<?xml version='1.0' encoding='utf-8'?>
<regulation prefix="Regulation" num=".06" citation="COMAR 10.12.01.06" title_num="10" subtitle_num="12" chapter_num="01" heading="Personnel.">
  <paragraph num="A.">
    <text>Qualifications of Physicians and Staff. A facility shall ensure that all physicians and other health professionals who are employees or contractual staff have been appropriately trained and licensed or certified under the Health Occupations Article, Annotated Code of Maryland.</text>
  </paragraph>
  <paragraph num="B.">
    <text>Credentialing of Physicians. The facility shall collect, review, and document the following information concerning a physician licensed under Health Occupations Article, Title 14, Annotated Code of Maryland:</text>
    <paragraph num="(1)">
      <text>The physician's education;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>The professional experience of the physician, including:</text>
      <paragraph num="(a)">
        <text>Any board certification or specialty training of the physician; and</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Any post-graduate training;</text>
      </paragraph>
    </paragraph>
    <paragraph num="(3)">
      <text>Any license or registration to practice a health occupation ever held by the physician, including DEA registration;</text>
    </paragraph>
    <paragraph num="(4)">
      <text>Any hospital where the physician was appointed or employed during the last 10 years, including:</text>
      <paragraph num="(a)">
        <text>The name of the hospital;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>The term of appointment or employment; and</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Privileges held and any disciplinary action taken, including suspension, revocation, limitation, or voluntary surrender;</text>
      </paragraph>
    </paragraph>
    <paragraph num="(5)">
      <text>The physician's professional liability insurance for the last 5 years, including:</text>
      <paragraph num="(a)">
        <text>The physician's present carrier;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>The physician's current limits of coverage;</text>
      </paragraph>
      <paragraph num="(c)">
        <text>The physician's current types of coverage; and</text>
      </paragraph>
      <paragraph num="(d)">
        <text>Restrictions on the physician's coverage;</text>
      </paragraph>
    </paragraph>
    <paragraph num="(6)">
      <text>Any claim that has been made against the physician in the practice of a health occupation in the last 5 years, and the status of the claim;</text>
    </paragraph>
    <paragraph num="(7)">
      <text>Any physical or mental condition that currently impairs the physician's ability to exercise privileges;</text>
    </paragraph>
    <paragraph num="(8)">
      <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="(9)">
      <text>Data provided by the National Practitioner Data Bank.</text>
    </paragraph>
  </paragraph>
  <paragraph num="C.">
    <text>For a physician who has privileges in a licensed Maryland hospital, the administrator may verify, through the hospital, the credentials described in §B of this regulation.</text>
  </paragraph>
  <paragraph num="D.">
    <text>The administrator shall establish a procedure for the biennial reappointment of a physician which includes:</text>
    <paragraph num="(1)">
      <text>An update of the information required in §B of this regulation; and</text>
    </paragraph>
    <paragraph num="(2)">
      <text>An assessment of the physician's performance pattern based on an analysis of:</text>
      <paragraph num="(a)">
        <text>Complaints filed with the 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 practice patterns as reviewed through the facility's quality assurance program.</text>
      </paragraph>
    </paragraph>
  </paragraph>
  <paragraph num="E.">
    <text>Credentialing of Health Professionals.</text>
    <paragraph num="(1)">
      <text>Direct Hires.</text>
      <paragraph num="(a)">
        <text>The facility shall collect, review, and verify evidence of the following information for all licensed or certified health professionals that are employed by the 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 the health professional.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(2)">
      <text>Nondirect Hires. When a licensed physician uses a health professional to provide services at the facility, and that person is not employed by the facility, the licensed physician who employs the health professional is responsible for verifying the information required in §E(1) of this regulation.</text>
    </paragraph>
  </paragraph>
</regulation>