CMS SOM App. A, Tag A-0343

an agreement with a distant-site telemedicine entity, the governing body of the hospital

whose patients are receiving the telemedicine services may choose, in lieu of the

requirements in paragraphs (a)(1) and (a)(2) of this section, to have its medical staff rely

upon the credentialing and privileging decisions made by the distant- site telemedicine

entity when making recommendations on privileges for the individual distant-site

physicians and practitioners providing such services, if the hospital’s governing body

ensures, through its written agreement with the distant-site telemedicine entity, that the

distant-site telemedicine entity furnishes services that, in accordance with §482.12(e),

permit the hospital to comply with all applicable conditions of participation for the

contracted services. The hospital’s governing body must also ensure, through its written

agreement with the distant-site telemedicine entity, that all of the following provisions are

met:

(i) The distant-site telemedicine entity’s medical staff credentialing and privileging process

and standards at least meet the standards at §482.12(a)(1) through (a)(7) and §482.22(a)(1)

through (a)(2).

(ii) The individual distant-site physician or practitioner is privileged at the distant-site

telemedicine entity providing the telemedicine services, which provides the hospital with a

current list of the distant-site physician’s or practitioner’s privileges at the distant-site

telemedicine entity.

(iii) The individual distant-site physician or practitioner holds a license issued or

recognized by the State in which the hospital whose patients are receiving such

telemedicine services is located.

(iv) With respect to a distant-site physician or practitioner, who holds current privileges at

the hospital whose patients are receiving the telemedicine services, the hospital has

evidence of an internal review of the distant-site physician’s or practitioner’s performance

of these privileges and sends the distant-site telemedicine entity such performance

information for use in the periodic appraisal of the distant-site physician or practitioner.

At a minimum, this information must include all adverse events that result from the

telemedicine services provided by the distant-site physician or practitioner to the hospital’s

patients, and all complaints the hospital has received about the distant-site physician or

practitioner.

Interpretive guidelines §482.22(a)(4)

For the purposes of this rule, a distant-site telemedicine entity is defined as an entity that -- (1)

provides telemedicine services; (2) is not a Medicare-participating hospital; and (3) provides

contracted services in a manner that enables a hospital using its services to meet all applicable

Conditions of Participation, particularly those requirements related to the credentialing and

privileging of practitioners providing telemedicine services to the patients of a hospital. A

distant-site telemedicine entity would include a distant-site hospital that does not participate in

the Medicare program that is providing telemedicine services to a Medicare-participating

hospital. (See 76 FR 25553, May 5, 2011)

The hospital’s governing body has the option, when considering granting privileges to

telemedicine physicians and practitioners, to have the hospital’s medical staff rely upon the

credentialing and privileging decisions of the distant-site telemedicine entity for these physicians

and practitioners. This process would be in lieu of the traditional process required under

§482.22(a)(1) and §482.22(a)(2), whereby the medical staff conducts its own review of each

telemedicine physician’s or practitioner’s credentials and makes a recommendation based on that

individualized review.

In order to exercise this alternative credentialing and privileging option, the hospital’s governing

body must ensure that its written agreement with the distant-site hospital enables the hospital, as

required under the regulation at §482.12(e) governing services provided under arrangement, to

comply with all applicable hospital Conditions of Participation. In particular, the written

agreement between the hospital and the distant-site telemedicine entity must ensure that all of the

following requirements are met:

• The distant-site telemedicine entity utilizes a medical staff credentialing and privileging

process and standards that at least meets the standards for the medical staff of a hospital

established at §482.12(a)(1) through (a)(7) and §482.22(a)(1) through (a)(2);

• The distant-site telemedicine entity provides a list to the hospital of all physicians and

practitioners covered by the agreement, including their privileges at the distant-site

telemedicine entity. The list may not include any physician or practitioner who does not

hold privileges at the distant-site telemedicine entity. The list must be current, so the

agreement must address how the distant-site telemedicine entity will keep the list current;

• Each physician or practitioner who provides telemedicine services to the hospital’s

patients under the agreement holds a license issued or recognized by the State where the

hospital is located. States may have varying requirements as to whether they will

recognize an out-of-state license for purposes of practicing within their State, and they

may also vary as to whether they establish different standards for telemedicine services.

The licensure requirements governing in the State where the hospital whose patients are

receiving the telemedicine services is located must be satisfied, whatever they may be;

and

• The hospital has evidence that it reviews the telemedicine services provided to its patients

and provides a written copy of this review to the distant-site telemedicine entity for the

latter’s use in its periodic appraisal of the physicians and practitioners providing

telemedicine services under the agreement. At a minimum, the hospital must review and

send information to the distant-site telemedicine entity on all adverse events that result

from a physician or practitioner’s provision of telemedicine services and on all

complaints it has received about a telemedicine physician or practitioner.

Survey Procedures 482.22(a)(4)

• If the hospital provides telemedicine services to its patients under an agreement with a

one or more distant-site telemedicine entities, ask whether the hospital’s governing body

has exercised the option to have the medical staff rely upon the credentialing and

privileging decisions of the distant-site telemedicine entity in making privileging

recommendations on telemedicine physicians and practitioners. If yes, ask to see:

• The written agreement(s) with the distant-site telemedicine entity(ies). Does each

agreement address the required elements concerning the distant-site telemedicine

entity’s utilization of a medical staff credentialing and privileging process that meets

the requirements of the hospital CoPs, appropriate licensure of telemedicine

physicians and practitioners, current list of telemedicine physicians and practitioners

specifying their privileges, and written review by the hospital of the telemedicine

physicians’ and practitioners’ services and provision of information based on its

review to the distant-site hospital?

• The list provided by the distant-site telemedicine entity of the telemedicine physicians

and practitioners covered by the agreement, including their current privileges and

pertinent licensure information.

• Evidence that the hospital reviews the services provided by the telemedicine

physicians and practitioners, including any adverse events and complaints, and

provides written feedback to the distant-site telemedicine entity.

• Ask the hospital how it verifies that the telemedicine entity employs a credentialing

and privileging process that meets or exceeds what is required for hospitals under the

Medicare CoPs? (Surveyors do not attempt to independently verify whether or not

the distant-site telemedicine entity’s credentialing and privileging process fulfills the

regulatory requirements. Surveyors focus only on whether the hospital takes steps to

ensure that the distant-site telemedicine entity complies with the terms of the written

agreement.)