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Department of Veterans Affairs VHA HANDBOOK 1100.19 Veterans Health Administration Transmittal Sheet Washington, DC 20420 November 14, 2008

CREDENTIALING AND PRIVILEGING

1. REASON FOR ISSUE. This revised Veterans Health Administration (VHA) Handbook provides VHA procedures regarding credentialing and privileging.

2. SUMMARY OF CONTENTS/MAJOR CHANGES. This revision of VHA Handbook 1100.19 incorporates:

a. VHA policy on participation and actions related to the National Practitioner Data Bank (NPDB) including participation in the Proactive Disclosure Service and changes concerning second level review by the Veterans Integrated Service Network Chief Medical Officer of the appointment and privileging process.

b. Clarification of identified issues related to verification and follow-up of State licenses, including a requirement for written verification of licensure in follow-up to other methods of verification, as well as timely follow-up of actions taken by State licensing boards. Specific guidance is provided for those instances where a practitioner enters into an agreement to not practice in a State.

c. The educational requirement for facility medical staff leaders to complete training in Medical Staff Leadership and Provider Profiling within 3 months of assuming the position.

d. The Focused Professional Practice Evaluation and ongoing monitoring of privileges, as well as clarifies information on practitioner specific information to be compiled in the provider profile and evaluated as part of the facility’s ongoing monitoring of practitioner health care practice, as well as for the reappraisal and privileging process.

e. Sample letters for the Summary Suspension of Privileges, Automatic Suspension of Privileges, and Clinical Practice Review.

3. RELATED ISSSUE. VHA Directive 1100 (to be published).

4. RESPONSIBLE OFFICE. The Office of Quality Performance (10Q), is responsible for the contents of this VHA Handbook. Questions may be addressed to (919) 993-3035, extension 236.

5. RESCISSIONS. VHA Handbook 1100.19, dated October 2, 2007, is rescinded.

6. RECERTIFICATION. This VHA Handbook is scheduled for recertification on or before the last working day of November 2013.

JMichael J. Kussman, MD, MS, MACP Under Secretary for Health

DISTRIBUTION: CO: E-mailed 11/21/2008 FLD: VISN, MA, DO, OC, OCRO, and 200 – E-mail 11/21/2008

November 14, 2008 VHA HANDBOOK 1100.19 i

CONTENTS

PARAGRAPH PAGE

1. Purpose

2. Scope

3. Definitions

4. Responsibilities

a. Under Secretary for Health

b. Principal Deputy Under Secretary for Health

c. Deputy Under Secretary for Health for Operations and Management

d. Facility Director

e. Facility COS

f. Service Chiefs

g. Chief Medical Officer, Veterans Integrated Service Network (VISN CMO)

h. Director, Management Review Service

i. Applicant and Practitioner

5. Credentialing

a. Provisions

b. Procedures

c. Application Forms

d. Documentation Requirements

e. Educational Credentials

f. Verifying Specialty Certification

g. Licensure

h. Drug Enforcement Agency (DEA) Certification

i. Employment Histories and Pre-employment References

j. Health Status

k. Malpractice Considerations

l. National Practitioner Data Bank (NPDB)- Health Integrity and Protection Data Bank (HIPDB) Screening . 21

m. Appointment and Termination of Title 5 and Title 38 Staff Relative to NPDB-HIPDB Screening

n. Credentialing and Privileging in Telehealth and

Teleconsultation

o. Expedited Appointment to the Medical Staff

p. Temporary Appointments for Urgent Patient Care Needs

q. Reappraisal

r. Transfer of Credentials

VHA HANDBOOK 1100.19 November 14, 2008 ii

CONTENTS Continued

PARAGRAPH PAGE

s. Disposition of Credentialing and Privileging Files

6. Privileging

a. Provisions

b. Review of Clinical Privileges

c. Procedures

d. Initial Privileges

e. Temporary Privileges for Urgent Patient Care Needs

f. Disaster Privileges

g. Focused Professional Practice Evaluation

h. On-Going Monitoring of Privileges

i. Reappraisal and Re-privileging

j. Denial and Non-renewal of Privileges

k. Reduction and Revocation of Privileges

l. Inactivation of Privileges

m. Deployment and/or Activation Privilege Status

7. Documentation of the Medical Staff Appointment and Clinical Privileges

8. References

APPENDICES

A Standard Credentialing and Privileging Folder .................................................................... A–1

