Periodic appraisal of a provider’s current competence after they’ve been granted initial privileges and/or appointed to the medical or professional staff is the process you know as reappointment.

Your organization may follow the accreditation or regulatory standards of CMS, Joint Commission, DNV, or NCQA. Regardless, they each provide a solid foundation for healthcare organizations to develop their own reappointment policies. Each requires provider re-evaluation following a standardized process and timeline.


We’ve taken common questions regarding reappointment and include guidance below:

Q: What’s best practice for reappointing providers with privileges at multiple facilities in a healthcare system?

Standardization and efficiency in reappointing providers better serves both the provider and the medical staff office or credentials verification organization (CVO). Let’s say a provider has privileges at three facilities in a system. With separate reappointment cycles at two years, that equals a lot of paperwork and administrative time. Facilities within your system may even use differing criteria for the reappointment trigger. Common ones are birth year/month, specialty/department, or alphabetical order. Best practice is to move toward a reappointment system where providers who have clinical privileges at multiple facilities in the same system receive one application, once during the two-year cycle, with privilege forms from each hospital or facility. Software helps simplify the task of managing multi-facility reappointment data.

Q: Is it better for our reappointment policies to exceed accreditors’ standards?

Regulators and accreditation bodies tell organizations what they must do to comply when reappointing providers. But they don’t specify exactly how to achieve the goal. It’s the case not only for reappointment, but for most standards. This enables differentiating factors like culture, population served, location, provider-body composition, and others to factor in.

If your organization has stringent reappointment polices that exceed regulatory or accreditation standards, remember two important factors:

  • Apply the reappointment standards uniformly to individuals granted initial privileges and/or appointed to the medical or professional staff per your organization’s own policies
  • A regulator/accreditor will hold your organization to the higher standards documented in your bylaws and/or policies and procedures for reappointment

Q: Should reappointment verifications match the initial appointment checklist?

Not necessarily. Best practices in reappointment warrant the verification and collection of data that’s not evergreen or which may have been affected by changes in practice since the last cycle. In addition, low-volume or no-volume issues may affect what data to collect and verify at reappointment. Generally, the reappointment checks include:

  • Licenses
  • Professional liability insurance and claims history
  • National Practitioner Data Bank
  • Lifetime criminal record
  • Healthcare-related employment and appointment history
  • Privilege history
  • Peer references for ability to perform the requested privileges
  • Clinical activity for the past 24 months
  • Performance assessment for ability to perform the requested privileges
  • General internet search

Q: Do you have sample provider reappointment bylaws language?

One example follows, and many healthcare organizations also post their bylaws online. Note the inclusion of quality and performance improvement criteria:

It is hospital policy to approve reappointment and/or renewal of privileges for only those providers who meet the criteria for initial appointment. In addition, the [Medical Executive Committee] must positively determine that the practitioner provides effective care that is consistent with the hospital’s ongoing and focused quality and performance improvement programs. The providers must supply all information required in order to fulfill the criteria for reappointment. All reappointments and renewals of clinical privileges are for a period not to exceed [twenty-four] months.