<?xml version='1.0' encoding='utf-8'?>
<regulation prefix="Regulation" num=".05" citation="COMAR 10.05.05.05" title_num="10" subtitle_num="05" chapter_num="05" heading="Personnel.">
  <paragraph num="A.">
    <text>Credentialing of Physicians, Dentists, Podiatrists.</text>
    <paragraph num="(1)">
      <text>As part of the formal written appointment process, the administrator, in consultation with the medical director, shall collect, review, and document the following information concerning a physician, dentist, or podiatrist licensed under the Health Occupations Article, Annotated Code of Maryland:</text>
      <paragraph num="(a)">
        <text>The physician's, dentist's, or podiatrist's education;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>The professional experience of the physician, dentist, or podiatrist, including:</text>
        <paragraph num="(i)">
          <text>Any board certification or specialty training of the physician, dentist, or podiatrist, and</text>
        </paragraph>
        <paragraph num="(ii)">
          <text>Any post-graduate training;</text>
        </paragraph>
      </paragraph>
      <paragraph num="(c)">
        <text>Any license or registration to practice a health occupation ever held by the physician, dentist, or podiatrist, including DEA registration;</text>
      </paragraph>
      <paragraph num="(d)">
        <text>Whether any license or registration to practice a health occupation ever held by the physician, dentist, or podiatrist has been:</text>
        <paragraph num="(i)">
          <text>Suspended, or</text>
        </paragraph>
        <paragraph num="(ii)">
          <text>Revoked;</text>
        </paragraph>
      </paragraph>
      <paragraph num="(e)">
        <text>Any hospital where the physician, dentist, or podiatrist was appointed or employed during the last 10 years, including:</text>
        <paragraph num="(i)">
          <text>The name of the hospital,</text>
        </paragraph>
        <paragraph num="(ii)">
          <text>The term of appointment or employment, and</text>
        </paragraph>
        <paragraph num="(iii)">
          <text>Privileges held and any disciplinary action taken, including suspension, revocation, limitation, or voluntary surrender;</text>
        </paragraph>
      </paragraph>
      <paragraph num="(f)">
        <text>The physician's, dentist's, or podiatrist's professional liability insurance for the last 5 years, including:</text>
        <paragraph num="(i)">
          <text>The physician's, dentist's, or podiatrist's present carrier,</text>
        </paragraph>
        <paragraph num="(ii)">
          <text>The physician's, dentist's, or podiatrist's current limits of coverage,</text>
        </paragraph>
        <paragraph num="(iii)">
          <text>The physician's, dentist's, or podiatrist's current types of coverage, and</text>
        </paragraph>
        <paragraph num="(iv)">
          <text>Restrictions on the physician's, dentist's, or podiatrist's coverage;</text>
        </paragraph>
      </paragraph>
      <paragraph num="(g)">
        <text>Any claim that has been made against the physician, dentist, or podiatrist in the practice of a health occupation in the last 5 years, and the status of the claim;</text>
      </paragraph>
      <paragraph num="(h)">
        <text>Any physical or mental condition that currently impairs the physician's, dentist's, or podiatrist's ability to exercise privileges;</text>
      </paragraph>
      <paragraph num="(i)">
        <text>Any complaint or report, permitted to be disclosed by law, which has been filed with any state licensing or disciplinary body, or comparable body of the armed forces; and</text>
      </paragraph>
      <paragraph num="(j)">
        <text>Data provided by the National Practitioner Data Bank.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(2)">
      <text>The administrator shall consider the delineation of services requested by each physician, dentist, or podiatrist and approve, deny, or modify the request as the administrator deems appropriate.</text>
    </paragraph>
  </paragraph>
  <paragraph num="B.">
    <text>For a physician, dentist, or podiatrist who has privileges in a licensed Maryland hospital, the administrator may verify, through the hospital, the credentials described in §A(1) of this regulation.</text>
  </paragraph>
  <paragraph num="C.">
    <text>The administrator shall establish a procedure for the biennial reappointment of each physician, dentist, or podiatrist. The procedures shall include an evaluation of the following for all physicians, dentists, or podiatrists:</text>
    <paragraph num="(1)">
      <text>An update of the information required in §A(1) of this regulation; and</text>
    </paragraph>
    <paragraph num="(2)">
      <text>An assessment of the physician's, dentist's, or podiatrist's performance pattern based on an analysis of:</text>
      <paragraph num="(a)">
        <text>Complaints filed with the freestanding ambulatory surgical facility,</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Malpractice claims filed,</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Utilization, quality, and risk data,</text>
      </paragraph>
      <paragraph num="(d)">
        <text>Adherence to policies, bylaws, and procedures, and</text>
      </paragraph>
      <paragraph num="(e)">
        <text>Physician, dentist, or podiatrist practice patterns as reviewed through the freestanding ambulatory surgical facility's quality assurance program.</text>
      </paragraph>
    </paragraph>
  </paragraph>
  <paragraph num="D.">
    <text>Credentialing of Allied Health Professionals.</text>
    <paragraph num="(1)">
      <text>Direct Hires.</text>
      <paragraph num="(a)">
        <text>The Administrator, in consultation with the medical director, shall collect, review, and verify evidence of the following information for all licensed or certified allied health professionals that are employed by the freestanding ambulatory surgical facility:</text>
        <paragraph num="(i)">
          <text>A current license or certificate to practice in this State; and</text>
        </paragraph>
        <paragraph num="(ii)">
          <text>Malpractice insurance, if required by the facility.</text>
        </paragraph>
      </paragraph>
      <paragraph num="(b)">
        <text>The administrator shall approve the delineation of services to be provided by each allied health professional.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(2)">
      <text>Nondirect Hires. When a licensed physician, dentist, or podiatrist uses an allied health practitioner to provide services at the freestanding ambulatory surgical facility, and that person is not employed by the facility, the licensed physician, dentist, or podiatrist who employs the allied health practitioner is responsible for verifying the information required in §D(1) of this regulation.</text>
    </paragraph>
  </paragraph>
  <paragraph num="E.">
    <text>Medical Director.</text>
    <paragraph num="(1)">
      <text>The freestanding ambulatory surgical facility shall have a medical director who:</text>
      <paragraph num="(a)">
        <text>Is responsible for the overall medical care that is provided by the facility; and</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Advises and consults with the staff of the facility on all medical issues relating to services provided by the facility.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(2)">
      <text>The medical director shall be a physician, dentist, or podiatrist licensed to practice in the general areas for which the freestanding ambulatory surgical facility provides services.</text>
    </paragraph>
  </paragraph>
</regulation>