B Occupations Covered By Title 38 United States Code (U.S.C.) Section 7402(F), Requirements .................................................................................................................... B–1

C Guidance on When to Query the Federation of State Medical Boards ................................ C–1

D Decision Process for Queries of the Federation of State Medical Board ............................. D–1

E Sample Advisement to Licensed Health Care Professional of Summary Suspension of Privileges ....................................................................................................................... E–1

F Sample Advisement to Licensed Health Care Professional of Automatic Suspension of Privileges ....................................................................................................................... F–1

G Sample Advisement to Licensed Health Care Professional of Clinical Practice Review .............................................................................................................................. G–1

1. PURPOSE

This Veterans Health Administration (VHA) Handbook provides VHA procedures regarding credentialing and privileging of all health care professionals who are permitted by law and the facility to practice independently. NOTE: This Handbook does not apply to residents, except those who function outside the scope of their training program; i.e., Admitting Officer of the Day.

2. SCOPE

a. All VHA health care professionals who are permitted by law and the facility to provide patient care services independently must be credentialed and privileged as defined in this Handbook. The requirements of The Joint Commission (TJC) standards and VHA policies have been used to define the processes for credentialing, privileging, reappraisal, re-privileging, and actions against clinical privileges, including denial, failure to renew, reduction, and revocation.

This Handbook applies to all VHA licensed independent practitioners permitted by law and facility to provide direct patient care, including telemedicine, and who are appointed or utilized on a full-time, part-time, intermittent, consultant, attending, without compensation (WOC), on-station fee-basis, on-station contract, or on-station sharing agreement basis. The credentialing, but not privileging, requirements of this Handbook apply to all Advanced Practice Registered Nurses (APRN) and Physician Assistants (PA) even though these practitioners may not practice as licensed independent practitioners, as well as physicians, dentists, and other practitioners assigned to research or administrative positions not involved in patient care.

b. Policy and procedures related to the denial, failure to renew, reduction, and revocation of clinical privileges, where based on professional competence, professional misconduct, or substandard care, apply to all health care professionals who are granted privileges within the scope of this Handbook.

c. VetPro is VHA’s electronic credentialing system and must be used for credentialing all providers who are granted clinical privileges or are credentialed for other reasons. One component of VHA’s Patient Safety Program is quality credentialing and the use of VetPro is necessary to reduce the potential for human error in the credentialing process. In addition, documentation other than in VetPro that is required by this Handbook must be maintained in a paper or electronic medium. The requirements of this policy are the same whether carried out on paper or electronically. For example, if a signature is required and the mechanism in use is electronic, then that modality must provide for an electronic signature.

d. Credentialing and privileging must be completed prior to initial appointment or reappointment to the medical staff and before transfer from another medical facility. If the primary source verification(s) of the practitioner’s credentials are on file (paper or electronic), those credentials that were verified at the time of initial appointment (and are not time-limited or specifically required by this policy or TJC to be updated or re-verified) can be considered verified.

e. All procedures described in this Handbook are applicable to Chiefs of Staff (COS) and facility Directors who are involved in patient care. Differences in specific procedures are noted where applicable.

f. This policy applies to licensed health care personnel in VHA Central Office, Veterans Integrated System Network (VISN) offices, and other organizational components that would be credentialed in accordance with this policy if in a VA facility, to include but not limited to physicians, dentists, advanced practice nurses, and physician assistants.

NOTE: In those instances where the VISN Chief Medical Officer (CMO) is not a physician, the CMO must be credentialed in accordance with this policy.

