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

Current through Register Vol. 51, No. 14, July 12, 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.