Your Top 5 Privileging Questions Answered: Requirements, Procedures, and More

Your Top 5 Privileging Questions Answered: Requirements, Procedures, and More

Jan 24, 2023
  • Author:
    Noelle Abarelli

In our Privileging 101 webinar series, we covered a variety of topics, like legal aspects of privileging, the anatomy of a privilege delineation, and much more. As you can imagine, we received many follow-up privileging questions when the series concluded. Below, you can find some of the most frequently asked questions and our answers to them. For a deeper dive into all questions asked, check out the series Q&A session.

Question #1

When it comes to telemedicine and virtual visits, does this require separate or specific privileging outlined in the privilege set? What certifications or requirements can be waived for telemedicine (i.e., life support certifications, etc.)?

If a provider is delivering healthcare services both in-person in a facility and other services are provided virtually, typically, the virtual services would not need to be privileged separately. If a provider is delivering services only virtually, they would then need appropriate privileges for the services to be provided.

Any requirements that would only be important if a provider was delivering services in person could be waived. This could include health screening, vaccinations, life support certifications, etc. activities that may not be required for telemedicine.

Question #2

Should education be verified through the National Student clearinghouse?

Yes, you can verify education through the National Student Clearing House. It can also be verified by pulling an AMA profile for your MD providers, and/or by pulling an AOA for your DO providers. You can also verify their education by outsourcing it to the Provider’s Educational Institution.

Question #3

What is the difference between the Centers for Medicare & Medicaid Services (CMS) Conditions For Coverage (CFCs) and Conditions for Participation (CoPs)?

Both CFCs and CoPs are the health and safety requirements put in place by the CMS. They are the foundation for protecting the health and safety of beneficiaries while improving the quality of care. Organizations must meet these requirements in order to participate in both Medicare and Medicaid programs.

Conditions for Coverage define the covered services within Health Care Organizations that are covered/eligible for payment by Medicare and Medicaid.


Conditions of Participation are the Federal Standards that Health Care Organizations are required to be in compliance with, in order to receive Medicare and Medicaid certification and payment. There are specific CMS CoPs related to Privileging:

Condition of Participation: Governing Body

  1. Standard: Medical staff. The governing body must:
    • Ensure the criteria for selection are individual character, competence, training, experience, and judgment; and
    • Ensure that under no circumstances is the accordance of staff membership or professional privileges in the hospital dependent solely upon certification, fellowship, or membership in a specialty body or society.

    Condition of Participation: Medical Staff

  2. Standard: Medical staff bylaws. The medical staff must adopt and enforce bylaws to carry out its responsibilities. The bylaws must:
    • Include criteria for determining the privileges to be granted to individual practitioners and a procedure for applying the criteria to individuals requesting privileges.

Question #4

Is there a CMS requirement for the automatic suspension of a provider's privileges if they do not complete their patient medical records within 30 days post-discharge?

Enforcing suspension of Privileges due to medical records delinquency is at the discretion of the hospital’s medical staff. Many hospitals choose to enforce this type of suspension to encourage completion of medical records within 30 days, so they are able to bill Medicare within the required timeframe to maintain their Provider Interim Payment (PIP) status.


  • The requirement for completion of medical records should be defined in the hospital’s medical staff rules and regulations
  • The provisions for an administrative suspension due to not meeting the requirements for completion of medical records should be defined in the medical staff bylaws (if the medical staff has to enforce this.)

Question #5

Does the CMS define who the responsibility falls on for the review of privilege forms every two years? Is it the responsibility of the CVO, MSO, Medical Director, Department Chair, or someone else?

There are no regulatory requirements that specifically state the titles of clinical leaders who must participate in the process of reviewing privilege forms. The organized medical staff should have a policy regarding the review of privilege forms, so you should refer to your policy to determine if your medical staff has defined any clinical leaders as required members for participating in this process.

Once privilege forms have been developed, the medical staff should have a plan for regular review and updating of all privilege forms in order to keep privilege forms relevant and in alignment with current requirements. Some privilege forms will require annual review while others may be reviewed every two years.

Also, in between formal review periods, the medical staff should have policies and procedures in place for when new technology, equipment, or procedures are introduced, which would require new privileges to be added to their delineations. They must determine that the privilege/procedure in question should be added to the scope of services for the medical staff, and they must develop criteria for what providers will be eligible to apply for the new privilege or procedure.

More Q&A

These are just five of the privileging questions we received at the close of our Privileging 101 webinar series. To access more questions and answers, listen to our bonus Q&A webinar session. If you still have some unanswered questions, worry not, that’s what we’re here for. Just give us a shout and we’ll do all we can to get you the answers you need to become a privileging pro!