UHC MD / APP Profile Form (Example) 2013
UHC MD / APP Profile Form (Example) 2013
UHC MD / APP Profile Form (Example) 2013
Rev. 12/12 Attachment H
Approved
Medical Staff Office (MSO) receives signed Letter of Offer and Pre-Application from Human Resources
Data Verified with Primary Source: Medical School, Internship, Residency, Fellowship, Hospital Affiliations, Medical License, State CDS, Federal DEA, Board Certification, and AMA Profile* (Except on International Medical Graduates and LSUHSC graduates). ECFMG Primary Verification completed on International Medical Graduates. Verification of VISA status completed on International Medical Graduates through Legal Affairs Office and Human Resources.
Data Collected From Primary Source: Peer References (2), Program Chair Evaluations, Data Bank Report, and Medicare/Medicaid Sanctions (OIG and EPLS).
Medicare Part B Opt Out verification will be provided by the Managed Care representative and added to the completed credentialing file.
Primary source verifications are obtained directly from Educational institutions attended, hospitals where privileges were held (past and present), State Boards of Medical Examiners (for licensure). Competency is verified with applicant’s educational program chairs and peer references.
(MSO) Mails:
Cover letter, Application, Request for delineations, Medicare/Medicaid Attestation Form, and the Medical Staff Bylaws to the applicant.
Physician/Adjunctive Staff completes and returns all forms to the MSO for processing. The applicant is responsible for completing all forms.
MSO verifies pre-app. to ensure core requirements are met. If YES, precede with application process. If NO, Notify Department Chairperson that candidate does not meet membership requirements.
Upon receipt of completed application, MSO begins data collection/Primary Source Verification Process.
Utilizing the Privilege List by Provider form pulled from MDSTAFF; the Clinical Chief completes substantive review, recommends membership category, and clinical privileges with or without modifications.
Credentials Committee reviews and approves the applicant for recommendation to the Clinical Board.
Credentials Chair presents all applicants to the Clinical Board the same month that Credentials meets.
Applicants approved at the next Clinical Board Meeting.
Applicants not approved require prompt written notification.
MSO generates letter RE: Board approval signed by CEO and sent to applicant with copy of approved clinical
LSUHSC Medical Staff Initial Application Process (FPPE)
NO
Application returned to the Department and Chair of the Clinical Board notified. The applicant may appeal.
YES
Applicants are a Provisional Status for one year at which time a proctor report is completed by Dept. Chair to assign membership status.
All members are reappointed every two years based on the date of initial appointment and must be evaluated on six competencies based on Dept as outlined in the FPPE process. approved are notified by the Dean /designee.
The applicant may then request an appeal.
Attachment I
Rev. 12/12 Medical Staff Office
(MSO) sends notice at least 120 days prior to the reappointment date to the Clinical Chief to review and approve.
(MSO) Mails:
Cover letter, provider profile application, including, current delineated clinical privileges on file, sanct Medical Staff Office (MSO) sends notice at least 120 days prior to the reappointment date to the Clinical Chief to review and approve.
i hi d
Physician completes and returns forms or documents required to the MSO at least 60 days or 2 months prior to the expiration date of the current appointment period.
MSO receives Notice from Department Chairperson YES to approve NO not to approve.
Approved applicants are mailed a reappointment application.
Applicants not approved are sent a letter stating the Department did not approve the applicant for reappointment.
Upon receipt of a completed application the MSO begins data verification. All incomplete applications are returned to the applicant for completion.
MSO verifies data for reappointment: Medical License, State CDS, Federal DEA and Board Certification, National Practitioner’s Data Bank, Medicare/Medicaid Sanctions, and hospital affiliations for the previous two (2) years.
MSO completes physician specific aggregate data including, quality profiles, infection control rates, committee attendance, medical records statistics, and patient complaints.
Utilizing UHC and MDSTAFF / APP Profile form; the MSO forwards compiled data to the Clinical Chief for completion of the substantive review (Attachment Q), membership category, and clinical privileges with or without modifications.
Each physician must be evaluated on six competencies which are specified by the individual department chairs as outlined in the OPPE process.
After approval by the Clinical Chief, the applicant must be approved by the Departmental Education Committee (2 signatures).
Medicare Part B Opt Out verification will be provided by the Managed Care representative and added to the completed credentialing file.
Credentials Committee reviews and approves the applicant for recommendation to the Clinical Board.
Credentials Chair presents all applicants to the Clinical Board the same month that Credentials Committee meets.
Applicants approved at the next Clinical Board Meeting.
Applicants not approved require prompt written notification by the Dean/designee. The applicant may request an appeal.
MSO generates letter RE:
Board approval signed by the CEO and sent to the applicant with a copy of the approved privileges.
LSUHSC Medical Staff Reappointment Application Process (OPPE)
Application returned to the Department and follow up is completed as applicable.
No
Yes
Physician Profile (Example)
Review Dates From 02/01/2009 To 01/31/2012 LSU Health Sciences Center Provider: Doe, Smith Z.
All Review Reasons
_______Review_______
MD ID / Name Dept Acct# Var CCC Out Comp Indicator Outcome
XX9090XX – Doe, Smith Z. Inpatient
Physician Review 1055495XXX Y N 1 Y 1000 Appropriateness of care rendered 1010 Legal review completed
Inpatient
Physician Review 1060195XXX N N 1 Y 1000 Appropriateness of care rendered
1001 Mortality review completed and documentation of autopsy offered which meet criteria
1018 All medication orders are appropriate/accurate 1019 H&P updated within 24 hours of admission
500 106019XXX N N 1 Y Completed post-op note
No surgery cancelled after the patient is in the Operating Room/Surgeries canceled must have documented medical reason.
