Cred Report Card Document

Notice of licensure sanction received from practitioner, State FOIA response, or others (not NPDB)

Enter applicable information in facility report card blue tab

Identify source and/or document

Open Never Archive

NPDB - CQ Cancel Cred Image Response YESConfirmation of cancelled enrollment in CQ

Default comment is No Reports


NPDB - CQ Enrollment or Status

Cred Image Response YESNPDB report of new enrollment or current status


NPDB - CQ Renew Cred Image Response YES Confirmation of annual CQ renewalDefault comment is No Reports


NPDB - CQ Report Disclosure Cred Image Response YESNPDB report when a new incident is reported to the Data Bank.

Default comment is Number of Reports


NPDB - Query Response Cred Image Response YES NPDB query results

Default comment is Number of Reports or No Reports

Facility Retain Last

NPDB - Report Cred Report Card DocumentUsed by Management to report to NPDB

Enter applicable information in facility report card blue tab


NPDB - Report Change Notification

Cred Image ResponseNPDB report when a previously filed report is updated or changed

1 Reports FacilityArchive if greater than 2 years

NPDB - Report Disclosure Cred Report Card DocumentCQ report disclosure copied into Report Card blue button by MSO

Enter applicable information in facility report card blue button


NPI Number Cred ID Number Response YES Internet grabber Open Never Archive

NRP - Neonatal Resuscitation Program

Cred ID Number Document YES Copy of card








Cred, AHP or Apogee


Resp or DocUsed in

ARM packet?




Observation Report CredObservation Report

Document Never Archive

OIG Cred Image Response YES Web Crawl image Open Retain Last

OPPE Report Cred Report Card Document Never Archive

Packet - Privs for Authoritative Reference

Cred Image DocumentCombined image of privileges to attach to Authoritative Reference for review

This is a combined image Open Retain Last

PALS Cred ID Number Document YES Copy of card



Payer Application Apogee Image Document ApplicationUpload .pdf or scan document

Payer name SHMG Retain Last

Payer Confirmation Apogee Image Document Email or LetterUpload .pdf or scan document


Payer Termination Apogee Image Document Email or LetterUpload .pdf or scan document


Payment Cred Image Document Copy of checkRecord in CVO facility Dues blue buttons

Initial Application YEAR

CVOArchive if greater than 2 years

PCP Patient Reassignments Apogee Image Document Various TypesUpload .pdf or scan document

SHMG Retain Last

PCP Payer Close Requests Apogee Image Document Various TypesUpload .pdf or scan document

SHMG Retain Last

PCP Payer Open Requests Apogee Image Document Various TypesUpload .pdf or scan document

SHMG Retain Last

Perfect Serve Notice Cred KEEP? - Yes, for now. Never Archive

Photo Identification Cred Image Document Copy of drivers license or federal ID Open Never Archive

Physician Finder Form Cred Image DocumentThe physician finder form from the physician


Physician Referral Form Cred Image DocumentThe physician referral form from the physician


Post Graduate AHP Credential Document YESPost graduate education (MS, PhD, MPH)

Open Never Archive

Practice Specialties Cred Specialties Document YES

Data entry to identify practice specialty for practitioner if different than board specialty. Will pull into physician finder.

No document to scan Open Never Archive






Cred, AHP or Apogee


Resp or DocUsed in

ARM packet?




Practitioner Photo Cred Photo Document

Professional photo of the practitioner - used for Physician Finder page. Can be seen on the staff screen on the Photo/Signature grey tab

Open Never Archive

Practitioner Signature Cred Signature Open Never Archive

Privilege Changes Documentation

Cred Image DocumentPaperwork relating to additional or relinquishment of privileges.

Scan documents as received into one packet and replace with complete packet upon board approval

Identify privileges pending or approved as applicable with effective date


Privilege Release Cred Image Document YESImage of approved privileges posted or uploaded by MSO

Effective date Facility Never Archive

Privilege Release (non PCCB) Cred Image Document YESImage of approved privileges uploaded by MSO

Effective date FacilityArchive if greater than 2 years

Privilege Request Cred Image Document YESPrivilege request form completed by applicant.

Identify form if provider as multiple (ex. Sedation, Robotics, etc.)


Privilege Request SHBRH Cred Image Document YESPrivilege request form completed by applicant.


facilityArchive if greater than 2 years

Privilege Request SHCCSH Cred Image Document YESPrivilege request form completed by applicant.



Privilege Request SHGERBER Cred Image Document YESPrivilege request form completed by applicant.



Privilege Request SHGR Cred Image Document YESPrivilege request form completed by applicant.








Cred, AHP or Apogee


Resp or DocUsed in

ARM packet?




Privilege Request SHKEL Cred Image Document YESPrivilege request form completed by applicant.



Privilege Request SHLH Cred Image Document YESPrivilege request form completed by applicant.



