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H H S Department of Health and Human Services
Health Resources and Services Administration
Primary Care: The Health Center Program

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Clarification of Credentialing & Privileging Policy Outlined in PIN 2001-16

Policy Information Notice 2002-22

INTRODUCTION

Policy Information Notice (PIN) 2001-16, Credentialing and Privileging of Health Center Practitioners requires that "all Health Centers assess the credentials of each licensed or certified health care practitioner to determine if they meet Health Center standards." This policy applies to all health center practitioners, employed or contracted, volunteers and locum tenens, at all health center sites. Questions have arisen regarding the specific requirements for credentialing and privileging these individuals. This PIN explains these requirements in more detail for all Bureau of Primary Health Care-supported Health Centers.

DEFINITIONS

Credentialing: the process of assessing and confirming the qualifications of a licensed or certified health care practitioner.

Licensed or Certified Health Care Practitioner: 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: a) licensed independent practitioners (LIPs) and b) other licensed or certified practitioners. As explained in this PIN, the credentialing and privileging requirements of these two groups may vary.

Licensed Independent Practitioner: 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: 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.

Primary Source Verification: 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 Appendix A) is also an acceptable method of primary source verification.

Secondary Source Verification: Methods of verifying a credential that are 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).

Privileging/Competency: 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.

CREDENTIALING REQUIREMENTS

1. Credentialing of 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).

Please Note: 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 REQUIREMENTS

Policy Information Notice 2001-16 requires privileging of each licensed or certified health care practitioner specific to the services being provided at each of the Health Center's care delivery settings.

  • The initial granting of privileges to 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 Appendix B).

PRIVILEGING REVISION OR RENEWAL REQUIREMENTS 

  • The revision or renewal of a LIP's 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.

The following table summarizes the credentialing and privileging requirements of both categories of “licensed or certified health care practitioners,” Licensed Independent Practitioners, and other licensed or certified health care practitioners.

NOTE: The requirements specified in this PIN are not identical to accreditation-related standards pertaining to credentialing and privileging. Therefore, Health Centers that are accredited or seeking accreditation should also review the applicable credentialing and privileging standards to insure appropriate compliance. 

TABLE: COMPARATIVE SUMMARY OF REQUIREMENTS FOR CREDENTIALING AND PRIVILEGING “LICENSED OR CERTIFIED HEALTH CARE PRACTIONERS

CREDENTIALING OR PRIVILEGING“LICENSED OR CERTIFIED HEALTH CARE PRACTITIONER”
ACTIVITYLicensed Independent Practitioner (LIP)Other licensed or certified practitioner
Examples of StaffPhysician, Dentist,RN, LPN, CMA, Registered Dietician
A. CREDENTIALINGMETHOD
1. Verification of licensure, registration, or certificationPrimary sourcePrimary Source
2. Verification of educationPrimary sourceSecondary source
3. Verification of trainingPrimary sourceSecondary source
4. Verification of current competencePrimary source, writtenSupervisory evaluation per job description
5. Health fitness (Ability to perform the requested privileges)Confirmed statementSupervisory evaluation per job description
6. Approval authorityGoverning Body (usually concurrent with privileging)Supervisory function per job description
6. National Practitioner Data Bank QueryRequired, if reportableRequired, if reportable
7. Government issued picture identification, immunization and PPD status, and life support training (if applicable)Secondary sourceSecondary source
8. Drug Enforcement Administration (DEA) registration, hospital admitting privilegesSecondary source, if applicableSecondary source if applicable
 
CREDENTIALING OR PRIVILEGING ACTIVITY“LICENSED OR CERTIFIED HEALTH CARE PRACTITIONER”
Licensed Independent Practitioner (LIP)Other licensed or certified practitioner
B. INITIAL GRANTING OF PRIVILEGESMETHOD
1. Verification of current competence to provide services specific to each of the organization’s care delivery settingsPrimary source, based on peer review and/or performance improvement data.Supervisory evaluation per job description
2. Approval authorityGoverning Body (usually concurrent with credentialing)Supervisory evaluation per job description
C. RENEWAL OR REVISION OF PRIVILEGESMETHOD
1. FrequencyAt least every 2 yrsAt least every 2 yrs
2. Verification of current licensure, registration, or certificationPrimary sourcePrimary source
3. Verification of current competencePrimary source based on peer review and/or performance improvement data.Supervisory evaluation per job description
4. Approval authorityGoverning BodySupervisory function per job description
5. Appeal to discontinue appointment or deny clinical privilegesProcess requiredOrganization option

If you have any questions, please contact BPHC Help Line at 1-877-974-BPHC or bphchelpline@hrsa.gov.

