Credentialing & Privileging in an ASC

Definitions, in plain English

Credentialing is the verification process. Privileging is the facility's authorization to perform specific procedures based on documented training, experience, and current competence.

Elements of a credentialing file

• Signed application, attestation, and release.
• Current state license(s); DEA registration; controlled-substance permit.
• Medical school diploma; residency and fellowship certificates; board certification.
• Work history with explanations for any gap > 30 days.
• NPDB query (initial and Continuous Query thereafter).
• OIG LEIE exclusion check, SAM.gov check, state Medicaid sanction list.
• Malpractice claims history and current Certificate of Insurance.
• Health attestations: immunizations, TB screen, drug screen.
• BLS/ACLS/PALS as required by privilege scope.

Primary-source verification

Verification must come from the primary source, not the provider. Acceptable sources: the issuing authority itself or a CMS-recognized equivalent (AMA Profile, ABMS, FSMB, NPDB). Document verifier name, date, and capture the source response.

Privileging

Privileges must be specific (procedure level), supported by training/case-log evidence, time-limited (typically not exceeding 24 months), and reviewed via FPPE on initial grant and OPPE thereafter.

FPPE and OPPE

FPPE = Focused Professional Practice Evaluation. A time-limited focused evaluation of a newly privileged provider. OPPE = Ongoing Professional Practice Evaluation. The routine periodic review of every privileged provider's performance against measurable indicators.

Expiration tracking

License, DEA, board certification, malpractice, BLS/ACLS, fit testing — every credential has a clock. The single most common credentialing finding is an item that expired between application and survey. Fix: a single dashboard with every expiration and automated reminders at 90, 60, 30, and 7 days.

Re-credentialing and reappointment

Standards typically require re-credentialing and reappointment every 24 months. The reappointment file is a fresh credentialing file plus the OPPE record from the prior cycle.

Common survey findings

• Expired licenses, DEA, board certifications, or COIs in active provider files.
• NPDB queries documented at initial credentialing but not at reappointment.
• Privileges granted without documented training or case volume.
• FPPE not performed on initial privileges, or not documented.
• Verification by photocopy from the provider rather than primary source.

FAQ