Credentialing

Credentialing is a term that usually encompasses two separate processes: credentialing and privileging.

• Credentialing: Primary source verification of a health care practitioner’s education, training, work experience, license, etc.
• Privileging: Granting approval for an individual to perform a specific procedure or specific set of procedures based on documented competency.

Practitioners who are independently responsible for patient care at Hennepin Healthcare by virtue of their license and hospital authority must be credentialed (regardless of whether they are Hennepin Healthcare employees or not). Credentialed providers at Hennepin Healthcare include:

• Physicians
• Dentists
• Podiatrists
• Chiropractors
• Optometrists
• Advanced Practice Nurses
• Physician assistants
• Psychologists
• Acupuncturists
• Advanced Dental Therapists
• Pharmacists doing Medication Therapy Management
• Radiology Practitioner Assistants

Hennepin Healthcare, like other health care organizations, is legally responsible for knowing that individuals providing patient care are qualified and competent to do so. The Joint Commission, The Centers for Medicare and Medicaid Services (CMS), National Committee on Quality Assurance (NCQA), Minnesota Department of Health and Human Services and other oversight organizations require that members of the medical and allied health staff be credentialed and privileged before working in the facility.

No. It is Hennepin Healthcare’s legal obligation to ensure that all practitioners have gone through the credentialing process and have been approved by the HHS Board of Directors to work at Hennepin Healthcare. A practitioner working at Hennepin Healthcare before the credentialing process is complete places the hospital and the practitioner at legal risk and can directly impact Hennepin Healthcare’s accreditation status.

Any medical student, resident or fellow who is in an ACGME accredited training program affiliated with Hennepin Healthcare can work in the facility without being credentialed as long as their practice does not fall outside the scope of their current training program.

Physicians in training who wish to moonlight outside of their residency or fellowship program must be credentialed. For example, a Cardiology fellow who plans to moonlight as an internist must be credentialed for internal medicine privileges.

Contact Hennepin Healthcare's Provider Credentialing Services at 612-873-9696 (option 5).

All requests for credentialing and privileging must be submitted through the appropriate department chief. Please contact the department service office for the department in which you wish to obtain privileges. If you do not have contact information for the department, you can call Provider Credentialing Services at 612-873-9696 (option 5) to request contact information.

Initial applications require a fee of $250. Payment must be received by Hennepin Healthcare Provider Credentialing Services before the application is processed.

• PSV is the process of verifying credentials directly with the source. For example, a credentialing office cannot accept a copy of a medical school degree as evidence that the physician graduated from medical school. The school must be contacted directly to verify the physician’s attendance and graduation.
• PSV is required so that hospitals and credentialing offices do not receive fraudulent documents from applicants or other non-primary sources.
• A credentialing office cannot accept any verification that comes through a third party rather than the primary source.
• PSV is a requirement by accrediting bodies as well as the cornerstone of a good credentialing process.

• The Joint Commission is an accrediting organization with a mission to improve the safety and quality of care provided to the public.
• Hospitals voluntarily submit to The Joint Commission accreditation surveys every three years; the survey is a comprehensive evaluation of the overall quality and safety of the organization.
• Hennepin Healthcare Provider Credentialing Services complies with all of The Joint Commission credentialing standards.

Most health care organizations advise submitting an application 120 days before a practitioner’s start date. This lead time allows extra time when verification sources do not respond in a timely manner or clarification of discrepancies is required.

• The Credentialing process consists of two steps:
  1. Verification and evaluation processes performed by Hennepin Healthcare Provider Credentialing Services; and
  2. Review and approval of the verified application by the Hennepin Healthcare Medical Staff and the HHS Board of Directors
• Offices that perform primary source verification of credentialing applications have very little control over process time. The process time is affected by outside verification sources (other hospitals, training programs, peer references, employers, etc.) responding to requests for information.
• An application can be completed in less time if peer references and other verification sources promptly respond to Hennepin Healthcare’s requests for information, requested documentation is supplied by the applicant in a timely fashion and there are no red flags identified in the application process which require further investigation.
• The verification process could be done in 2-3 weeks if all sources respond to first requests for information. If a response is not received, credentialing staff execute additional requests to sources; this causes a significant time delay in completing applications.
• After the verification process is complete, it may take another month or more for the Hennepin Healthcare Medical Staff and the HHS Board of Directors to make their final decision about membership and privileges for the applicant.