Privilege Request SHP Cred Image Document YESPrivilege request form completed by applicant.



Privilege Request SHREED Cred Image Document YESPrivilege request form completed by applicant.



Privilege Request SHUH Cred Image Document YESPrivilege request form completed by applicant.



Privilege Request SHZCH Cred Image Document YESPrivilege request form completed by applicant.



Proctoring - CombinedCred Image Document YES Cindy created and needs to define facility Retain Last

Proctoring - Concurrent Cred Image Document YESCopies of completed proctoring forms


Proctoring - Prospective Cred Image Document YESCopies of completed proctoring forms


Proctoring - Retrospective Cred Image Document YESCopies of completed proctoring forms


Professional Reference Cred References Response YES Completed reference forms.Identify Relationship/Role in Comments Tab


Profile Long Report Cred Image Document YESInitial application profile report for MSO

CVO handoff to MSO


PSES CS Prescribing Delegation

Apogee Image Document FormUpload .pdf or scan document

SHMG Retain Last






Cred, AHP or Apogee


Resp or DocUsed in

ARM packet?




PSES Electronic Signature Apogee Image Document FormUpload .pdf or scan document

SHMG Retain Last

PSES Offboarding Form Apogee Image Document FormUpload .pdf or scan document

SHMG Retain Last

PSES Provider Acknowledgement and Consent


SHMG Retain Last

PSES Provider Announcement

Apogee Image Document Email Upload .pdf or scan document

SHMG Retain Last

PSES Provider Intake/Onboarding Form


SHMG Retain Last

PSES Resignation Documentation

Apogee Image Document Various TypesUpload .pdf or scan document

SHMG Retain Last

Reappointment Application Cred Image Document YESApplication submitted usually through MSONet.

YYYY OpenArchive if greater than 2 years

Reappointment Documentation

Cred Image Document

All paperwork from practitioner for reappointment will be combined: board letter, privileges, reappointment application, other supporting documents as one packet.

Each reappointing facility will use the original 'open' reappointment application and add their specific finalized documents. Final reapp packets are then scanned by each MSO into their own facility - leaving the original intact and open.

YYYY FacilityArchive if greater than 2 years

Reappointment Profile Cred Image DocumentProfile generated at reappointment for file handoff to MSO

CVO handoff to MSO


Recommendation Signature Page

Cred Image DocumentSignature page with department chair thru Board approval signatures

Effective Date: xx/xx/xxxx


Report Card Cred Report Card DocumentMSOs use to record adverse actions or findings.


Research - GME Cred Credential ResponseResearch that may occur anytime after Med Ed; CVO will attempt to verify

Open Never Archive

Research - Work History CredWork History

Response Research (employed Open Never Archive

Residency Cred Credential Response YES Training verification form from PSVUse document type for copy of certificate



Open Never Archive

Resignation Documentation Cred Image DocumentAll paperwork associated with resignation

Combined Image feature enabled

Effective : xx/xx/xxxx


SAR - Catalog Cred Image Document Access request for IS applications Depends Never Archive






Cred, AHP or Apogee


Resp or DocUsed in

ARM packet?




SHMG NP Collaborative Practice Agreement


SHMG Retain Last

State Disciplinary Report Cred Report Card Response YESFOIA response from State licensing board


State License Cred ID Number Response YES Web Crawl imageUse document type for copies of licenses from practitioner

If used for copy not PSV, identify with comment


Status Change Documentation

Cred Image DocumentAll paperwork associated with change in status

Effective mm/dd/yyyy and replace request with completed packet


Summary Suspension - Clinical

Cred Report Card DocumentDocumentation of summary suspension


TB verification Cred Health Item DocumentObtained at initial application and annually thereafter.

Open Retain Last

Teaching appointment CredWork History

DocumentAcademic teaching appointments entered as work history and generally no PSV is required.

Open Never Archive

Temporary Privileges Documentation

Cred Image Document

Includes (1) Temporary privilege recommendation and approval form; (2) Temporary privileges letter to physician; (3) the temporary privileges list; (4) NPDB query result; and (5) State License Verification.

Upload final approved privilege form and delete privilege request form; Combined Image feature is enabled for this document.

Effective xx/xx/xxxx; Identify privileges pending or approved as applicable with effective date


Training Program - other Cred Credential DocumentAny non-accredited training related to practitioner's SH role.

Open Retain Last

Training Specialties Cred Specialties Document YES

Specialized training/certification (bariatric, echocardiography, TEE, etc.) typically with issue and expiration dates for expirables

Open Never Archive

Undergraduate or Professional Program

AHP Credential Response Use only for AHP Open Never Archive

Waiver - MPIE Sharing Cred image DocumentWaiver specificly for Insurance claims - to be able to share CVO claims with MPIE

Retain Last

Waiver and Release - Background

Cred Image DocumentApplicant's authorization and consent to background check

Open Retain Last

Waiver and Release - Credentialing

Cred Image DocumentApplicant's authorization and consent to credentialing process

Open Retain Last

Work History CredWork History

Document YESApplicant's employment history; generally no PSV is required.

