Credentialing & Privileging

Credentialing

Based on the Bureau of Primary Health Care (BPHC) PIN 2002-22, “Clarification of Bureau of Primary Health Care Credentialing and Privileging Policy outlined in Policy Information Notice 2001-16”, Credentialing is the process of assessing and confirming the qualifications of a licensed or certified health care practitioner.

Licensed or Certified Health Care Practitioner refers an individual required to be licensed, registered, or certified by the State, commonwealth or territory in which a Health Center is located. These individuals include, but are not limited to, physicians, dentists, registered nurses, and others required to be licensed, registered, or certified (e.g., laboratory technicians, social workers, medical assistants, licensed practical nurses, dental hygienists, nutritionists). The definition will vary dependent upon legal jurisdiction. “Licensed or certified health care practitioners” can be divided into two categories (note that the credentialing and privileging requirements of these two groups may vary):
a) Licensed independent practitioners (LIPs)
b) Other licensed or certified practitioners

Licensed Independent Practitioner (LIP) refers to a physician, dentist, nurse practitioner, and nurse midwife or any other “individual permitted by law and the organization to provide care and services without direction or supervision, within the scope of the individual’s license and consistent with individually granted clinical privileges” (from Joint Commission on Accreditation of Healthcare Organizations’(JCAHO) 2002-2003 Comprehensive Accreditation Manual for Ambulatory Care). It is the Health Center that should determine which individuals (including staff that may not be covered under Federal Tort Claims Act such as volunteers, certain part-time contractors, medical residents, and locum tenens) meet this definition based on law and the organization’s policy.

Other Licensed or Certified Health Care Practitioner refers to an individual who is licensed, registered, or certified but is not permitted by law to provide patient care services without direction or supervision. Examples include, but are not limited to, laboratory technicians, social workers, medical assistants, licensed practical nurses, dental hygienists.

According to BPHC PIN 2001-16 “Credentialing and Privileging of Health Center Practitioners”, Credentialing is a complex process that includes collecting and verifying information about a practitioner, assessing and interpreting the information, and making decisions about the practitioner. To bring uniformity and clarity to the credentialing requirements for BPHC grantees the BPHC is adopting the following policy for credentialing:

• All Health Centers shall assess the credentials of each licensed or certified health care practitioner to determine if they meet Health Center standards. This assessment must meet the requirement of 42 U.S.C.§233(h)(2) that calls for review and verification of “the professional credentials, references, claims history, fitness, professional review organization findings, and license status of its physicians and other licensed or certified health care practitioners.” The procedures used for credentialing these practitioners shall follow the requirements of the JCAHO or other nationally recognized accrediting organizations, and must include a query of the National Practitioner Data Bank.

• Health Centers may choose to have credentialing completed by a hospital or credentials verification organization. However, the Health Center must follow all guidelines that the JCAHO or other nationally recognized accrediting organization has placed on the use of these organizations for such a credentials verification process.

Primary Source Verification is the verification by the original source of a specific credential to determine the accuracy of a qualification reported by an individual health care practitioner. Examples of primary source verification include, but are not limited to, direct correspondence, telephone verification, internet verification, and reports from credentials verification organizations.

The Education Commission for Foreign Medical Graduates (ECFMG®), the American Board of Medical Specialties, the American Osteopathic Association Physician Database, or the American Medical Association (AMA) Masterfile can be used to verify education and training. The use of credentials verification organizations (CVOs) or hospitals that meet JCAHO’s “Principles for CVOs” (see PIN 02-22 Appendix A) is also an acceptable method of primary source verification.

Secondary Source Verification is the method of verifying a credential which is not considered an acceptable form of primary source verification. These methods may be used when primary source verification is not required. Examples of secondary source verification methods include, but are not limited to, the original credential, notarized copy of the credential, a copy of the credential (when the copy is made from an original by approved Health Center staff).

Requirements

PIN 2002-22, “Clarification of Bureau of Primary Health Care Credentialing and Privileging Policy outlined in Policy Information Notice 2001-16”, identifies the credentialing requirements listed below:

1. Credentialing of Licensed Independent Practitioners (LIPs) requires primary source verification of the following:

• Current licensure;
• Relevant education, training, or experience;
• Current competence; and
• Health fitness, or the ability to perform the requested privileges, can be determined by a statement from the individual that is confirmed either by the director of a training program, chief of staff/services at a hospital where privileges exist, or a licensed physician designated by the organization.
Credentialing of LIPs also requires secondary source verification of the following:

• Government issued picture identification;
• Drug Enforcement Administration registration (as applicable);
• Hospital admitting privileges (as applicable);
• Immunization and PPD status; and
• Life support training (as applicable)

The Health Center should also query the National Practitioner Data Bank (NPDB) (as applicable) for these LIPs. If the health center is ineligible to query, they should have the LIP provide the results of a self-query of the NPDB.

The determination that a LIP meets the credentialing requirements should be stated in writing by the Health Center’s governing board (or alternative mechanism as described in a governing board approved waiver). Ultimate approval authority is vested in the governing board which may review recommendations from either the Clinical Director or a joint recommendation of the medical staff (including the clinical director) and the Chief Executive Officer. Alternatively, the governing board may delegate this responsibility (via resolution or bylaws) to an appropriate individual to be implemented based on approved policies and procedures (including methods to assess compliance with these policies and procedures).

