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Overview Submitting Reports to the NPDB Reporting Medical Malpractice Payments Reporting Adverse Clinical Privileges Actions Reporting Adverse Professional Society Membership Actions Reporting State Licensure and Certification Actions Reporting Federal Licensure and Certification Actions Reporting Peer Review Organization Negative Actions or Findings Reporting Private Accreditation Organization Negative Actions or Findings Reporting Exclusions from Participation in Federal or State Health Care Programs Reporting Federal or State Health Care-Related Criminal Convictions Reporting Health Care-Related Civil Judgments Reporting Other Adjudicated Actions or Decisions

Q&A: Reporting Clinical Privileges Actions

  1. A physician's application for surgical privileges was denied because the physician is not board certified in the clinical specialty and subspecialty for which he applied, as required by the hospital to which he applied for surgical privileges. Must this action be reported to the NPDB?

    No. The action should not be reported to the NPDB if the physician failed to meet the hospital's established threshold criteria applied to all medical staff or clinical privilege applicants. Examples of threshold criteria may include:(1) minimum professional liability coverage, (2) board certification, (3) geographic proximity to the hospital, and (4) performance of a minimum number of procedures prescribed for a particular clinical privilege.

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