Biographical sketch, kathy matzka, cpmsm, cpcs

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Notification of Internal and External Parties Regarding Practitioner Privileges

Key external and internal persons and organizations must be notified whenever a change occurs in a practitioner’s privileges or when a new practitioner is granted privileges or appointment. Some internal sources require information regarding clinical privileges granted, while others require only a general notification.
Internal Sources:
General Notification of New Practitioner:
When a new practitioner is granted medical staff appointment or clinical privileges, a general notification should be distributed via email or memo to all hospital departments. The following information should be included:
Full name, credential, address, phone, fax, pager/paging service number, partners, alternates, effective date, picture, sponsoring physician (if AHP).
General Notification Practitioner Leaving Staff:
When a practitioner leaves the staff, a general notification should be distributed via email or memo to all hospital departments. The following information should be included:
Full name, credential, forwarding address (if applicable), and effective date.
Notification of Privileges
When new privileges are granted either to a new applicant or an existing medical staff member or allied health professional; or when there is a modification (addition, deletion, termination, proctorship, etc.) to current privileges; the following internal personnel should be notified via email or memo and a copy of the privileges (or modification to privileges) should be included with the notification. (Note: Will need to modify this language to reference privileges that are posted via intranet or other electronic means).
[Name] Admitting Department

[Name] Operating Room

[Name] Nursing Administration (for distribution to all nursing units)

[Name] Administration

[Name] Emergency Department

[Name] Outpatient/Ambulatory Clinic(s)

[Name] Quality Management

[Name] (Include others, as appropriate)

External Sources
National Practitioner Data Bank and State Licensing Boards
The Health Care Quality Improvement Act of 1986 includes a requirement for reporting of certain adverse actions to the National Practitioner Data Bank.
Hospitals must report:
(1) a professional review action which adversely affects a physician’s or dentist’s clinical privileges for more than 30 days and is based upon the physician’s or dentist’s professional competence or professional conduct; and
(2) the voluntary surrender of clinical privileges by a physician or dentist who is under investigation relating to questions of professional competence or conduct, or in return for no investigation or professional review action being conducted.
A professional review action includes denying, reducing, restricting, revoking and suspending privileges, and also includes a decision not to renew clinical privileges if that action is based on the physician’s or dentist’s professional competence or conduct.
Hospitals must submit adverse action reports to the appropriate state licensing board within 15 days of final Board action in the case of an adverse action or within 15 days of the date the physician surrenders his or her clinical privileges. These reports must be submitted electronically to the National Practitioner Data Bank as an Adverse Action Report. Within 15 days, a printed copy of the electronic report must be forwarded to the state medical licensing board.
Revisions to previously reported adverse actions must also be reported. For example, if a physician’s clinical privileges are reinstated after a 45 day suspension, both the suspension and the reinstatement must be reported.
Note: All reports to state licensing boards and the NPDB should be coordinated with the Legal Department.

NPDB Query


[Facility Name]
It is the facility’s policy to comply with the requirements of the Healthcare Quality Improvement Act by performing a query of the National Practitioner Data Bank (NPDB) at each of the following times:

  • A physician, dentist, or other health care practitioner applies for medical staff appointment or for clinical privileges at the facility

  • At least every 2 years (biennially) on all physicians, dentists, and other health care practitioners who are on the medical staff or have clinical privileges.

  • When a practitioner wishes to add to or expand existing privileges

  • When a practitioner submits an application for temporary privileges

In addition, the facility may, in its discretion, query the NPDB as necessary for professional review activities.

The following information is required to perform a query:
Entity Data Bank Identification Number: [insert DBID Number]

User ID Number: [insert ID number]

Password: [insert password]
Note: Each facility should add information here regarding the password and entity ID number.
If the facility uses the Data Bank’s Querying and Reporting XML Service (QRXS) to store and manage their subject and report data within their own information or credentialing systems, this process should be included on this procedure.

For more information, see

Identification of Excluded Providers


[Facility Name]

It is the policy of the facility to verify that providers are not currently excluded from participation in Medicare, Medicaid, or other Federal health care programs.
The Office of Inspector General's (OIG) List of Excluded Individuals/Entities (LEIE) database provides information regarding individuals and entities currently excluded from participation in Medicare, Medicaid and all Federal health care programs.
System for Award Management (SAM) identifies those parties excluded throughout the U.S. Government (unless otherwise noted) from receiving Federal contracts or certain subcontracts and from certain types of Federal financial and nonfinancial assistance and benefits.

The System for Award Management (SAM) includes the following systems:

  • Central Contractor Registry (CCR)

  • Federal Agency Registration (Fedreg)

  • Online Representations and Certifications Application

  • Excluded Parties List System (EPLS)

Procedure for accessing the OIG’s LEIE:
1. Access the exclusion database at

2. Enter the last name and first name of the provider.

3a. If no results are found, print the search results.

3b. If results are found, click on the name field and this will bring up a page in a printable format along with a place to enter the social security number. Enter the social security number and click Verify.

4. Print out the page

5. Place report in the credentials file.

6. If results show that an action was taken, notify [include appropriate name].
Procedure for accessing the System for Award Management:
1. Access database at and click Search Records tab.

2. Enter name of the provider and click the Search button (a new page will open with results)

3. Click on the Printer Friendly link. A new page will open. Print the search results.

4. If no records, print out the page and place report in the credentials file.

5. If results show that an action was taken, click on View Details button, print the page and place report in the credentials file. Notify [include appropriate name].

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