NOTE: The Site Visit Protocol (SVP) is the tool for assessing compliance with Health Center Program requirements during Operational Site Visits (OSVs). Use this resource along with the SVP to prepare for OSVs.
Purpose
This resource applies to the SVP Chapter 3: Clinical Staffing, and addresses the credentialing and privileging of all current clinical staff. This resource can be used during the site visit when reviewing credentialing and privileging files. Health centers may also use this resource to prepare for a site visit and ensure their credentialing and privileging files are complete.
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, registered dietician, 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 two years). However, to maintain Federal Tort Claims Act (FTCA) deeming status, a health center must credential and privilege deemed providers at least every two years. For more information, refer to FTCA Policies and Program Guidance.
- The health center determines whether to have separate credentialing processes for LIPs versus other provider types. For example, the health center determines what specific aspects of the credentialing process (such as verification of current licensure, registration, or certification) might not apply to “other clinical staff.”
- 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.
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. Note: As long as an individual’s identification was verified as part of the health center’s credentialing and privileging processes, a copy of the individual’s identification (for example, government-issued picture identification) is not required to be in the health center files or records. |
Same as LIPs. |
| 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 degrees listed on their 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 or certification agency/body. Not applicable (N/A) for other clinical staff in states, territories or jurisdictions that do not require licensure or certification for other clinical 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 any 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 verifying education and training (for example, primary versus secondary source verification as well as the sources of verification). When a health center is in a state, territory, or jurisdiction that allows other clinical staff to begin their positions with either no education or no training, the health center would not be required to verify training or education for such staff without education or training. |
| 4. National Practitioner Data Bank (NPDB) Query (for NPDB-reportable provider types) | 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 Examples of Health Care Practitioners. |
| 5. Verification of Drug Enforcement Administration (DEA) registration (if applicable) | If applicable, copy of the physician's/provider’s current DEA registration certificate, which indicates the issue and expiration dates. | Same as LIPs. Only applies to 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). |
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 by:
|
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 or status in provider’s file or provider attestation, including any declinations. 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: Many states have their own recommendations or standards for provider immunization and communicable disease screening. The health center determines immunization and communicable disease screening protocols for its clinical staff as well as what sources will be accepted as verification, and circumstances, if any, when clinical staff can decline to provide verification of immunization, 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 through peer review or other comparable methods (for example, supervisory performance reviews). |
Supervisory evaluation of clinical competence based on the job description. When a health center is in a state, territory, or jurisdiction that allows other clinical staff to begin their positions with either no education or no training, the health center would address how the clinical competence of such staff without education or training will be assessed in its initial privileging procedures. |
Footnotes
1 States may have different scope of practice and licensure and certification requirements that affect how the providers (for example, pharmacists or registered dietitians) are categorized as LIPs or OLCPs.