Welcome to the Medical Staff Services Department
Hours of Operation
2nd Floor, Room B207
Mon - Fri 0730 - 1600
· Credentialing Review Committee
· Resuscitative Credentials
· DEA Registration
· NPI Number
· Privilege Types
· Requesting Privileges
· Staff Appointments
· Reservists/TAD Personnel
· Contact Us
The primary objective of Naval Hospital Guam's Credential Staff, and of the Credentialing and Privileging process, is to protect you, the provider, our patients and our facility. We ensure that all of the credentials are IAW BUMEDINST 6320.66 and meet Joint Commission standards. It is also our goal to have you practicing what you have been trained to do as soon as possible.
The Credentialing/Privileging Process can be very frustrating at times. Hopefully, the information we have provided will help you to understand our process. We are committed to making this process a pleasant experience. If you have any questions, please do not hesitate to contact us. Our staff is here to serve you. Thank you and welcome to Guam!
What is credentialing?
Credentialing is a term that usually encompasses two separate processes: credentialing and privileging.
Credentialing: Primary source verification of a health care practitioner’s education, training, work experience, license, etc. A variety of resources are used to verify the information involving direct communication from the educational and training institutions, past and current hospital affiliations and employers, peer reference letters, certification boards, licensing agencies and other sources.
Privileging: Granting approval for an individual to perform a specific procedure or specific set of privileges based on documented competence in the specialty in which privileges are requested.
Credentialing and privileging are processes that are used by hospitals and health care organizations to ensure that their customers and the public are treated by licensed professionals who have been educated, trained, certified and/or licensed to perform certain medical and health care tasks. These two processes also provide a measure of confidence by the facility that the health care professionals are able to provide a high level of care and avoid malpractice.
Credentials Review Committee
The Credentials Review Committee is comprised of Medical Service Professionals, Executive Committee of Medical Staff Chairperson, Credentials Review Committee Chairperson and selected privileged providers. We meet once a month to ensure compliance with the Medical Staff Bylaws, BUMED Credentialing Policies and Procedures, and Naval Hospital Guam Instruction requirements; reviews and approves new or revised forms and processes and credentialing policies and procedures.
The Navy requires you to possess a current, valid, unrestricted license to practice before granting a medical staff appointment with privileges. The license may be from any state, the District of Columbia, Commonwealth of Puerto Rico, Guam, or the U.S. Virgin Islands.
Practitioners must maintain a current and unrestricted license to see patients. The CCQAS system will automatically notify providers via email when license or certification is due for renewal 90 days prior to expiration of licensure.
This office tracks and verifies all licenses ever held by a provider; active, inactive and expired. Some providers have multiple licenses. Providers electing not to renew a license must inform our office in writing prior to the expiration date. Our office will contact the primary source and verify with the state Board that the license/certification lapsed in good standing.
All providers are required to have a current BLS card. Depending on your specialty, you may be required to have additional certifications. Please make sure you give a front and back copy of all resuscitative credentials to the Medical Staff Services office so your credentials file will be updated.
In accordance with NAVMED POLICY 11-006, all credentialed health care providers are required to obtain a Drug Enforcement Administration (DEA) number. The Medical Staff Services office assists the provider in completing the forms and submits all verified credentials to the DEA for the DEA Registration Certificate. A fee exempt DEA certificate may be obtained by active duty military and civil service providers. At this time, civilian contractors that work at a military facility do not qualify for the fee exemption and must comply with state license requirements where they are currently working.
The National Provider Identifier (NPI) is a 10 digit unique identification number for covered health care providers for administrative and financial transactions. The NPI is an intelligence-free identifier so that the numbers do not carry HIPPA information about health care providers such as the state in which they live or their medical specialty.
If you do not already one, the NPI number can be obtained online through the National Plan and Provider Enumeration System (NPPES) pages on CMS's website. The Medical Staff Services will be happy to assist you with this process. Turnaround time for obtaining a number is from 1 to 20 days. NPI numbers can be searched on the CMS website listed in external links, 'Apply Now - National Plan and Provider Enumeration System (NPPES Website)'.
There are two kinds of privileges: "Core" and "Non-Core". Core privileges represent a set list of predetermined procedures, diseases, and injury types that you would likely have gained an understanding of and proficiency in during medical school and internship. "Non-Core" privileges, encompasses areas that you may be trained in and might want to do but are not on the "core" list. Since non-core privileges are hospital-specific (based on equipment, staff, and provider competency), they may not be granted.
To request privileges at NH Guam, log onto CCQAS https://ccqas.csd.disa.mil/ using your CAC card. Your detaching command will initiate an application for you to complete which you will see in your work list. Click here for our guide to completing CCQAS applications <link here>
Once your CCQAS e-app /application is returned to our office, it is checked for completion and accuracy. Primary Source Verification is done on all certificates, licensure, education, and residency programs. NPDB/HPDB (National Practitioners Data Bank) queries are completed. A Provider Credential File is created and the review process will begin.
For providers coming from a civilian residency, your first military medical staff appointment is the "initial" medical staff appointment, and is good for up to 1 year. The initial appointment period exists to allow the medical staff and administration to observe your skills before granting an "active staff appointment" good for 2 years. Experienced providers coming from another command or a military residency program may be granted an "active staff appointment". To renew an initial or staff appointment, your medical records and care will be reviewed through the quality management program and the results will be used to decide future renewal of privileges.
Reservists and TAD Personnel
For reservists and TAD personnel requesting to come to Naval Hospital Guam, please contact your command's Medical Staff Services department so that an ICTB (Interfacility Credentials Transfer Brief) can be initiated. After an ICTB has been initiated, CCQAS automatically will send an email notification to the provider. Providers may then open, complete, and submit the transfer application.
