Section 3.05 - Qualified Patient Care Assessment Program - Credentialing(1) No health care facility in the Commonwealth shall appoint, hire, associate with for the purpose of providing patient care, or grant privileges to a licensee, unless the health care facility first completes the credentialing requirements set forth below. The health care facility must repeat these credentialing requirements at least every two years. These credentialing requirements are modified as follows: (a) The credentialing requirements may be performed during the time period in which the health care facility grants temporary appointment or privileges for up to 120 days in any one year period to a licensee seeking initial staff membership, provided the health care facility maintains on file a completed application for staff membership and written and timely evidence of a valid Massachusetts license, malpractice insurance, a current DEA certificate of registration for licensees who will be prescribing controlled substances, and appropriate references; and provided further that the health care facility pursues in good faith the credentialing of each licensee holding such temporary appointment or privileges.(b) The credentialing requirements do not apply when the health care facility grants temporary appointment or privileges for up to 30 days in any one year period to a licensee who is not seeking staff membership, provided the health care facility maintains on file written and timely evidence of a valid Massachusetts license, malpractice insurance, a current DEA certificate of registration for licensees who will be prescribing controlled substances, and letters of recommendation or references as deemed appropriate by the health care facility.(2) For the purposes of 243 CMR 3.05, Health Care Facility includes a substantially equivalent facility outside of the Commonwealth.(3) No health care facility in the Commonwealth shall appoint, hire, associate with for the purpose of providing patient care, or grant to or renew privileges of any licensee unless: (a) The health care facility verifies that the licensee holds a current license to practice medicine.(b) The licensee provides to the health care facility a copy of his or her most recent application for initial or renewal registration to practice medicine in the Commonwealth, including all attachments and other explanatory materials submitted with the application, whether required or voluntarily submitted. Only to the extent allowed by M.G.L. c. 151B, § 4, the licensee may delete from such application information disclosing: 1. an arrest, detention, or disposition, regarding any violation of law in which no conviction resulted;2. a first conviction for any of the following misdemeanors: drunkenness, simple assault, speeding, minor traffic violations, affray, or disturbance of the peace; and3. any conviction of a misdemeanor where the date of such conviction or the completion of any period of incarceration resulting therefrom, whichever date is later, occurred five or more years prior to the date of the credentials application, unless the licensee has been convicted of any offense within five years immediately preceding the date of the credentials application.(c) The licensee provides to the health care facility a listing and description of all malpractice claims and lawsuits pending or closed during the previous ten years, including the information listed in 243 CMR 3.05(3)(e) and any further relevant information requested by the health care facility. 243 CMR 3.05 applies, whether or not the transaction giving rise to the malpractice claim arose at the health care facility where the licensee is seeking or renewing appointment, employment, practice, association for the purpose of providing patient care, or privileges. 243 CMR 3.05 also applies, whether or not the malpractice claim is filed with an insurance carrier, a court, or another entity to which the malpractice claim is presented.(d) The health care facility has established criteria for documenting and analyzing, and so documents and analyzes, where available, a licensee's: 1. professional performance, judgment and clinical skills;2. mental and physical status;3. compliance with continuing education requirements;4. data dealing with utilization;5. adherence to health care facility and medical staff bylaws, policies and procedures;6. malpractice claims filed against the licensee; and7. information regarding any criminal proceedings.(e) The licensee authorizes his or her medical malpractice liability insurance carrier or carriers to release to the health care facility the following information, described in M.G.L. c. 112, § 5C, as to claims or actions for damages pending or closed during the previous ten years, whether or not there has been a final disposition: 1. the policy number of the licensee against whom the claim is made;2. the name, address and age of the claimant or plaintiff;3. the nature and substance of the claim;4. the date and place at which the claim arose;5. the amounts paid, if any, and the date and manner of disposition, judgment, settlement, or otherwise;6. the date and reason for final disposition, if no judgment or settlement; and7. such additional information as the Board shall require pursuant to M.G.L. c. 112, § 5C(g).(f) The licensee provides to the health care facility the name of any health care facility where the licensee has had employment, practice, association for the purpose of providing patient care, or privileges. The licensee must also provide the reasons for any discontinuance of employment, practice, association or privileges at any of the named health care facilities.(g) The licensee authorizes release to the health care facility any information from any other health care facility where the licensee has had employment, practice, association for the purpose of providing patient care, or privileges, if such information is relevant, either directly or indirectly, to the licensee's competence to practice medicine.(h) The licensee authorizes the health care facility to exchange information with any other health care facility and with any professional organization with which the licensee has or had employment, practice, association or privileges, regarding any pending or final disciplinary action as defined by 243 CMR 1.01(2), which includes but is not limited to any voluntary or involuntary course of counseling, treatment or testing for drug or alcohol abuse.(i) The health care facility makes reasonable inquiry to other health care facilities, where the licensee has or has had employment, practice, association for the purpose of providing patient care, or privileges, regarding the licensee, before allowing the licensee to practice medicine at the health care facility. In the case of an initial application, the health care facility shall make reasonable inquiry of every health care facility where the licensee has had employment, practice, association for the purpose of providing patient care, or privileges during at least the previous ten years. In the case of a renewal appointment, reasonable inquiry shall be directed to every health care facility where the physician has had employment, practice, association for the purpose of providing patient care, or privileges in the previous three years. "Reasonable inquiry" must include up to three requests, in writing, for: 1. an assessment of clinical skills; and2. information regarding any pending or final disciplinary action, malpractice litigation, and any other information relevant, either directly or indirectly, to the licensee's character or competence to practice medicine. In the case of an inquiry to a health care facility concerning a period of time when the licensee held a limited license under M.G.L. c. 112, § 9 (or performed equivalent post-graduate work outside of the Commonwealth), the health care facility where the licensee had his primary assignment may respond on behalf of its affiliated health care facilities where the licensee practiced medicine.(j) The health care facility, pursuant to its by-laws or by agreement with the licensee, will require the licensee to undergo a mental or physical examination, if requested by 1. the executive committee of the medical staff or2. the credentials committee, or3. by such other supervisory body, which includes members of the medical staff, as may be authorized in the facility's by-laws to make such request; and if there is a known mental or physical impairment, to provide evidence that the impairment does not interfere with the licensee's competence to practice medicine.