Privileging 101 - Navigating the Regulatory and Legal Aspects of Privileging

Privileging 101 - Navigating the Regulatory and Legal Aspects of Privileging

Oct 20, 2022
  • Author:
    Noelle Abarelli

As a Medical Service Professional (MSP), you must adhere to a series of rules and regulations to ensure patients are safe. And when it comes to the regulatory and legal aspects of the job, there is a lot to consider when it comes to compliance. We understand how hard this can be, and this is why we created our webinar series, Privileging 101, which provides all the information you need to become a privileging pro.

In this series, we cover everything from the basics to the fundamentals of clinical privileging as well as how to navigate all the regulatory and legal aspects involved. Click here to access the webinar series at any time. In part three of the series, Privileging 101 - Navigating the Regulatory and Legal Aspects of Privileging, we go over the difference between credentialing and privileging, and provide an overview of the many accreditation bodies and their privileging standards. Read on for the highlights of this session.

Credentialing vs. Privileging

Let’s start by clarifying what the difference between credentialing and privileging. Credentialing is the process of assessing and confirming the qualifications of a licensed or certified healthcare practitioner. This includes verification of their education and training, as well as state licensure board certification. Credentialing is an essential process that healthcare organizations and medical practices must perform to ensure those providing services are qualified to do so.

Privileging is the process whereby a specific scope of a patient care services (that is clinical privileges) are authorized for a healthcare practitioner by a healthcare organization, based on an evaluation of the individual’s credentials and performance. Practitioners are granted privileges based on their education and training, which would include completion of medical school, residency, or fellowship depending on their specialty. For example, an internal medicine physician would not be granted privileges to do surgery as their residency training does not include training in any surgical techniques or procedures.


Privileging is required for a few reasons:

  • Legal requirements established for corporate liability
  • Regulatory requirements based on the CMS and accrediting bodies, like Centers for Medicare and Medicaid Services (CMS), The Joint Commission (TJC), DNV, AAAHC, HRSA, ACHC, HFAP.

Privileging Standards

When it comes to privileging, all accreditation organizations focus on specific health care organizations and have differing standards. See below for general guidance:

Accreditation Organization Health Care Organization Privilege Standards
The Joint Commission (TJC)
  • Hospitals (acute care, critical access, psychiatric)
  • Surgery Centers
  • Behavioral/Mental health centers
  • FQHCs
  • Hospitals must have a clearly documented and approved procedure for initial granting, renewal, or revision of privileges.
  • The privilege delineation system must be tailored to the hospital, taking technical and staff capabilities into consideration.
  • Practitioners must be privileged through the medical staff process.
  • An objective and evidence-based process must be used to grant/deny/renew privileges.
DNV-GL (Det Norske Veritas, Germanischer Lloyd) Hospitals
  • Patients must be under the care of a member of the medical staff.
  • Patient care must be provided in accordance with practitioner orders who meet medical staff criteria for granted privileges.
  • Practitioners must work within the scope of granted privileges.
  • Medical staff bylaws must describe medical staff duties and privileges of each category of treatment.
  • Medical staff must ensure acceptable standards are met for all diagnostic, medical, surgical, and rehabilitative services.
Accreditation Commission for Health Care (ACHC)
  • Hospitals
  • Surgery Centers
  • Behavioral/Mental health centers
  • These standards are taken directly from the CMS Conditions of Participation (CoP).
  • Governing Body must ensure the criteria for selection are individual character, competence, training, experience, and judgment.
  • Ensure professional privileges is not solely dependent on certification, fellowship, or membership in a specialty body.
  • Medical staff must adopt and enforce bylaws to carry out its responsibilities.
  • These bylaws must include criteria for the privileges to be granted in addition to a procedure for applying the criteria.
Accreditation Association for Ambulatory Health Care (AAAHC)
  • Surgery Centers
  • Behavioral/Mental health centers
  • FQHCs
  • Privileging is a three-phase process that involves 1: determination of procedures to be offered; 2: determination of qualifications required to obtain privileges; and 3: an established process for evaluating qualifications.
  • Privileges are granted for a specific period of time based on the provider’s qualifications.
  • The provider must be legally qualified for the privilege granted.
  • There must be a system in place to notify licensing/disciplinary bodies when privileges are suspended or terminated.
Bureau of Primary HealthCare (BPHC) & Health Resources and Services Admin (HRSA)
  • Surgery Centers
  • Behavioral/Mental health centers
  • FQHCs
  • Health centers must have operating procedures for the initial granting and renewal of privileges for clinical staff members, employees, individual contractors, or volunteers.
  • The privilege procedures must address: fitness for duty, verification of current clinical experience, current clinical competence via peer review, process for denying or modifying privileges based on assessments, and much more.

For full details on the standards requires by each accreditation organization, visit their websites:

In Summary

Healthcare organizations have a multitude of responsibilities they must abide by, and it’s a lot to keep track of, especially when it comes to regulatory and legal requirements. From the differing standards for each accreditation body, to the multitude of paperwork that must be completed to keep patients safe, having a grasp of all that is necessary to remain compliant takes time. VerityStream is all about providing guidance, so be sure to catch the whole Privileging 101 Webinar series for insight into the entire privileging process. And of course, if you have any questions, you know where to reach us.