NOTE: Wherever the policy defines an action or responsibility of the medical facility Director, or designee, that role belongs to the head of that organizational component, or designee.

g. Nothing in the VA medical center Medical Staff Bylaws, Rules, and Regulations can have any effect inconsistent with, or otherwise be inconsistent with, law, Department of Veterans Affairs (VA) regulations, this Handbook’s policies and procedures, or other VA policies.

3. DEFINITIONS

a. Appointment. The term "appointment" refers to the medical staff. It does not refer to appointment as a VA employee (unless clearly specified), but is based on having an appropriate personnel appointment action, scarce medical specialty contract, or other authority for providing patient care services at the facility. Both VA employees and contractors may receive appointments to the medical staff.

b. Associated Health Professional. The term "Associated Health Professional" is defined as those clinical professionals other than doctors of allopathic, dental, and osteopathic medicine.

c. Authenticated Copy. The term "authenticated copy" means that each page of the document is a true copy of the original document; each page is stamped “authenticated copy of original” and is dated and signed by the person doing the authentication. NOTE: Facsimile copies of verification documents may not be used for final verification.

d. Credentialing. The term "credentialing" refers to the systematic process of screening and evaluating qualifications and other credentials, including licensure, required education, relevant training and experience, and current competence and health status.

e. Clinical Privileging. The term "clinical privileging" is defined as the process by which a practitioner, licensed for independent practice (i.e., without supervision, direction, required sponsor, preceptor, mandatory collaboration, etc.), is permitted by law and the facility to practice independently, to provide specified medical or other patient care services within the scope of the individual’s license, based on the individual's clinical competence as determined by peer references, professional experience, health status, education, training, and licensure. Clinical privileges must be facility-specific and provider-specific.

NOTE: There may be practitioners, who by the nature of their position, are not involved in patient care (i.e., researchers or administrative physicians). These health care professionals must be credentialed, but may not need to be privileged.

f. Competency. Competency is documented demonstration of an individual having the requisite or adequate abilities or qualities capable to perform up to a defined expectation.

g. Current. The term "current" applies to the timeliness of the verification and use for the credentialing and privileging process. No credential is current and no query of the Federation of State Medical Boards (FSMB) is current if performed prior to submission of a complete application by the practitioner to include submission of VetPro. At the time of initial appointment, all credentials must be current within 180 days of submission of a complete application. For reappointment, all time-limited credentials must be current within 180 days of submission of the application for reappointment including peer appraisals, confirmation of National Practitioner Data Bank (NPDB)-Health Integrity and Protection Data Bank (HIPDB) Proactive Disclosure Service (PDS) annual registration, and other credentials with expirations.

h. Independent Practitioner. The term "independent practitioner" is any individual permitted by law (the statute which defines the terms and conditions of the practitioner’s license) and the facility to provide patient care services independently; i.e., without supervision or direction, within the scope of the individual’s license and in accordance with individually-granted clinical privileges. This is also referred to as a licensed independent practitioner (LIP).

NOTE: Only LIPs may be granted clinical privileges.

i. Licensure. The term "licensure" refers to the official or legal permission to practice in an occupation, as evidenced by documentation issued by a State, Territory, Commonwealth, or the District of Columbia (hereafter, “State”) in the form of a license, registration, or certification.

j. One Standard of Care. The term "one standard of care" means that one standard of care must be guaranteed for any given treatment or procedure, regardless of the practitioner, service, or location within the facility. In the context of credentialing and privileging, the requirements or standards for granting privileges to perform any given procedure, if performed by more than one service, must be the same.

k. Post-graduate (PG). The term PG is the acronym for post-graduate.

l. Primary Source Verification. Primary source verification is documentation from the original source of a specific credential that verifies the accuracy of a qualification reported by an individual health care practitioner. This can be documented in the form of a letter, documented telephone contact, or secure electronic communication with the original source.

