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Administrative (Non-Clinical) Policy
UWHC only (Hospital Administrative-entity wide) UWMF only (entity wide)
UWHC Departmental (indicate name) UWMF Departmental (indicate name)
UWHC and UWMF (shared)
Policy Title: Credentialing and Professional Privileging of Advanced Practice
Policy Number: 8.75
Effective Date: June 1, 2015
Chapter: Patient Care
To establish a process for credentialing and professionally privileging advanced practice providers (APPs)
practicing at University of Wisconsin Hospital and Clinics (UWHC) locations. The Advanced Practice
Nurse Credentialing Council (APNCC) and Physician Assistant Credentialing Committee (PACC) are
responsible for reviewing and submitting recommendation of approval applications for credentialing and
professional privileges, Final approval for credentialing is granted by the UWHC Credentials Committee,
Medical Board and Board of Directors.
A. "Advanced Practice Nurse" (APN) is defined as a registered nurse currently licensed by the State
of Wisconsin Nursing Board or registered nurse license in another state that is recognized by the
State of Wisconsin with a master's or doctorate degree and certification as a nurse practitioner,
certified nurse midwife (CNM), certified nurse anesthetist (CRNA), or clinical nurse specialist
who provides a medical level of care.
B. “Physician Assistant (PA)” has graduated from an accredited PA program, certification as a PA
and currently licensed by the State of Wisconsin Medical Examining Board.
C. “Anesthesiologist Assistant (AA)” has graduated from an accredited AA program, certification as
a AA and currently licensed by the State of Wisconsin Medical Examining Board
D. “Advanced Practice Providers (APP)” – is defined as an advanced practice nurse, physician
assistant, or anesthesiologist assistant that provides a medical level of care.
E. "Advanced Practice Nurse Credentialing Council (APNCC)" - This Council is appointed by the
SVP Chief Nursing Officer & Patient Care Services and includes an administrative liaison from
the Nurse Executive Council. Member responsibility is to review professional
experience/training/certification/licensure of APNs and make recommendation for credentialing
F. “Physician Assistant Credentialing Committee (PACC)” – Member responsibility is to review
professional experience/training/certification/licensure of PAs and make recommendation for
credentialing and privileging.
G. “Scope of Practice” refers to duties approved to perform based on
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H. A "Collaborative statement of agreement" is a statement on the professional privilege list between
the APN and one physician within the department who represents the physicians within the
practice. The collaborating physicians agree to be available for consultation.
I. “Professional Privileges” are specific care and procedures that the APP is competent to perform
based on his/her experience/training/certification/licensure. Authorization to perform specific
procedures must be granted by UWHC Credentials Committee.
A. An APP's credentials and professional privileges must be approved by the UWHC Credentials
Committee before he/she can engage in practice or any patient contact at UWHC facilities. When
approved, the APP must act within their scope of practice and approved professional privileges,
as well as, abide by all relevant state and federal regulations and UWHC/UW Health
Administrative Manual policies and procedures.
B. The following documents are part of the credentialing and professional privileging packet:
application, applicant's consent and release, health history form, and professional privilege list.
C. When an APP would like to perform specific procedures not listed on their current professional
privilege list, he/she will request the additional privilege by providing documentation of
successfully performing the procedure under the supervision of another practitioner who is
authorized to perform the procedure and have it approved by the UWHC Credentials Committee.
D. When Registered Nurse First Assist (RNFA) privileges are requested by an APN, the Operating
Room Credentialing Sub-Council will review the application and forward to the APN
E. When a PA needs to add a supervising physician, he/she must complete an addendum form
signed by the PA, supervising physician they are adding, and the department chair or his/her
designee. This form must be approved by the UWHC Credentials Committee before they can
work with the new supervising physician.
F. A copy of the approved professional privilege list will be provided to the APP, kept on file in the
Medical Staff Affairs Office, available on U-Connect under Departments/UWHC/Medical
Staff/Privilege List Search.
G. APPs are initially approved for a period of up to two years. An APP is reappointed every two
years unless otherwise noted in their approval letter. Prescriptive practice for PAs must be
reviewed by a supervising physician annually.
H. Current national certification is required for all APPs who are approved to practice at UWHC
unless otherwise approved.
A. At the time of hire, the employing organization (UWHC, UWMF or UWSMPH or UWSON) will
notify the Medical Staff Affairs Office with the APP's name, contact information, department
administrator, collaborating/supervising physician(s), CV/resume and estimated start date.
B. The Medical Staff Affairs Office will send the APP applicant the credentialing packet. The
Medical Staff Affairs Office will also send a department privilege verification form to the
department administrator for completion.
C. After the Medical Staff Affairs Office has received the application, they will perform primary
source verification on all Wisconsin license(s), DEA certification (if applicable), national
certification, education and relevant work experience. They will also query the National
Practitioner Data Bank. This is performed before the application is reviewed by the appropriate
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D. Any applicant with malpractice history will be reviewed by UWHC Legal prior to the application
being reviewed by the APNCC/PACC. Documentation of this review will be given to the
APNCC/PACC for their review prior to decision making.
E. The APNCC/PACC will review all APN/PA credentialing applicants and requested professional
privileges and will submit recommendation for approval, modification or disapproval to the
UWHC Credentials Committee. The AA credentialing applications and requested professional
privileges are sent directly to the UWHC Credentials Committee.
F. The APP and the employing organization will receive written notification of UWHC Credentials
Sr. Management Sponsor: SVP, Medical Affairs; SVP Chief Nursing Officer & Patient Care Services
Author: Director, GME & Medical Staff Administration
Reviewer(s): APN Credentialing Council; PA Credentialing Committee; UWHC Credentials Committee
Approval Committee(s): Administrative Policy and Procedure Committee; Medical Board
President and CEO
Previous revision: 012015
Next revision: 062018