• Yes. Practitioners can greatly influence the length of processing time by contacting their verification sources and asking each source to mail or fax Hennepin Healthcare’s verification requests back as soon as possible.
• Practitioners can also help to speed the process by providing complete and accurateinformation on the application that they submit to Provider Credentialing Services.

All incomplete applications are returned to the practitioner for completion; this creates a substantial delay in the practitioner credentialing process.

• The Joint Commission accreditation standards require hospitals have privilege forms that indicate the type of care, treatment and services, or procedures that a practitioner will be authorized to perform.
• Upon applying for initial appointment or reappointment, practitioners complete a privilege form indicating what privileges or procedures they want to perform at Hennepin Healthcare.
• HennepinHealthcare’s privilege forms include two types of privileges:
  1. Primary (or core) privileges are those privileges that are routinely taught in most residency programs for the particular specialty. Practitioners that meet the threshold criteria for the specialty are qualified to request core privileges
  2. Specialty Privilege Clusters are procedures that require additional training or special competence. Additional documentation is required to demonstrate competence.

• Physicians within each specialty help to develop the privilege forms, including privilege qualifications. For example, family medicine physicians review and make recommendations on the Family Medicine privilege form, cardiologists review and make recommendations on the Cardiovascular Disease form, etc.
• At Hennepin Healthcare, the Credentials Committee then reviews the revisions proposed by physicians within the specialty and forwards recommendations to the Medical Executive Committee and the HHS Board of Directors. The Board of Directors has the final approval for all privilege forms at Hennepin Healthcare.

• The Joint Commission accreditation standards require that hospitals verify a practitioner’s current competency at each reappointment.
• Documentation criteria on privilege forms are established by the medical staff.
• If procedures were performed at Hennepin Healthcare, Provider Credentialing Services can obtain documentation on your behalf. Documentation of procedures performed at other institutions will need to be submitted by you along with your other reappointment paperwork.

• Hennepin Healthcare has a duty to ensure that all practitioners on staff are currently competent; reappointment is the process by which the medical staff periodically re-evaluates provider competency.
• The Joint Commission hospital accreditation standards require all practitioners to complete a reappointment process at least every 24 months.

• The Joint Commission accreditation standards require practitioners complete the reappointment process at least every 24 months; if a practitioner does not complete reappointment paperwork on time, the practitioner’s appointment and privileges will expire and they can no longer work or see patients at Hennepin Healthcare.
• If a practitioner’s reappointment expires, the practitioner must complete the initial application process in order and be re-appointed to the medical or professional staff in order to treat patients at Hennepin Healthcare.

“Expirables” are professional items with an expiration date that Provider Credentialing Services tracks and verifies on an on-going basis. At Hennepin Healthcare, Expirables include a practitioner's:

• License to practice
• Liability insurance
• DEA registration
• Board certification

Medical Staff Bylaws at Hennepin Healthcare require practitioners to maintain current Expirables at all times. Failure to renew Expirables may result in the suspension of medical staff privileges at Hennepin Healthcare until the renewal is verified by Provider Credentialing Services. All practitioners must be able to provide Provider Credentialing Services staff with renewed credentials or certificates PRIOR to expiration.

• An expired license, DEA certificate, board certification, or liability certificate may cause suspension of your privileges—for your sake, and for the sake of Hennepin Healthcare’s patients, we don’t want that to happen. Because of this, we have our system programed to send you automated e-mail reminders for the following documents:
  • Licenses, DEAs: You will receive reminders starting at 30 days prior to the expiration date.
  • Physician Board Certifications: You will receive a yearly reminder of the importance of keeping up with your board's MOC requirements and deadlines
  • Non-Physician Certifications:  You will receive reminders starting at 60 days prior to the expiration date.
  • Liability Certificates: If you are not covered by Hennepin Healthcare’s Tort policy, you will receive an e-mail several weeks prior to the expiration of your insurance certificate.
• The easiest way to reduce the number of e-mails you receive from credentialing is to renew your license, DEA, BLS, liability insurance and/or board certifications as soon as possible. Once credentialing can verify renewal, they will update your credentialing record.

If you receive a reminder e-mail for an item you’ve recently completed and notified credentialing of, please disregard the e-mail; it is common for there to be a short processing time before your record is updated in the Credentialing office. However, if at any time you believe you are receiving an e-mail in error, please feel free to contact Provider Credentialing Services at 612-873-9696 (option 5); we would be happy to check your data for errors and/or explain the reason for the e-mail.