Attestation Statement

Question 1

TJC
Attestation Statement

Answer 1

No specifically addressed

Question 2

NCQA
Attestation Statement

Answer 2

CR3 Element C factors 1-6
1. Practitioners complete an application (and reapplication) that includes an inquiry regarding illegal drug use and inability to perform essential functions, history of loss or limitations of licensure or privileges or disciplinary actions, current malpractice coverage, and felony convictions.
2. Attestation must indicate that the applicant personally attests that the application was correct and complete when they applied to the organization. If a copy of an application from an external entity is used, it must include an attestation to the correctness and completeness of the application.
3. NCQA does not require the attestation to be received prior to the organization conducting credentialing verifications and queries required for other elements.
CR1
4. Signature can be faxed, scanned, digital, electronic or photocopied. Use of signature stamp is not allowed unless the practitioner is physically impaired and the disability is documented in the credentials file.
5. If State regulations require the application not containing an attestation, an addendum to the application for the attestation must be used unless State regulations prohibit
CR3
6. Time limit: must be signed within 365 days (MCO)/305 days (CVO) of the credentialing decision

Question 3

ACHC
Attestation Statement

Answer 3

Responsibilities for credentialed practitioners must include:
1. participating in Medical Staff functions, committee activity, educational and quality assessment/performance improvement activities.
2. abiding by bylaws, rules and regulations, and
3. adhering to ethical guidelines
Practitioners must attest to the above listed responsibilities at appointment and reappointment which is verified during the survey process

Question 4

DNV
Attestation Statement

Answer 4

Not specifically addressed

Question 5

URAC
Attestation Statement

Answer 5

1. The application includes a signed and dated statement attesting that the information submitted with the application is complete and accurate to the practitioners knowledge
2. Electronic signature is acceptable. Written policies and procedures should establish controls and manage risk for electronic signatures
   eg: acceptable signatures include faxed, digital, electronic, scanned or photocopied signatures.
3. Time limit: must signed and dated no more than 180 day prior to the credentials committee review

Question 6

AAAHC
Attestation Statement

Answer 6

1. The application and reapplication must have a formal statement releasing the organization from any liability in connection with the credentialing decisions and includes the applications attestation to the accuracy and completeness of the application and the information provided and the applicants dated signature.
2. The application includes a written attestation and the following information:
   a. professional liability claims history
   b. refusal or cancelation of professional liability coverage
   c. licensure revocation, suspension, voluntary relinquishment, licensure probationary status, or other licensure conditions or limitations
   d. complaints or adverse action reports filed against the applicant with a local, state of national professional society or licensure board
   e. denial, suspension, limitation, termination, or nonrenewal of privileges at any hospital, health plan, medical group, or other health care entity
   f. federal actions or sanctions including DEA and Medicare/Medicaid
   g. conviction of a criminal offense (other than minor traffic violations)
   h. current physical, mental health, or chemical dependency problems that would interfere with applicants ability to provide high-quality care and professional services.
3. Verify on an ongoing basis, at a minimum, at expiration, appointment and reappointment

Question 7

Medicare
Attestation Statement

Answer 7

Not specifically addressed