1. A. General. In accordance with this regulation, a hospital shall have in effect a credentialing process.
2. B. Scope of Credentialing Process. The credentialing process shall apply to any physician who shall admit or treat patients in the hospital.

3. C. Specific Standard — Appointment and Employment Process.

   1. (1) In accordance with this section, a hospital shall establish a formal written process for the appointment or employment of a physician by the hospital.
   2. (2) The term of an appointment may not exceed the term established by the standards of the accreditation organization that accredits the hospital.
   3. (3) The formal written appointment or employment process shall provide for a probationary period that shall be successfully completed before the finalization of the appointment or employment of the physician.

   4. (4) As part of the formal written appointment and employment process, the hospital shall collect, verify, review, and document the following information about the physician:

      1. (a) The physician's education;
      2. (b) The clinical expertise of the physician;

      3. (c) The professional experience of the physician including:

         1. (i) Any board certification or specialty training of the physician;
         2. (ii) The internship of the physician; and
         3. (iii) The residencies of the physician;

      4. (d) Any license or registration to practice a health occupation ever held by the physician, including:

         1. (i) A license to practice medicine; and
         2. (ii) DEA registration;

      5. (e) Whether any license or registration to practice a health occupation ever held by the physician has been:

         1. (i) Suspended;
         2. (ii) Revoked;
         3. (iii) Voluntarily surrendered or not renewed;

      6. (f) Concerning any hospital where the physician was appointed or employed:

         1. (i) The name of the hospital;
         2. (ii) The term of appointment or employment;
         3. (iii) Privileges held and any disciplinary action taken on the privileges, including suspension, revocation, limitation, or voluntary surrender;

      7. (g) Concerning the physician's professional liability insurance:

         1. (i) The physician's present carrier;
         2. (ii) The physician's current limits of coverage;
         3. (iii) The physician's current types of coverage;
         4. (iv) Restrictions on the physician's coverage; and
         5. (v) Whether or not the physician has maintained continuous malpractice coverage since first obtaining professional insurance;
      8. (h) Any claim that has been made against the physician in the practice of any health occupation and the status of the claim;
      9. (i) The physician's medical history including the physician's current mental and physical health status;

      10. (j) A complaint or report filed with:

          1. (i) The Board of Physicians or any other state medical discipline agency;
          2. (ii) A state medical society;
          3. (iii) A state disciplinary body; or
          4. (iv) A professional or specialty association.
   5. (5) The formal written process shall provide for the documentation of any action taken by the hospital regarding the appointment or employment of the physician.

   6. (6) Uniform Standard Credentialing Form.

      1. (a) A hospital shall use the uniform standard credentialing form approved by the Department for the initial credentialing of a physician seeking appointment or employment.
      2. (b) Use of the uniform standard credentialing form does not preclude a hospital from requiring additional information, attestations, or supplemental documentation as required by that hospital's credentialing process.
      3. (c) A physician seeking hospital privileges shall submit an updated and complete uniform standard credentialing form at the time of application to each hospital.

4. D. Specific Standard — Granting of Delineated Clinical Privileges.

   1. (1) In accordance with this section, a hospital shall establish a formal written process for the granting of delineated clinical privileges.

   2. (2) The formal written process shall include:

      1. (a) Criteria for determining whether a physician shall be granted privileges by the hospital to provide specific services;
      2. (b) Criteria for ongoing evaluation of the performance of the services for which privileges have been granted;
      3. (c) Procedures for altering, suspending, or revoking the delineated privileges.
   3. (3) The formal written process shall provide for documentation of any actions taken regarding delineated privileges.

5. E. Specific Standard — Reappointment.

   1. (1) In accordance with this section, a hospital shall establish a formal written process for the reappointment of a physician who has been appointed to the hospital.
   2. (2) The term of reappointment shall be 2 years or less.

   3. (3) As part of the formal written appointment process, a hospital shall collect, verify, review, and document the following information about the physician:

      1. (a) An update of the information regarding appointment under §C of this regulation;

      2. (b) Concerning the physician's pattern of performance based on an analysis of the following:

         1. (i) Claims filed against the physician;
         2. (ii) Utilization, quality and risk data;
         3. (iii) A review of clinical skills;
         4. (iv) Adherence to hospital bylaws, policies, and procedures;
         5. (v) Compliance with continuing medical education requirements;
         6. (vi) An assessment of current mental and physical health status;
         7. (vii) Attitudes, cooperation, and the ability to work with others; and
         8. (viii) The results of the Practitioner Performance Evaluation process as described in Health-General Article, §§19-3B-01—19-3B-09, Annotated Code of Maryland.

