Code of Maryland Regulations
Title 10 - MARYLAND DEPARTMENT OF HEALTH
Part 1
Subtitle 07 - HOSPITALS
Chapter 10.07.01 - Acute General Hospitals and Special Hospitals
Section 10.07.01.24 - Physician Credentialing Process
Universal Citation: MD Code Reg 10.07.01.24
Current through Register Vol. 51, No. 19, September 20, 2024
A. General. In accordance with this regulation, a hospital shall have in effect a credentialing process.
B. Scope of Credentialing Process. The credentialing process shall apply to any physician who shall admit or treat patients in the hospital.
C. Specific Standard - Appointment and Employment Process.
(1) In accordance with this section, a
hospital shall establish a formal written process for the appointment or
employment of a physician by the hospital.
(2) The term of an appointment shall be 2
years or less.
(3) The formal
written appointment or employment process shall provide for a probationary
period that shall be successfully completed before the finalization of the
appointment or employment of the physician.
(4) As part of the formal written appointment
and employment process, the hospital shall collect, verify, review, and
document the following information about the physician:
(a) The physician's education;
(b) The clinical expertise of the
physician;
(c) The professional
experience of the physician including:
(i) Any
board certification or specialty training of the physician;
(ii) The internship of the physician;
and
(iii) The residencies of the
physician;
(d) Any
license or registration to practice a health occupation ever held by the
physician, including:
(i) A license to
practice medicine; and
(ii) DEA
registration;
(e)
Whether any license or registration to practice a health occupation ever held
by the physician has been:
(i)
Suspended;
(ii) Revoked;
(iii) Voluntarily surrendered or not
renewed;
(f) Concerning
any hospital where the physician was appointed or employed:
(i) The name of the hospital;
(ii) The term of appointment or
employment;
(iii) Privileges held
and any disciplinary action taken on the privileges, including suspension,
revocation, limitation, or voluntary surrender;
(g) Concerning the physician's professional
liability insurance:
(i) The physician's
present carrier;
(ii) The
physician's current limits of coverage;
(iii) The physician's current types of
coverage;
(iv) Restrictions on the
physician's coverage; and
(v)
Whether or not the physician has maintained continuous malpractice coverage
since first obtaining professional insurance;
(h) Any claim that has been made against the
physician in the practice of any health occupation and the status of the
claim;
(i) The physician's medical
history including the physician's current mental and physical health
status;
(j) A complaint or report
filed with:
(i) The Board of Physicians or any
other state medical discipline agency;
(ii) A state medical society;
(iii) A state disciplinary body; or
(iv) A professional or specialty
association.
(5) The formal written process shall provide
for the documentation of any action taken by the hospital regarding the
appointment or employment of the physician.
(6) Uniform Standard Credentialing Form.
(a) A hospital shall use the uniform standard
credentialing form approved by the Department for the initial credentialing of
a physician seeking appointment or employment.
(b) Use of the uniform standard credentialing
form does not preclude a hospital from requiring additional information,
attestations, or supplemental documentation as required by that hospital's
credentialing process.
(c) A
physician seeking hospital privileges shall submit an updated and complete
uniform standard credentialing form at the time of application to each
hospital.
D. Specific Standard-Granting of Delineated Clinical Privileges.
(1) In accordance with this section, a
hospital shall establish a formal written process for the granting of
delineated clinical privileges.
(2)
The formal written process shall include:
(a)
Criteria for determining whether a physician shall be granted privileges by the
hospital to provide specific services;
(b) Criteria for ongoing evaluation of the
performance of the services for which privileges have been granted;
(c) Procedures for altering, suspending, or
revoking the delineated privileges.
(3) The formal written process shall provide
for documentation of any actions taken regarding delineated
privileges.
E. Specific Standard-Reappointment.
(1) In accordance with
this section, a hospital shall establish a formal written process for the
reappointment of a physician who has been appointed to the hospital.
(2) The term of reappointment shall be 2
years or less.
