CMS SOM App. A, Tag A-0051

§482.12(a)(7) 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.

Interpretive Guidelines §482.12(a)(7)

In making a judgment on medical staff membership, a hospital may not rely solely on the fact that a

MD/DO is, or is not, board-certified. This does not mean that a hospital is prohibited from requiring

board certification when considering a MD/DO for medical staff membership, but only that such

certification must not be the only factor that the hospital considers. In addition to matters of board

certification, a hospital must also consider other criteria such as training, character, competence and

judgment. After analysis of all of the criteria, if all criteria are met except for board certification, the

hospital has the discretion to decide not to select that individual to the medical staff.

Survey Procedures §482.12(a)(7)

Verify that written criteria for appointment to the medical staff and granting of medical staff privileges

are not dependent solely upon certification, fellowship, or membership in a specialty body or society.