6. F. Specific Standard — Record Maintenance.

   1. (1) In accordance with this section, a hospital shall maintain a separate credentialing file for each physician.
   2. (2) The credentialing file for each physician shall contain documentation relating to the credentialing process required under this regulation.

7. G. Disaster Privileges.

   1. (1) During an emergency or disaster in which the hospital's disaster or emergency management plan has been activated, when the Governor has declared that a state of emergency exists, or when the Secretary has issued an order pursuant to Health-General Article, §18-905, Annotated Code of Maryland, the chief executive officer, medical staff president, or designee may grant temporary disaster privileges to licensed physicians who have not been appointed to the hospital's medical staff.

   2. (2) The hospital shall develop a medical staff plan for the granting of disaster privileges that identifies:

      1. (a) The individual responsible for granting disaster privileges;
      2. (b) The responsibilities of that individual;
      3. (c) A system to manage, assign, and supervise the physicians who have been granted disaster privileges; and
      4. (d) The process by which credentials and privileges are verified as soon as the situation allows, ensuring that the process complies with §C of this regulation.

   3. (3) Physicians granted disaster privileges by a hospital shall:

      1. (a) Be registered and trained by the Department as part of the Department's Maryland Physician Volunteer Corps and possess the Department issued photo identification; or

      2. (b) Comply with the hospital's medical staff plan for granting privileges in a disaster, which shall require at least one of the following:

         1. (i) Presentation of a current Maryland license to practice medicine and a valid identification picture (ID) issued by a state, federal, or regulatory agency;
         2. (ii) Presentation of a license to practice medicine from another state if a state of emergency has been declared by the Governor and the assistance of the physician has been requested by Maryland pursuant to the Emergency Management Assistance Compact, Public Safety Article, §14-702, Annotated Code of Maryland;
         3. (iii) Presentation of a current photo identification card from another Maryland hospital where the physician is a member of the medical staff; or
         4. (iv) Verification by a current member of the hospital's medical staff who has personal knowledge regarding the practitioner's identity and current Maryland medical licensure.
   4. (4) Disaster privileges shall be discontinued when the hospital's chief executive officer, medical staff president, or designee determines that the emergency condition no longer exists and that the hospital has adequate resources to meet the patient's needs.

   5. (5) The hospital shall maintain records that include:

      1. (a) The number of hours worked by each physician;
      2. (b) The type of service provided by each physician;
      3. (c) The location where these services were provided; and
      4. (d) Any additional information required by the Department for federal and State reimbursement.

8. H. Telemedicine. Notwithstanding any other provision of COMAR 10.07.01.24, in its credentialing and privileging process for a physician who provides medical services to the patients at the hospital only through telemedicine from a distant-site hospital or distant-site telemedicine entity, a hospital may rely on the credentialing and privileging decisions made for the physician by the distant-site hospital or distant-site telemedicine entity as authorized under 42 C.F.R. Part 482, if:

   1. (1) The physician who provides medical services through telemedicine holds a license to practice medicine in the State under Health Occupations Article, Title 14, Annotated Code of Maryland; and

   2. (2) The credentialing and privileging decisions with respect to the physician who provides medical services through telemedicine are:

      1. (a) Approved by the medical staff of the hospital; and
      2. (b) Recommended by the medical staff of the hospital to the hospital’s governing body.

9. I. Request for Documentation by Department. On request from the Department, a hospital shall provide documentation that before:

   1. (1) Appointment or employment of a physician or granting delineated privileges, the hospital has complied with the requirements of this regulation; and
   2. (2) Reappointment or renewing of employment or specific privileges, the hospital has complied with the requirements of this regulation.

10. J. Penalties. If a hospital fails to have in effect a credentialing process in accordance with these regulations, the Secretary may impose upon the hospital the following penalties:

    1. (1) Delicensure of the hospital; or
    2. (2) A fine of $500 for each day that the hospital is in violation of these regulations.