2. Credentialing of other licensed or certified health care practitioners requires primary source verification of the individual’s license, registration, or certification only. Education and training may be verified by secondary source verification methods. Verification of current competence is accomplished through a thorough review of clinical qualifications and performance.
Credentialing of other licensed or certified health care practitioners also requires secondary source verification of the following:

• Government issued picture identification;
• Immunization and PPD status;
• Drug Enforcement Administration registration (as applicable),
• Hospital admitting privileges (as applicable), and
• Life support training (as applicable).

Note that these requirements are a minimum and do not prevent the Health Center from credentialing these individuals similarly to LIPs.

Credentialing of other licensed or certified health care practitioners should be completed prior to the individual being allowed to provide patient care services. 

Privileging

Based on the Bureau of Primary Health Care (BPHC) PIN 2002-22, “Clarification of Bureau of Primary Health Care Credentialing and Privileging Policy outlined in Policy Information Notice 2001-16”,Privileging/Competency is the process of authorizing a licensed or certified health care practitioner’s specific scope and content of patient care services. This is performed in conjunction with an evaluation of an individual’s clinical qualifications and/or performance.

According to BPHC PIN 2001-16 “Credentialing and Privileging of Health Center Practitioners”, Privileging also refers to the process that health care organizations employ to authorize practitioners to provide specific services to their patients. The BPHC adopts the following policy on privileging:

• A Health Center must verify that its licensed or certified health care practitioners possess the requisite skills and expertise to manage and treat patients and to perform the medical procedures that are required to provide the authorized services. It is incumbent on the Health Centers to assure their users that Health Center practitioners have met standards of practice and training that enable them to manage and treat patients and/or perform procedures and practices with a level of proficiency which minimizes the risk of causing harm. The organization must adopt its own policy that outlines specific privileging requirements and the periodicity of the review of privileges for all licensed or certified health care practitioners.
The privileging process could, for a physician, involve any combination of the following:

• Primary source verification of a course of study from a recognized and certifying educational institution showing that the clinician met or passed a level of training required to perform a defined procedure or management protocol;
• Direct, first hand one-on-one documentation by a supervising clinician who possesses the privilege of the particular procedure or management protocol;
• Direct proctoring by a qualified clinician possessing a degree of expertise in the particular procedure or protocol beyond the level of expertise of most primary care providers. Whatever verification procedures used should be appropriate to the specialty of each practitioner, the breadth of clinical services offered by the Health Center and the particular circumstances of the clinic’s accessibility to ancillary and tertiary medical practitioners.

Requirements

PIN 2002-22, “Clarification of Bureau of Primary Health Care Credentialing and Privileging Policy outlined in Policy Information Notice 2001-16”, identifies the privileging requirements listed below:

• The initial granting of privileges to Licensed Independent Practitioners (LIPs) is performed by the health center (see PIN 2001-16 for specifics) with ultimate approval authority vested in the governing board which may review recommendations from either the clinical director or a joint recommendation of the medical staff (including the Clinical Director) and the Chief Executive Officer. Alternatively, the governing board may delegate this responsibility (via resolution or bylaws) to an appropriate individual to be implemented based on approved policies and procedures (including methods to assess compliance with these policies and procedures).
• For other licensed or certified health care practitioners, privileging is completed during the orientation process via a supervisory evaluation based on the job description.
• Temporary privileges may be granted if the Health Center follows guidelines specified by JCAHO (see PIN 2002-22 Appendix B).

Renewals & Revisions

PIN 2002-22, “Clarification of Bureau of Primary Health Care Credentialing and Privileging Policy outlined in Policy Information Notice 2001-16”, identifies the privileging revision or renewal requirements listed below:

• The revision or renewal of a Licensed Independent Practitioner’s (LIP) privileges should occur at least every 2 years and should include primary source verification of expiring or expired credentials, a synopsis of peer review results for the 2 year period and/or any relevant performance improvement information. Similar to the initial granting of privileges, approval of subsequent privileges is vested in the governing board which may review recommendations from either the clinical director, or a joint recommendation of the medical staff (including the Clinical Director) and the Chief Executive Officer, or delegate this responsibility (via resolution or bylaws language) to be implemented according to approved policies and procedures (including methods to assess compliance with these policies and procedures).
• The revision or renewal of privileges of other licensed or certified health care practitioners should occur at a minimum of every 2 years. Verification is by supervisory evaluation of performance that assures that the individual is competent to perform the duties described in the job description.
• The health center should have an appeal process for LIP's if a decision is made to discontinue or deny clinical privileges. An appeal process is optional for other licensed or certified health care practitioners.

Resources

Here’s the list of websites that deal with credentialing and privileging in health centers:

HRSA BUREAU OF PRIMARY HEALTH CARE (BPHC)
PUBLIC POLICY INFORMATION NOTICES (PINS)

PIN 2001-16“Credentialing and Privileging of Health Center Practitioners”
PIN 2002-22“Clarification of Bureau of Primary Health Care Credentialing and Privileging Policy outlined in Policy Information Notice 2001-16”
PIN 1998-23“Health Center Program Expectations”

NATIONAL ACCREDITING ORGANIZATIONS

Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
Accreditation Association for Ambulatory Health Care Inc. (AAAHC)

CREDENTIALS VERIFICATION ORGANIZATIONS (CVO) AND DATA BANK

Education Commission for Foreign Medical Graduates (ECFMG®)
American Board of Medical Specialties
American Osteopathic Association Physician Database
American Medical Association (AMA)
National Practitioner Data Bank (NPDB)

FEDERAL REGULATIONS

Federal Tort Claims Act (FTCA)
Federally Supported Health Centers Assistance Act of 1992 (Act)