(3) As part of the
formal written appointment process, a hospital shall collect, verify, review,
and document the following information about the physician:
(a) An update of the information regarding
appointment under §C of this regulation;
(b) Concerning the physician's pattern of
performance based on an analysis of the following:
(i) Claims filed against the
physician;
(ii) Utilization,
quality and risk data;
(iii) A
review of clinical skills;
(iv)
Adherence to hospital bylaws, policies, and procedures;
(v) Compliance with continuing medical
education requirements;
(vi) An
assessment of current mental and physical health status;
(vii) Attitudes, cooperation, and the ability
to work with others; and
(viii) The
results of the Practitioner Performance Evaluation process as described in
Health-General Article, §§ 19-3 B-01-19-3B-09, Annotated Code of
Maryland.
F. Specific Standard-Record Maintenance.
(1) In accordance with this section, a
hospital shall maintain a separate credentialing file for each
physician.
(2) The credentialing
file for each physician shall contain documentation relating to the
credentialing process required under this regulation.
G. Disaster Privileges.
(1) During an emergency or disaster in which
the hospital's disaster or emergency management plan has been activated, when
the Governor has declared that a state of emergency exists, or when the
Secretary has issued an order pursuant to Health-General Article, §18-905,
Annotated Code of Maryland, the chief executive officer, medical staff
president, or designee may grant temporary disaster privileges to licensed
physicians who have not been appointed to the hospital's medical
staff.
(2) The hospital shall
develop a medical staff plan for the granting of disaster privileges that
identifies:
(a) The individual responsible
for granting disaster privileges;
(b) The responsibilities of that
individual;
(c) A system to manage,
assign, and supervise the physicians who have been granted disaster privileges;
and
(d) The process by which
credentials and privileges are verified as soon as the situation allows,
ensuring that the process complies with §C of this regulation.
(3) Physicians granted disaster
privileges by a hospital shall:
(a) Be
registered and trained by the Department as part of the Department's Maryland
Physician Volunteer Corps and possess the Department issued photo
identification; or
(b) Comply with
the hospital's medical staff plan for granting privileges in a disaster, which
shall require at least one of the following:
(i) Presentation of a current Maryland
license to practice medicine and a valid identification picture (ID) issued by
a state, federal, or regulatory agency;
(ii) Presentation of a license to practice
medicine from another state if a state of emergency has been declared by the
Governor and the assistance of the physician has been requested by Maryland
pursuant to the Emergency Management Assistance Compact, Public Safety Article,
§14-702, Annotated Code
of Maryland;
(iii) Presentation of
a current photo identification card from another Maryland hospital where the
physician is a member of the medical staff; or
(iv) Verification by a current member of the
hospital's medical staff who has personal knowledge regarding the
practitioner's identity and current Maryland medical licensure.
(4) Disaster privileges
shall be discontinued when the hospital's chief executive officer, medical
staff president, or designee determines that the emergency condition no longer
exists and that the hospital has adequate resources to meet the patient's
needs.
(5) The hospital shall
maintain records that include:
(a) The number
of hours worked by each physician;
(b) The type of service provided by each
physician;
(c) The location where
these services were provided; and
(d) Any additional information required by
the Department for federal and State reimbursement.
H. Telemedicine.Notwithstanding any other provision of COMAR 10.07.01.24, in its credentialing and privileging process for a physician who provides medical services to the patients at the hospital only through telemedicine from a distant-site hospital or distant-site telemedicine entity, a hospital may rely on the credentialing and privileging decisions made for the physician by the distant-site hospital or distant-site telemedicine entity as authorized under 42 C.F.R. Part 482, if:
(1) The physician who provides medical
services through telemedicine holds a license to practice medicine in the State
under Health Occupations Article, Title 14, Annotated Code of Maryland;
and
(2) The credentialing and
privileging decisions with respect to the physician who provides medical
services through telemedicine are:
(a)
Approved by the medical staff of the hospital; and
(b) Recommended by the medical staff of the
hospital to the hospital's governing body.
I. Request for Documentation by Department. On request from the Department, a hospital shall provide documentation that before:
(1) Appointment or employment of a
physician or granting delineated privileges, the hospital has complied with the
requirements of this regulation; and
(2) Reappointment or renewing of employment
or specific privileges, the hospital has complied with the requirements of this
regulation.
J. Penalties. If a hospital fails to have in effect a credentialing process in accordance with these regulations, the Secretary may impose upon the hospital the following penalties:
(1) Delicensure of
the hospital; or
(2) A fine of $500
for each day that the hospital is in violation of these regulations.
Disclaimer: These regulations may not be the most recent version. Maryland may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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