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Health Center Program Site Visit Protocol: Examples of Credentialing and Privileging Documentation

NOTE: This resource complements the Site Visit Protocol (SVP), which is the primary tool for assessing compliance with Health Center Program requirements during Operational Site Visits (OSVs). Refer to the Health Center Program Compliance Manual as the principal resource to assist health centers in understanding and demonstrating compliance with Health Center Program requirements and the SVP for complete guidance on OSVs.

Purpose

This resource applies to the Site Visit Protocol (SVP) Clinical Staffing section and addresses the credentialing and privileging of all current clinical staff. This resource is intended to facilitate site visit review of documentation found in credentialing and privileging files. Health centers may also use this resource to prepare for a site visit and evaluate the completeness of their credentialing and privileging files. 

This resource provides common examples of credentialing and privileging documentation that may demonstrate compliance with credentialing and privileging requirements. The examples are NOT exhaustive, and health centers may have other documentation that demonstrates compliance. HRSA encourages health centers and site visit reviewers to use this resource along with the SVP and the Compliance Manual.     

Note the following when using this resource:

  • Clinical staff include all staff who provide clinical services (for example, medical services, dental services, behavioral health services). 
  • Clinical staff are licensed independent practitioners (LIPs), other licensed or certified practitioners (OLCPs), and other clinical staff who are health center employees, individual contractors, or volunteers. 
    • Examples of LIPs include: physician, dentist, physician assistant, nurse practitioner, clinical psychologist. 
    • Examples of OLCPs1 include: registered nurse, licensed practical nurse, certified medical assistant, phlebotomist, respiratory therapist, licensed or certified behavioral health support staff.   
    • Examples of other clinical staff include: medical assistants, peer navigators or community health workers in states, territories or jurisdictions that do not require licensure or certification. 
  • The health center chooses the timeframe for recurring credentialing and renewal of privileges (for example, every 2 years).  
  • The health center chooses what specific credentialing activities apply to “other clinical staff.” For example, if your state does not certify medical assistants, you would verify their training instead of licensure.  
  • A health center that does not employ “other clinical staff” would not need to include them in its operating procedures or make that type of provider file available for review. 

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Examples of Credentialing Documentation

CREDENTIALING Activity EXAMPLES of documentation for licensed independent practitioner (LIP) include but are not limited to the following: EXAMPLES of documentation for other licensed or certified practitioner  (OLCP) and other clinical staff include but are not limited to the following:
1. Verification of identity (for initial credentialing) Completed using government-issued picture identification. Completed using government-issued picture identification.
2. Verification of current licensure, registration, or certification

Primary source verification directly from the state licensing agency/body.

Primary source verification for LIPs could include direct correspondence and telephone, fax, e-mail, or paper reports received from original sources (for example, telephone confirmation from an educational institution that the individual graduated with the degree[s] listed on his or her application, confirmation through a state’s database that a provider’s license is current, reports from credentials verification organizations).

Primary source verification directly from the state licensing agency/body or certification agency/body, as applicable.

Not applicable (N/A) for other clinical staff in states, territories or jurisdictions that do not require licensure or certification for such staff.

3. Verification of education and training (for initial credentialing)

Primary source verification required. Verification of graduation from medical, dental, or other clinical professional school and, if applicable, residency, including receipt of sealed transcripts.

Possible sources of verifying education and residency for physicians: American Medical Association (AMA) Physician Masterfile, American Osteopathic Association (AOA) Physician Profiles, Educational Commission for Foreign Medical Graduates (ECFMG) for international graduates licensed after 1986. 

Possible sources of verifying certifications for other LIPs: American Nurses Credentialing Center (ANCC), American Midwifery Certifying Board (AMCB), National Commission on Certification of Physician Assistants (NCCPA)

Note: The health center may rely on the state licensing agency, specialty board or registry to verify education and training if the health center can document that these entities conduct education and training primary source verification. When using such a source, the health center should verify at least annually the state licensing agency continues to primary source verify.

For OLCPs and any other clinical staff, the health center determines the process for verification of education and training (for example, primary versus secondary source verification as well as the sources of verification).
4. National Practitioner Data Bank (NPDB) Query Copy of completed report from National Practitioner Data Bank (NPDB) query or documentation that the health center is signed up for continuous query from the NPDB. Continuous query is real-time reporting from the NPDB of any changes in a provider’s file for providers enrolled by the health center.

Same as LIPs.

Note: The NPDB’s subjects include all health care practitioners, providers, and suppliers in the United States. Health care practitioners include any individual who is licensed or otherwise authorized by a state to provide health care services (or any individual who, without authority, holds himself or herself out to be so licensed or authorized). Therefore, anyone involved in the delivery or provision of health care services may be reported to the NPDB. For more information, visit National Practitioner Data Bank.

5. Verification of Drug Enforcement Administration (DEA) registration (if applicable) If applicable, copy of the physician/provider’s current DEA registration certificate, which indicates the issue and expiration dates. Same as LIPs. Only applicable for any OLCPs authorized to dispense controlled substances by the state in which they practice.
6. Verification of basic life support training Documentation of completion of basic life support training (for example, a copy of certificate of completion of training, course completion dates) or documentation of training included as part of provider licensure or certification. Documentation of completion of basic life support training (for example, a copy of certificate of completion of training, course completion dates).

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Examples of Privileging Documentation

PRIVILEGING Activity EXAMPLES of documentation for licensed independent practitioner (LIP) include but are not limited to the following: EXAMPLES of documentation for other licensed or certified practitioner (OLCP) and other clinical staff include but are not limited to the following:
1. Verification of fitness for duty to assess to ensure all clinical staff have the physical and cognitive ability to safely perform their duties. Completed statement or attestation of fitness for duty from the provider that is confirmed either by the director of a training program, chief of staff/services at a hospital where privileges exist, or a licensed provider designated by the health center. Completed statement or attestation of fitness for duty from the provider that is confirmed by a licensed provider designated by the health center.
2. Verification of immunization and communicable disease status

Immunization Status: Copy of immunization records/status in provider’s file or provider attestation, including, if applicable, any declinations. 

Note: The CDC has published recommendations, and many states have their own recommendations or standards for provider immunization and communicable disease screening. For more information about CDC recommendations, visit CDC: Recommended Vaccines for Healthcare Workers. Health centers will determine what vaccinations are required for their clinical staff based on state requirements and other resources.

Communicable Disease Status: Copy of completed tuberculosis (TB) test or screening (for example, copy of purified protein derivative (PPD) testing or chest x-ray (CXR)) and any other communicable disease testing or screening as determined by the health center (for example, Hepatitis).

Note: The health center determines communicable disease screening protocols for its health care workers as well as what sources will be accepted as verification, and circumstances, if any, when providers can decline to present for testing or screening.

Same as LIPs.
3. Verification of current clinical competence 

For initial privileging: Verification of current clinical competence via training, education, and, as available, reference reviews.

For renewal of privileges: Verification of current clinical competence via peer review or other comparable methods (for example, supervisory performance reviews).

Supervisory evaluation of clinical competence per job description.

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Footnotes

1 Categorization of providers (for example, pharmacists or registered dietitians) as LIPs or OLCPs may vary from state to state based on the specific licensure and certification requirements and scope of practice prescribed by that state.

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