Start/end date and position REQUIRED.

Open Never Archive



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Sample Audit Summary Report (Exhibit F)

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SHCVO Operating Manual | Last updated August, 2014 41

Morrisey Downtime Log (Exhibit G) Date/Time Downtime

Began

Date/Time Notification

Sent

Date/Time Service

Restored Description of Downtime Episode Initials


REQUEST FOR CHANGE IN PRACTICE/PROVIDER DEMOGRAPHICS

Provider Name Last First Middle

NPI Number

PROVIDER DEMOGRAPHICS Type/Print Information to be Changed Effective Date

Home Address

Home Phone Email Address Pager Cell/Mobile Other (specify) Other (specify)

PRACTICE OR GROUP DEMOGRAPHICS Type/Print Information to be Changed Effective Date

Office Name Office Address Line 1 Office City, State Zip Office Phone 1 Office Phone 2 Office Fax Website Other (specify) Other (specify) Indicate Office Type (check all that apply) Does this office replace an existing location?

If yes, print/type Practice Name and Address to be removed for this provider

PERSON REQUESTING CHANGE Printed Name Date

Email Phone

Email completed form to [email protected] or fax to the Credentials Verification Office at 616.391.3115 or send interoffice mail to MC233

CVO Form 2/23/16


mailto:[email protected]

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Mailing

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Secondary

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Billing

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Yes

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No

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Practice Name:

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Practice Address:

jud84067

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Practitioner Demographic Update Form (Exhibit H)


Principles to guide evaluation of a CVO (Exhibit I)

1. The SHCVO makes known to the PMSO the data and information it can provide.

2. The SHCVO provides documentation to the PMSO describing how its data collection,information development, and verification processes are performed.

3. The PMSO is given sufficient, clear information on database functions, including anylimitations of information available from the SHCVO (such as practitioners not included inthe database), the time frame for SHCVO responses to requests for information, and asummary overview of quality control processes related to data integrity, security,transmission accuracy, and technical specifications.

4. The PMSO and SHCVO agree on the format for transmitting credentials information aboutan individual from the CVO.

5. The PMSO can easily discern what information transmitted by the CVO is from a primarysource and what is not.

6. For information transmitted by the SHCVO that can go out of date (for example, licensure,board certification), the CVO provides the date the information was last updated from theprimary source.

7. The CVO certifies that the information transmitted to the PMSO accurately represents theinformation obtained by it.

8. The PMSO can discern whether the information transmitted by the CVO from a primarysource is all the primary source information in the CVO’s possession pertinent to a givenitem or, if not, where additional information can be obtained.

9. The PMSO can engage the CVO’s quality control processes when necessary to resolveconcerns about transmission errors, inconsistencies, or other data issues that may beidentified from time to time.

10. The PMSO has a formal arrangement with the CVO for communicating changes incredentialing information.

Source: The Joint Commission’s Comprehensive Accreditation Manual for Hospitals, Glossary, July 2, 2014.


Profile For: Oakley TEST

Generated: September 23, 2014 12:46 PM

Anticipated Start Date:

Facility: Spectrum Health Grand Rapids

Information

Home Address: 123 Spectrum Health

Home Phones: (000)000-0000

Mobile Phone:

Beeper/Pager:

24Age:

Sex: M

Allied Health:

Sponsors:

Directory Reprint:

E-mail: [email protected]

Yes

No

Offices

Test

PO Box 123

Grand Rapids, MI

Office Contact:

Phone Number 1:

Phone Number 2:

Fax Number:

Answering Service:

(312)555-1414(312)555-1212

215-251Xx2

Mailing Address: Primary: YesYes

20th Street Clinic

105 20th Street N

Battle Creek, MI 49015

Office Contact:

Phone Number 1:

Phone Number 2:

Fax Number:

Answering Service:

(269)964-8422(111)888-7878

Mailing Address: Primary: YesNo

Status

Date on Staff:

Current Status:

Status Catg:

Department:

Section: Hospital Medicine

Medicine

Temporary Privileges

Applicant

Next Reappointment:

Status From Date:

Status Thru Date:

03/14/2014

Section 2:

Department 2:

Specialties

Board:

Physician Assistant

Board Specialties

NCCPA-National Commission on Certification of PA's

Document:

Specialty:

Comment:

Page 1 of 5Morrisey MSOW


jud84067

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Sample Profile Report (Exhibit J)



Primary:

Expiration

Eligible:

Certified: Certified Year:

No

No

Yes

General Certificate

No Last Verified Date:Lifetime:

Specialty Categ:

Exam Date:

