The hospital credentialing and privileging process is complicated, and you likely have many questions. These answers can help you understand the basics and navigate common challenges.
Note that details and individual requirements differ across hospitals and organizations. Secure and reference a copy of your medical staff bylaws as you prepare your application.
Physicians who work in a practice that contracts with federal or private insurers must undergo credentialing. Credentialing is the process of verifying a physician’s education, training, experience, current competence, and licensure to provide services.
Hospitals and other health care employers and payers both have credentialing processes to complete. Credentialing is closely tied with privileging and is frequently a first step for physicians seeking hospital privileges.
Privileging is the process of authorizing a specific scope of practice at a healthcare organization based on credentials and performance. Hospital governing boards grant privileges based on the recommendations from a physician's department and the credentialing committee. The hospital governing board should consider all recommendations, including to deny, accept, or referral back for further consideration. At least every 24 months, or more frequently if required by state law, physicians will need ongoing professional practice evaluation (OPPE) for continued or revised hospital privileges.
Read our how-to article to learn more about what documents you need and general steps you'll take to complete credentialing and secure privileges.
Yes, typically there are active and courtesy privileges. Some hospitals may have more categories of medical staff membership that may qualify for privileges. Review the medical staff bylaws for a statement of duties and privileges in each category of medical staff.
The purpose of credentialing and privileging is to ensure that qualified, well-trained physicians are providing quality care to patients. Although the steps are clear, credentialing and privileges are unique from location to location, and challenges can arise, including stressful privilege disputes. Practices may use different services for obtaining credentials, and for privileges to be secured, you’ll need to understand your hospital’s individual bylaws. These resources can help you in the event of an anticipated or actual privileging dispute:
Most insurers use the Council for Affordable Quality Healthcare (CAQH) Provider Data Portal https://proview.caqh.org. There is no cost for health care providers to enter and maintain their professional and practice information.
Medicare Credentialing and Enrollment is managed through the Medicare Provider Enrollment, Chain and Ownership System (PECOS).
Medical staff bylaws stem from various regulatory sources, including state hospital licensing laws, federal conditions of hospital participation in Medicare, and rules from accrediting organizations, such as The Joint Commission. They describe a hospital’s organizational structure, the medical staff‘s organizational responsibility, rules for self-governance, and outline privileges of all licensed physicians and non-physician practitioners. They are created and approved by medical staff with final approval from the hospital governing board. Revisions to medical staff bylaws must be approved by the governing board.
Because decisions about granting privilege are made locally, it's important for family physicians to participate in the medical staff meetings at their hospital and serve on the privileging committee.
Support your pursuit for privileges with help from the AAFP. These policies were written to help you advocate for the practice scope that fits your training. They can be provided as documentation in support of your request.