AAAHC Standards require a recredentialing cycle of no more than 3 years, or more frequently if state law or the organization’s own policies so stipulate. (See Standards 2.II.B.5 & 7.)

CMS Conditions for Coverage at §416.45(b) state, “Medical staff privileges must be periodically reappraised by the ASC. ” This standard does not provide a specific timeframe for reappraisal. The State Operations Manual, Appendix L(SOM; Pub. 100-07) states, “The ASC’s governing body must have a process reappraising the medical staff privileges granted to each practitioner. CMS recommends a reappraisal at least every 24 months.”

We requested clarification from CMS regarding the recommendation for a 24-month reappraisal cycle in the Interpretive Guidelines. CMS has confirmed that the 24-month cycle is a recommendation only and that AAAHC (and therefore AAAHC Medicare Deemed Status ASCs) can only be held accountable to the regulatory language.

Organizations should pay close attention to their own written bylaws and policies, which our surveyors will use to determine compliance with the requirement that medical staff are reappraised.

Media Contact

Contact: Tarin English
Assistant Director, Regulatory Compliance