ID Numbers

Type/Number State Expiration Date Verified Date Comments

State license: 1234567 MI

Controlled Substance: 123124321421 12/12/1212

State license: 1234567 MI 02/02/2222

DEA-Resident: 123456789

Credentials

Grand Valley State University (PA Program)

From: 1/1/2000 Thru: 1/1/2002

Grad Year: 2002 Degree: PA

Specialty:

APP Education Comment:

Program Completed: No

Verification Completed:

Hospital Affiliations

Hospital: Spectrum Health Hospitals (Midlevels verif

HR)

From: 1/1/2001 Thru:

Status:

Verified Completed:

Specialty:

Comment:Affiliations: Hospital Affiliation - Current

Hospital City:

Hospital State:

Grand Rapids

MI

Hospital: Metro Health Hospital

From: 1/1/2001 Thru: 1/1/2002

Status:

Verified Completed:

Specialty:

Comment:Affiliations: Hospital Affiliation - Prior

Hospital City:

Hospital State:

Wyoming

MI

Work History

Test 123

,

Work Phone:

Fax:

Position Held:

Dates:

Type:

From to

Work History





Contact:

Contact Phone: Comments:

Test 321

,

Work Phone:

Contact:

Contact Phone:

Fax:

Position Held:

Dates:

Type:

From to

Teaching appointment

Comments:

Test 911

,

Work Phone:

Contact:

Contact Phone:

Fax:

Position Held:

Dates:

Type:

From to

Military Service

Comments:

ABC

,

Work Phone:

Contact:

Contact Phone:

Fax:

Position Held:

Dates:

Type:

From to

Work History

Comments:

ABC

,

Work Phone:

Contact:

Contact Phone:

Fax:

Position Held:

Dates:

Type:

From to

Work History

Comments:

References

Authoritative Reference:

Hannah Thomas

,

Phone:

bdEmail:

Verification Date:

Comment:

Professional Reference:

Cindy Smeenge

,

Phone: 8889990909

bdEmail:

Verification Date:

Comment:

Professional Reference:

Judy Roberts

,

Phone: 0009998989

bdEmail:

Comment:





Verification Date:

Insurance Companies

Company: Michigan Professional Insurance Exchange

Suite 403 221 Michigan St NE

Grand Rapids, MI 49503

Policy Number:

Issued:

123456

Insurance - Current MalpracticeInsurance:

Expires:Retroactive Date

Comment:

Amount Per Incident:

Aggregate Amount:

$0.00

$0.00


NoClaim Filed:

Comment:

Company: The Doctors Company - East Lansing

PO Box 1471

East Lansing, MI 48826

Policy Number:

Issued:

987654321

Insurance - Prior MalpracticeInsurance:


Comment:


Aggregate Amount:

$0.00

$0.00


NoClaim Filed:

Comment:

Company: Medical Protective Company - Fort Wayne

5814 Reed Road

Fort Wayne, IN 46835

Policy Number:

Issued:

121212

Insurance - Claims HistoryInsurance:


Comment:


Aggregate Amount:

$0.00

$0.00


NoClaim Filed:

Comment:

Company: Michigan Professional Insurance Exchange

Suite 403 221 Michigan St NE

Grand Rapids, MI 49503

Issued: 01/01/1212

Insurance - Current MalpracticeInsurance:

Expires: 02/02/2222Retroactive Date

Comment:





Policy Number: 123456Amount Per Incident:

Aggregate Amount:

$0.00

$0.00


NoClaim Filed:

Comment:




Designated Equivalent Sources (Exhibit K) Selected agencies that have been determined to maintain a specific item(s) of credential(s) information that is identical to the information at the primary source.

Designated equivalent sources include, but are not limited to the following:

1. The American Medical Association (AMA)The Physician Masterfile may be used for verification of a physician’s United States and Puerto Rican medical school graduation and postgraduate education completion.

2. The American Board of Medical Specialties (ABMS)The website may be used for verification of a physician’s board certification.

3. The Educational Commission for Foreign Medical Graduates (ECFMG)The website may be used for verification of a physician’s graduation from a foreign medical school.

4. The American Osteopathic Association (AOA) – Physician DatabaseThe AOA Physician Database may be used for verification of pre-doctoral education accredited by the AOA Bureau of Professional Education; postdoctoral education approved by the AOA Council on Postdoctoral Training; and Osteopathic Specialty Board Certification.

5. The Federation of State Medical Boards (FSMB)The FSMB may be used for verification of all actions against a physician’s Medical license.

6. The American Academy of Physician Assistants (AAPA)The AAPA Profile may be used for verification of physician assistant education, provided through the AMA Physician Profile Service (https://profiles.ama-assn.org/amaprofiles/).

Source: The Joint Commission’s Comprehensive Accreditation Manual for Hospitals, Glossary, July 2, 2014.


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