Introduction to Privileging

- November 03, 2015 -

A big part of the credential management process is granting "privileges" to the doctor. This means granting a doctor the authorization to provide a specific service, procedure or treatment for a certain condition at a specified health care facility.

The purpose of maintaining updated credential files is to have the physician's’ credentials at hand at all times for liability and accreditation reasons, and to also prepare the physician for appointment or reappointment, at which facility privileges are granted. The formal procedures for credentialing and privileging should be outlined in every facility’s bylaws.

In this article, we will be introducing the second part of the credentialing process, privileging, and the parties involved.

The Process

Which documents are required?
Before the credential file advances to the final stages of approval, the credential manager must complete collecting and verifying all documents. A completed file also includes the physician’s application for new privileges as well as documentation of the physician’s existing privileges and standings at other facilities.

The credential manager can request the existing privileges through a request letter to the hospitals at which the doctor currently holds privileges. In response to the requests, the hospital should each send a letter including information on the physician’s existing privileges.

Who is involved?
The final decision-making process is long and involves participation from two groups to ensure that the physician meets all Medical Staff criteria. The applicant must be recommended by the Medical Advisory Committee, and be approved by the Governing Body

Here is a breakdown:

Type of Recommendation Description
Medical Advisory Committee The Medical Advisory Committee reviews the credential file and makes the recommendation to the Governing Body
Governing Body Approval The Board of Trustees Representative reviews the credential file and can choose to approve the recommendation of the Medical Advisory Committee or not. This is the final approval in the process.


What does it look like?

The recommendations and approvals are recorded on a form sheet that is included in the file. The form includes fields for the decision of each group, signatures of recommenders, date the recommendation was made, and comments. The date of the Board minutes for the action taken by the Governing Body must be included in the form.

Here is an idea of the format:

Dummy Privileging ASC


What happens if the applicant is approved?
Following the Governing Body’s approval, the applicant receives an official letter that is also kept in the credential file. The letter congratulates and states the effective date of the appointment or reappointment as well as the privileges granted to the physician. The letter is usually signed by a facility administrator or sometimes the Medical Director.

After the physician is appointed for the first time, he or she is required to undergo the reappointment process every 2 years after the initial date.

What happens if the applicant is denied or restricted?
Privileges can be denied based on reasonable basis such as professional and ethical misqualifications. The applicant will receive a letter containing the Governing Body’s decision as well as reasoning for the restriction or denial of the requested privileges. When the applicant is denied of existing privileges, the decision and reasoning must be reported to the NPDB.

The facility’s bylaws should also include that in the event of a denial or restriction, the applicant may appeal the decision in a fair hearing with the opportunity for appellate review.

Keeping well-managed credential files is extremely helpful for avoiding mistakes during privileging. Find out how Silversheet’s smart software can help you keep your credential files in order the painless and paperless way.