Authority: Health-General Article, §§19-307.2, 19-308, 19-308.6, 19-308.8, 19-318—19-320, 19-323, 19-342, 19-349.1, and 19-380—19-385; Insurance Article, Title 4, Subtitle 4; Public Safety Article, §14-110.1; Annotated Code of Maryland

Effective date: December 19, 1946

Amended effective March 20, 1959

Amended effective September 1, 1964

Regulations .03C, G, I, K; .04B, D; .05A, B; .06C; .07B, E; .08A, B; .09B, C; .10F; .11A, B; .12F amended effective February 24, 1978 (5:4 Md. R. 226)

Regulations .01—.13 repealed and new Regulations .01—.10 adopted effective August 1, 1983 (10:15 Md. R. 1350)

Regulation .01 amended as an emergency provision effective August 12, 1985 (12:18 Md. R. 1756), emergency status expired December 10, 1985; adopted permanently effective December 16, 1985 (12:25 Md. R. 2471)

Regulation .01 amended effective May 23, 1994 (21:10 Md. R. 844)

Regulations .01, .02B, .04A, .05A, .07, .08B amended; .02C, .09D, and new .10 and .11 adopted; existing .10—.20 recodified as .12—.22 as an emergency provision effective July 1, 1986 (13:15 Md. R. 1726); adopted permanently effective December 1, 1986 (13:24 Md. R. 2558)

Regulation .01B amended effective December 28, 1987 (14:26 Md. R. 2746); August 6, 1990 (17:15 Md. R. 1858)

Regulation .01B amended as an emergency provision effective July 1, 2000 (27:15 Md. R. 1396); amended permanently effective October 30, 2000 (27:21 Md. R. 1975)

Regulation .01B amended effective November 11, 2002 (29:22 Md. R. 1721); April 21, 2008 (35:8 Md. R. 804); June 28, 2010 (37:13 Md. R. 852); April 16, 2012 (39:7 Md. R. 491); March 31, 2014 (41:6 Md. R. 378); March 27, 2017 (44:6 Md. R. 325); April 23, 2018 (45:8 Md. R. 420)

Regulation .02 recodified to be Regulation .03 and new Regulation .02 adopted effective July 4, 2016 (43:13 Md. R. 712)

Regulation .02 amended effective April 13, 2026 (53:7 Md. R. 328)

Regulation .02D adopted effective November 11, 2002 (29:22 Md. R. 1721)

Regulation .02D repealed effective June 28, 2010 (37:13 Md. R. 852)

Regulation .03 repealed and Regulation .02 recodified to be Regulation .03 effective July 4, 2016 (43:13 Md. R. 712)

Regulation .03 amended effective June 24, 1991 (18:12 Md. R. 1338)

Regulation .03A amended effective November 11, 2002 (29:22 Md. R. 1721); June 28, 2010 (37:13 Md. R. 852)

Regulation .04 amended effective June 28, 2010 (37:13 Md. R. 852)

Regulation .04A amended effective November 11, 2002 (29:22 Md. R. 1721)

Regulation .04A, C amended effective March 13, 2017 (44:5 Md. R. 292)

Regulation .04D amended effective February 26, 2007 (34:4 Md. R. 400)

Regulation .05 amended effective November 11, 2002 (29:22 Md. R. 1721)

Regulation .05A amended effective June 28, 2010 (37:13 Md. R. 852)

Regulation .06A amended as an emergency provision effective November 20, 2019 (46:26 Md. R. 1162); emergency status expired May 18, 2020

Regulation .06C adopted as an emergency provision effective November 20, 2019 (46:26 Md. R. 1162); emergency status expired May 18, 2020

Regulation .06-1 adopted as an emergency provision effective July 1, 2000 (27:15 Md. R. 1396); adopted permanently effective October 30, 2000 (27:21 Md. R. 1975)

Regulation .07 amended effective December 28, 1987 (14:26 Md. R. 2746); June 28, 2010 (37:13 Md. R. 852)

Regulation .07A amended effective November 11, 2002 (29:22 Md. R. 1721)

Regulation .08 amended effective November 11, 2002 (29:22 Md. R. 1721)

Regulation .08B adopted effective June 28, 2010 (37:13 Md. R. 852)

Regulation .08B amended effective April 13, 2026 (53:7 Md. R. 328)