Q: Why do I need to be credentialed?
In accordance with BUMEDINST 6320.66 and Joint Commission standards, all Licensed Independent Practitioners (LIPs) and Advanced Practice Providers (APPs) who wish to treat patients must have clinical privileges and be a member of the medical staff.
Q: How long does it take to process a new appointment application?
Our department goal is to complete new appointment applications within 90 days. However, this time frame is contingent upon the receipt of all verifying documentation.
Q: What happens after I submit my application in CCQAS?
Once your e-app /application is returned to our office, it is checked for completion and accuracy. Primary Source Verification is done on all certificates, licensure, education, and residency programs. NPDB/HPDB (National Practitioners Data Bank) queries are completed. A Provider Credential File is created and the review process will begin.
Q: What is the Review Process?
Your file will be reviewed electronically and signed by your Department Head, Director, Credentials Review Committee Chair, Executive Officer, ECOMS Chair and the Commanding Officer who, based on recommendations of the reviewers will award privileges.
Q: What's taking so long?
There are a number of reasons which could cause a delay in processing your application:
- Incomplete application
- Missing documentation (OPPE's, chart reviews, PARS)
- Delay in receiving verifications
We ask your assistance to ensure your application is complete, all supporting documentation is included and have provided explanations if needed.
Q: When can I see patients?
You may not engage in patient care until you get notified by the Medical Staff Services Office that your privileges have been approved and granted by the Commanding Officer.
Q: What about CHCS and AHLTA?
Access in CHCS and AHLTA is not granted until your privileges have been approved by the Commanding Officer.
Q: When I go to request privileges how can I tell which ones are supported or not supported at NH Guam?
Unfortunately there is no way to tell which privileges are supported or not supported when requesting privileges. For a copy of the Privilege Listing for your specialty, please contact NH Guam Medical Staff Services.
Q: How do I access CCQAS?
You can access CCQAS (Centralized Credentialing Quality Assurance System) through their website at https://ccqas.csd.disa.mil
Q: I'm locked out of my CCQAS account, how do I reset my password?
You should be able to log in using your CAC card however, after a period of inactivity your account deactivates. If this occurs, contact Medical Staff Services office at 344-9679 or 344-9543 and we will reset your password for you.
Q: What if I have a "Military" license?
Some states have permitted military physicians to be licensed in special licensure categories that waive certain requirements (such as standard license fees) and include restrictions on the scope of practice (such as limiting practice to federal facilities). Per Reference (), the Department of Defense (DoD) requires all physicians to have an unrestricted medical license to practice. There are a few states which label a license status as "Military" if the license holder is on Active Duty. A military "restricted" license does NOT meet the Navy's license requirements (if is Not fully active and unrestricted). For more information on the Physician licensing see BUMED MEMO COMPLIANCE WITH DOD PHYSICIAN LICENSURE POLICY
Q: What is an ICF?
The ICF or Individual Credential file is a hard copy record of all your past privilege applications, licenses, certifications, Performance Appraisal Reports, Internship/Residency/Fellowship and Education and training primary source verifications.
Your Credential File is extremely important. This will follow you throughout your Military career. It is your responsibility to keep your file current at all times. Therefore, you are encouraged to review and update your file on a regular basis. Remember, this is your responsibility.
Q: How do I get my special pay for my board certification?
Medical Staff Services will give you a verified copy of your certification letter to take to Human Resources office so that you can receive your special pay.
Q: What is a NPDB (National Practitioner Data Bank) Query?
During the initial application or renewal process, a query will be made to the National Practitioner Data Bank. The data bank is intended to be a repository of information about final actions on malpractice claims, adverse privilege actions, and adverse licensure actions. A copy of the query will be placed in your credentials file, which you may look at in the credentials office. A copy of any adverse information is supposed to be sent to you 30 days before anyone else can access the information. The data bank opened on 1 September 1990 and no retroactive reporting to the data bank was permitted.
Q: What is the DEA requirement?
All providers who are required to have a DEA must have a DEA registration. DOD fee-waived initiative applies to Physicians, DO's, Dentists, Podiatrists, and now, Nurse Practitioners, and Physician Assistants who meet the criteria. Providers are not authorized to use a facility DEA. That number is used by the pharmacy to order drugs for the facility. Your DEA registration will transfer with you from one MTF to another and you must relinquish your registration upon separation or retirement from military practice. If you are a new provider eligible for a DEA (fee-exempt) registration, and have not applied for your DEA registration, an application will be provided at this time. These original registrations are kept in your credential file.
Q: What is PECOS and why do I need to be registered?
PECOS stands for Provider Enrollment, Chain, and Ownership System. Section 6405 of the Affordable Health Care Act requires certain health care practitioners who provide care to Medicare eligible beneficiaries and order or refer home health services or supplies to enroll in the Center for Medicare & Medicaid Services (CMS) PECOS program. CMS will deny patient reimbursement claims for home health services or supplies from physicians not enrolled in PECOS. Access to home health care services is vitally important for many of our beneficiaries, PECOS enrollment is necessary so our patients can continue to receive the care they need. If the provider is not already enrolled in PECOS, NH Guam Medical Staff Services will assist providers with the enrollment process upon check-in. For more information about PECOS, please see CMS website at https://www.cms.gov/MedicareProviderSupEnroll/
U.S. Naval Hospital Guam
Attn: Medical Staff Services
PSC 490 Box 9095
FPO AP 96538-1600
Phone: (671) 344-9679 or (671) 344-9543
Fax: (671) 344-9305