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Frequently Asked Questions - Credentialing

General Questions

What is 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. A variety of resources are used to verify the information involving direct communication from the educational and training institutions, past and current hospital affiliations and employers, peer reference letters, certification boards, licensing agencies and other sources.

Privileging – Granting approval for an individual to perform a specific procedure or specific set of privileges based on documented competence in the specialty in which privileges are requested.

Who is Credentialed?

Each individual working in the hospital or clinic setting must be either:

  1. Credentialed through a MultiCare medical staff process; or
  2. Employed providers working in an outpatient MHS clinic; or
  3. Providing patient care services in any of our delegated outpatient clinics or with Behavioral health services

Practitioners who are independently responsible for patient care by virtue of their license and hospital authority must be credentialed even if they are employed by MHS. Licensed independent practitioners who must be credentialed regardless of whether they are MHS employees or not are physicians, dentists, certified nurse midwives, podiatrists, nurse practitioners, and psychologists.

Why Does MultiCare Credential?

MultiCare Health System, like other health care organizations, is legally responsible for knowing that individuals providing patient care are qualified and competent to do so. Over the past 30 years, there have been multiple legal cases where hospitals were held accountable because they had not done adequate credentialing.

The Joint Commission, The Centers for Medicare and Medicaid Services (CMS), National Committee on Quality Assurance (NCQA), Washington State 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.

Can a Physician or Other Practitioner Work Before Completing the Credentialing Process?

>No. It is MultiCare’s legal obligation to ensure that all practitioners have gone through the credentialing process and have been approved by the Board of Directors to work at an MHS entity.

A practitioner working for a MultiCare entity before the credentialing process is complete places MHS and the practitioner at legal risk and can directly impact MultiCare’s accreditation status.

What About Medical Students, Residents and Fellows?

MultiCare’s current bylaws and privileges do not allow a resident in training to work or moonlight independently within the health system. All residents are to work with the Graduate Medical Education office.

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

How Do I Know if I am Currently Credentialed with an MHS Entity?

Contact the MultiCare Health System Credentialing Office in Tacoma at 253-403-1085.

How Does a Practitioner Get Credentialed and Request Privileges at an MHS Entity?

For information on the online credentialing application and application checklist, see How to Submit an Application.

Does MHS require an application fee?

Initial applications require a fee of the following:

$250.00 - Tacoma General/Allenmore/Mary Bridge Children’s Hospital
$200.00 - Good Samaritan Hospital (Active staff & Locums)
$250.00 - Auburn Medical Center

Allied Health Professional
$200.00 - Tacoma General/Allenmore/Mary Bridge Children’s Hospital
$100.00 - Good Samaritan Hospital
$100.00 - Auburn Medical Center

Payment may be made by check or credit card and must be received by the MultiCare Health System Credentialing Office before the application is processed. The application fee payment form is included in the Initial Application packet, see How to Submit an Application.

How Does a Practitioner Submit a Name Change or Office Change to the MultiCare Health System Credentialing Office?

Complete the Practitioner Change Form and submit it to the MultiCare Health System Credentialing Office.

What is The Joint Commission?

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. MultiCare Health System Credentialing Office complies with all of The Joint Commission credentialing standards.

What is the NCQA?

National Committee for Quality Assurance (NCQA) is an accrediting organization for managed care organizations. MultiCare Health System Credentialing Office must comply with NCQA credentialing standards as a condition of our delegated credentialing contracts with health plans.

Initial Application Questions

Why Does Credentialing Take so Long?

The MultiCare Health System Credentialing Office, like other credentialing, perform primary source verification of credentialing applications, and have very little control over process time. The process time is affected by verification sources (other hospitals, training programs, peer references, employers, etc.) responding to our requests for information.

If a response is not received, credentialing staff will execute additional requests to sources. This causes a significant time delay in completing applications.

Is There Anything a Practitioner Can do to Speed up the Application Process?

Yes. Practitioners can greatly influence the length of processing time by contacting their verification sources and peer references and asking each source to mail or fax MultiCare’s verification requests back as soon as possible to the Credentialing Office.

What Happens if the Application Submitted is Incomplete or Missing Required Attachments?

MultiCare only processes complete applications.

All incomplete applications are returned to the practitioner for completion, this creates a substantial delay in the practitioner credentialing process. Use the Initial Application Checklist as a guide to identify what forms need to be submitted.

See How to Submit an Application for detailed information.

What is Primary Source Verification (PSV)?

  • 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 come 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.

How Do I Submit a Credentialing Application?

See: How to Submit an Application

If I am Already on Staff at an MHS Entity, How Do I apply to Another MHS Entity?

See: How to Submit an Application

If I am Already on Staff at an MHS Entity, How Do I Request Additional Privileges at that Entity?

See: How to Submit an Application
Reappointment Questions

What is a Reappointment?

Reappointment is the process of re-evaluating a practitioner’s current competency after they have been appointed to the medical staff or professional staff at a MultiCare Health System facility. See: Reappointments.

Once I’m on Staff, Why Do I Need to go Through the Paperwork Again?

The Joint Commission hospital accreditation standards require all practitioners to complete a reappointment process every 24 months.

MultiCare Health System has a duty to ensure that all practitioner’s on staff are currently competent, reappointment is the process of re-evaluating competency.

What Happens If I Don’t Complete My Reappointment Paperwork?

The Joint Commission standards require practitioners complete the reappointment process every 24 months. If a practitioner does not complete reappointment paperwork on time, the practitioner’s reappointment will expire and they can no longer work or see patients in an MHS entity. If a practitioner’s reappointment expires, the practitioner must complete the initial application process in order to be appointed to the medical or professional staff and to treat patients at an MHS entity.

How Can I Get More Information on my Reappointment Paperwork?

See Reappointments for detailed information.

Expirable Questions

What is an Expirable?

At MultiCare Health System, expirables include a practitioner’s:

  • State license to practice
  • Malpractice insurance
  • DEA certificate
  • Board certification

How Can I Get More Information on the Expirables Process?

See Expirables for detailed information.

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