( c) A decision not to process an application under this Section does not entitle the individual to the hearing and appeal rights outlined in this Manual and is not reportable to any state agency or to the National Practitioner Data Bank.
( d) The Medical Staff Office, along with the CMO / VPMA and the Credentials Committee Chair, oversees the process of gathering and verifying relevant information and confirming that all references and other information deemed pertinent have been received and are complete without the need for any additional follow-up.
3. B. 3. Steps to Be Followed for Initial Applicants:
( a) Evidence of the applicant’ s character, professional competence, qualifications, behavior, and ethical standing will be examined. This information may be contained in the application, and obtained from peer references and other available sources, including the applicant’ s past or current department chair at other health care entities, residency training director, and others who may have knowledge about the applicant’ s education, training, experience, and ability to work with others. The National Practitioner Data Bank will be queried, other state and federal databases, including but not limited to the Office of Inspector General’ s List of Excluded Individuals / Entities will be checked, and a criminal background check will be obtained.
( b) Interview( s) with the applicant are encouraged, especially for applicants seeking clinical privileges. The purpose of the interview is to discuss and review any aspect of the applicant’ s application, qualifications, and requested clinical privileges. This interview may be conducted by any of the following: department chair, section chief, Credentials Committee, MEC, Chief of Staff, or CMO / VPMA. The applicant will be notified if an interview is requested. Failure of the applicant to appear for a scheduled interview will be deemed a withdrawal of the application.
( c) The Medical Staff Office will notify the relevant department chair / section chief that the credentialing file and supporting materials are available for review.
3. B. 4. Department Chair / Section Chief Procedure:
The Medical Staff Services Department shall transmit the complete application and all supporting materials to the department chair / section chair in which the applicant seeks clinical privileges. Each chair shall document their findings regarding whether the applicant has satisfied all of the qualifications for appointment and the clinical privileges requested and make a recommendation.
3. B. 5. Credentials Committee Procedure:
( a) If the application is designated Category 1( Streamlined), it is presented to the Credentials Committee Chair for review and recommendation. The Credentials
4877-0873-6192, v. 3
19