APPENDIX A

Joint Commission on Accreditation of Healthcare Organizations

Principles for CVOs

2002-2003 Comprehensive Accreditation Manual for Ambulatory Care (p. HR-11)

“Any organization may use the services of a credentials verification organization (CVO). While using such agencies may relieve the organization from the process of gathering the information, it does not relieve the organization from the responsibility of having complete and accurate information. An organization that bases its decisions in part on information obtained from a CVO should achieve a level of confidence in the information provided by the CVO, by evaluating the following:

  • The CVO makes known to the user what data and information it can provide.
  • The CVO provides documentation to the user describing how its data collection, information development and verification process(es) are performed.
  • The user is provided with sufficient, clear information on database functions that includes any limitations of information available from the CVO (for example, practitioners not included in the database), the time frame for CVO responses to requests for information; and a summary overview of quality control processes related to data integrity, security, transmission accuracy, and technical specifications.
  • The user and CVO agree on the format for the transmission of credentials information about an individual from the CVO.
  • The user can easily discern which information, transmitted by the CVO, is from a primary source and what is not.
  • For information transmitted by the CVO that can go out of date (for example, licensure, board certification), the date the information was last updated from the primary source is provided by the CVO.
  • The CVO certifies the information transmitted to the user accurately presents the information obtained by it.
  • The user can discern whether the information transmitted by the CVO from a primary source is all the primary source information in the CVO's possession pertinent to a given item or, if not, where additional information can be obtained.
  • The user can engage the quality control processes of the CVO when necessary to resolve concerns about transmission errors, inconsistencies, or other data issues that may be identified from time to time.”

APPENDIX B

Joint Commission on Accreditation of Healthcare Organizations
GUIDELINES FOR ISSUING TEMPORARY PRIVILEGES
(Based on 3/15/02 Standards Clarification: Use of Temporary Privileges – CAMAC Standard HR.7.2)

The Joint Commission has reviewed its position on the use of temporary privileges and has determined that there are two circumstances for which the granting of temporary privileges would be acceptable:

  • to fulfill an important patient care need
  • when an applicant with a complete, clean application is awaiting review and
    approval of the medical staff executive committee and the governing body

In the first circumstance temporary privileges can be granted on a case by case basis when there is an important patient care need that mandates an immediate authorization to practice, for a limited period of time, while the full credentials information is verified and approved. Examples would include, but are not limited to:

  • a situation where a physician becomes ill or takes a leave of absence and an LIP would need to cover his/her practice until he/she returns (locum tenens)
  • a specific LIP has the necessary skills to provide care to a patient that an LIP currently privileged does not possess

In these circumstances, temporary privileges may be granted by the CEO upon recommendation of either the applicable clinical department chairperson or the president of the medical staff provided there is verification of:

  • current licensure
  • current competence

In the second circumstance temporary privileges may be granted when the new applicant for medical staff membership or privileges is waiting for a review and recommendation by the medical staff executive committee and approval by the governing body. Temporary privileges may be granted for a limited period of time, not to exceed 120 days, by the CEO upon recommendation of either the applicable clinical department chairperson or the president of the medical staff provided:

  • there is verification of :
    • current licensure
    • relevant training or experience
    • current competence
    • ability to perform the privileges requested o other criteria required by medical staff bylaws
  • the results of the National Practitioner Data Bank query have been obtained and
    evaluated
  • the applicant has:
    • a complete application
    • no current or previously successful challenge to licensure or registration
    • not been subject to involuntary termination of medical staff membership at another organization
    • not been subject to involuntary limitation, reduction, denial, or loss of clinical privileges

Temporary privileges are not to be routinely used for other administrative purpose such as the following situations:

  • the LIP fails to provide all information necessary to the processing of his/her reappointment in a timely manner
  • failure of the staff to verify performance data and information in a timely manner

In the above situations, the LIP would be required to cease providing care in the facility until the reappointment process is completed.

Issued July 10, 2002 - Last reviewed November 20, 2006

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