Inpatient
Physician Review 106028XXX N N 1 Y 1000 Appropriateness of care rendered
1018 All medication orders are appropriate/accurate 1019 H&P updated within 24 hours of admission
500 10602XXXX N N 1 Y Completed post-op note
No surgery cancelled after the patient is in the Operating Room/Surgeries canceled must have documented medical reason.
Inpatient
Physician Review 10602XXX N N 1 Y 1000 Appropriateness of care rendered
1018 All medication orders are appropriate/accurate 1019 H&P updated within 24 hours of admission
500 106028XXXX N N 1 Y Completed post-op note
No surgery cancelled after the patient is in the Operating Room/Surgeries canceled must have documented medical reason.
CANCER 106070XXX Y N 1 Y AJCC Staging Documented
Blood Consent Completed for Blood/Blood Products Administered Case Summary Complete
Case Summary Present
Consent and Procedure Performed Agree Consent Obtained
Consults Identified and Ordered in a Timely Manner Diagnosis and Treatment Consistent with Needs
Diagnosis and Treatment Consistent with Practice Guidelines Nursing Assessment Incomplete
Referrals Documented
CANCER 106087XX Y N 1 Y AJCC Staging Documented
Blood Consent Completed for Blood/Blood Products Administered Case Summary Complete
Case Summary Present
Consent and Procedure Performed Agree Consent Obtained
Consults Identified and Ordered in a Timely Manner Diagnosis and Treatment Consistent with Needs
Attachment J
Physician Profile (Example)
Review Dates From 02/01/2009 To 01/31/2012 Provider: Doe, Smith Z.
All Review Reasons
_______Review_______
MD ID / Name Dept Acct# Var CCC Out Comp Indicator Outcome
Inpatient
Physician Review 1067782XXX Y Y 2 Y 1018 All medication orders are appropriate/accurate Not Met Inpatient
Physician Review 10692XX N N 1 Y 1013 All documentation/forms completed Indicator Met
Inpatient
Physician Review 10693XXXX N N 1 Y 1013 All documentation/forms completed Indicator Met Inpatient
Physician Review 10693XXXX N N 1 Y 1013 All documentation/forms completed Indicator Met Inpatient
Physician Review 107063XXX N N 1 Y 1013 All documentation/forms completed Indicator Met Inpatient
Physician Review 10725XXX N N 1 Y 1013 All documentation/forms completed Met
Inpatient
Physician Review 10726XXX N N 1 Y 1013 All documentation/forms completed Met
Inpatient
Physician Review 10726XXXXX N N 1 Y 1013 All documentation/forms completed Met
Inpatient
Physician Review 1072XXXX N N 1 Y 1013 All documentation/forms completed Met
Inpatient
Physician Review 107273XX N N 1 Y 1013 All documentation/forms completed Met
Inpatient
Physician Review 10727XXXX N N 1 Y 1013 All documentation/forms completed Met
Inpatient
Physician Review 10727XX N N 1 Y 1013 All documentation/forms completed Met
Inpatient
Physician Review 10727XXX N N 1 Y 1013 All documentation/forms completed Indicator Met
Inpatient
Physician Review 107292XX N N 1 Y 1013 All documentation/forms completed Indicator Met
Inpatient
Physician Review 107297XXXX N N 1 Y 1013 All documentation/forms completed Indicator Met Inpatient
Physician Review 10730XX N N 1 Y 1013 All documentation/forms completed Indicator Met
Inpatient
Physician Review 10730XX N N 1 Y 1013 All documentation/forms completed Indicator Met
Inpatient
Physician Review 107324XX N N 1 Y 1013 All documentation/forms completed Met
Inpatient
Physician Review 107327XXX N N 1 Y 1013 All documentation/forms completed Met
Inpatient
Physician Review 107331XX N N 1 Y 1013 All documentation/forms completed Indicator Met
Inpatient
Physician Review 107337XX N N 1 Y 1013 All documentation/forms completed Indicator Met
Inpatient
Physician Review 10733XX N N 1 Y 1013 All documentation/forms completed Indicator Met
Attachment K
Medical Staff Office (MSO) sends notice at least 120 days prior to the reappointment date to the Clinical Chief to review and approve.
(MSO) Mails:
Cover letter, provider profile application, including,
current delineated clinical privileges on file, sanction history, and acknowledgement statement for signature for the reappointment period.
AHP completes and returns forms or documents required to the MSO at least 60 days or 2 months prior to the expiration date of the current appointment period.
MSO receives Notice from Department Chairperson YES to approve NO not to approve. Approved applicants are mailed a reappointment application.
Applicants not approved are sent a letter stating the Department did not approve the applicant for
reappointment.
Upon receipt of a completed application the MSO begins data verification. All incomplete applications are returned to the applicant for completion.
MSO verifies data for reappointment: Current License, National Practitioner’s Data Bank, Medicare/Medicaid Sanctions, and hospital affiliations for the previous two (2) years.
Utilizing the UHC and MDSTAFF / APP Profile form; MSO forwards compiled data to the Clinical Chief for completion of the substantive review (Attachment R), membership category, and clinical privileges with or without modifications.
Each AHP must be evaluated on six competencies which are specified by the individual department chairs as outlined in the OPPE process.
After approval by the Clinical Chief, the applicant must be approved by the Departmental Education Committee (2 signatures).
Credentials Committee reviews and approves the applicant for recommendation to the Credentials Chair presents all
applicants to the Clinical Board the same month that Credentials Committee meets.
Applicants approved at the next Clinical Board Meeting.
Applicants not approved require prompt written notification by the Dean/designee. The applicant may request an appeal.
MSO generates letter RE: Board approval signed by the CEO and sent to the applicant with a copy of the approved privileges.