Regulation .09 amended effective June 24, 1991 (18:12 Md. R. 1338); November 11, 2002 (29:22 Md. R. 1721); June 28, 2010 (37:13 Md. R. 852)

Regulation .09A amended effective February 26, 2007 (34:4 Md. R. 400); March 31, 2014 (41:6 Md. R. 378); April 13, 2026 (53:7 Md. R. 328)

Regulation .10A amended effective June 24, 1991 (18:12 Md. R. 1338); November 11, 2002 (29:22 Md. R. 1721)

Regulations .11—.20 adopted as an emergency provision effective August 12, 1985 (12:18 Md. R. 1756), emergency status expired December 10, 1985; adopted permanently effective December 16, 1985 (12:25 Md. R. 2471)

Regulation .13 amended effective May 23, 1994 (21:10 Md. R. 844)

Regulation .20 amended effective December 28, 1987 (14:26 Md. R. 2746)

Regulation .21 repealed effective March 13, 2017 (44:5 Md. R. 292)

Regulation .22 repealed effective May 23, 1994 (21:10 Md. R. 844)

Regulation .22 adopted effective April 16, 2012 (39:7 Md. R. 491)

Regulation .23 adopted effective February 22, 1988 (15:4 Md. R. 473)

Regulation .23A and C amended as an emergency provision effective June 9, 1988 (15:14 Md. R. 1653); emergency status expired December 9, 1988; adopted permanently effective December 26, 1988 (15:26 Md. R. 2982)

Regulations .24—.26 adopted effective December 28, 1987 (14:26 Md. R. 2746)

Regulation .24 amended effective March 1, 2004 (31:4 Md. R. 315); March 31, 2014 (41:6 Md. R. 378)

Regulation .24C amended as an emergency provision effective May 6, 2025 (52:11 Md. R. 531); adopted permanently effective October 13, 2025 (52:20 Md. R. 1001)

Regulation .24E amended effective April 16, 2012 (39:7 Md. R. 491)

Regulation .25 repealed effective March 15, 2004 (31:5 Md. R. 448)

Regulation .25 adopted effective February 25, 2008 (35:4 Md. R. 514)

Regulation .26 recodified to Regulation .27, and new Regulation .26 adopted effective March 20, 1989 (16:5 Md. R. 629)

Regulation .26 amended effective April 2, 1990 (17:6 Md. R. 741)

Regulations .27—.31 adopted effective August 6, 1990 (17:15 Md. R. 1858)

Regulation .27 recodified to Regulation .32 effective August 6, 1990 (17:15 Md. R. 1858)

Regulations .27—.31 repealed effective May 23, 1994 (21:10 Md. R. 844)

Regulation .27 adopted effective March 13, 2006 (33:5 Md. R. 520)

Regulation .28 adopted effective June 28, 2010 (37:13 Md. R. 852)

Regulation .28A amended effective April 13, 2026 (53:7 Md. R. 328)

Regulation .29 adopted effective March 31, 2014 (41:6 Md. R. 378)

Regulation .29F adopted effective April 23, 2018 (45:8 Md. R. 420)

Regulation .30 adopted effective July 4, 2016 (43:13 Md. R. 712)

Regulation .30A amended effective April 13, 2026 (53:7 Md. R. 328)

Regulation .31 adopted effective March 27, 2017 (44:6 Md. R. 325)

Regulation .32D amended effective November 11, 2002 (29:22 Md. R. 1721); June 28, 2010 (37:13 Md. R. 852)

Regulation .32-1 adopted effective March 13, 2006 (33:5 Md. R. 520)

Regulation .32-2 adopted effective March 13, 2006 (33:5 Md. R. 520)

Regulation .32-3 adopted effective March 13, 2006 (33:5 Md. R. 520)

Regulation .33 adopted effective November 11, 2002 (29:22 Md. R. 1721)

Regulation .33A amended effective March 2, 2015 (42:4 Md. R. 433)

Regulation .34 adopted effective April 21, 2008 (35:8 Md. R. 804)

Regulation .35 adopted effective April 23, 2018 (45:8 Md. R. 420)

Regulation .36 adopted effective April 23, 2018 (45:8 Md. R. 420)

Regulation .37 adopted effective April 23, 2018 (45:8 Md. R. 420)