m. Proctoring. Proctoring is the activity by which a practitioner is assigned to observe the practice of another practitioner performing specified activities and to provide required reports on those observations. The proctor must have clinical privileges for the activity being performed, but must not be directly involved in the care the observed practitioner is delivering. Proctoring that requires a proctor to do more than just observe, i.e., exercise control or impart knowledge, skill, or attitude to another practitioner to ensure appropriate, timely, and effective patient care, constitutes supervision. Such supervision may be a reduction of privileges (see the NOTE following subpar. 6j(2) for additional information).

n. Teleconsulting. Teleconsulting is the provision of advice on a diagnosis, prognosis, and/or therapy from a licensed independent provider to another licensed independent provider using electronic communications and information technology to support the care provided when distance separates the participants, and where hands-on care is delivered at the site of the patient by a licensed independent health care provider.

o. Telemedicine. Telemedicine is the provision of care by a licensed independent health care provider that directs, diagnoses, or otherwise provides clinical treatment delivered using electronic communications and information technology when distance separates the provider and the patient.

NOTE: A crucial consideration in making a distinction between consultation and care is that teleconsultation occurs when the consultant involved recommends diagnoses, treatments, etc., to the consulting provider requesting the consult, but does not actually write orders or assume the care of the patient. If the consultant diagnoses, writes orders, or assumes care in any way, this constitutes “care” and requires privileges. A Medical Staff appointment is required if the provider is entering documentation into the medical record, e.g., teleradiology, teledermatology, etc.

p. VetPro. VetPro is an Internet enabled data bank for the credentialing of VHA health care providers that facilitates completion of a uniform, accurate, and complete credentials file.

4. RESPONSIBILITIES

a. Under Secretary for Health. The Under Secretary for Health, or designee, is responsible for ensuring the development and issuance of the VHA credentialing and privileging policy.

b. Principal Deputy Under Secretary for Health. The Principal Deputy Under Secretary for Health, or designee, is responsible for ensuring oversight in the development and implementation of VHA credentialing and privileging for licensed health care professionals in VA Central Office, VISNs, and VA Medical Centers.

c. Deputy Under Secretary for Health for Operations and Management (10N). The Deputy Under Secretary for Health for Operations and Management (10N), is responsible for ensuring that VISN Directors maintain an appropriate credentialing and privileging process consistent with the VHA policy. In doing so, uniform prototype performance standards will be issued for key VHA medical facility managers, such as Directors, Associate or Assistant Directors, Human Resource Management Officers, and COS. Monitoring of credentialing and privileging must continue through periodic TJC consultative site visits and other reviews, as applicable.

d. Facility Director. The ultimate responsibility for credentialing and privileging resides with the facility Director. The facility Director, designated by the Under Secretary for Health as the Governing Body of the facility, is responsible for ensuring:

(1) The labor-management obligations are met prior to implementing a Credentialing and Privileging Program that involves Title 5 independent practitioners who are represented by a professional bargaining unit.

(2) Local facility policy, including Medical Staff Bylaws, Rules, and Regulations, is consistent with this Handbook.

(3) Medical staff leadership and all staff with responsibility in the credentialing and privileging process complete the one-time only training as determined by the Office of Quality and Performance (OQP). Training must be completed within 3 months of assuming this position. This training may be accessed through the VA Learning Management System at http://www.lms.va.gov . This target audience includes: Medical Staff and Credentialing Professionals; Service and Product Line Chiefs;

Credentials Committee Members (Professional Standards Boards); Medical Executive Committee Members; COSs and Medical Directors; Quality and Performance Improvement Professionals; and Risk Managers. NOTE: Additional information may be found at EES Mandatory Training website at http://vaww.ees.lrn.va.gov/mandatorytraining.

e. Facility COS. The facility COS is responsible for:

(1) Maintaining the Credentialing and Privileging system and ensuring that all health care professionals applying for clinical privileges agree to provide continuous care to the patients assigned to them and are provided with a copy of, and agree to abide by the Medical Staff Bylaws, Rules, and Regulations; and ensuring that the Medical Staff Bylaws are consistent with this Handbook and any other VHA policy related to Medical Staff Bylaws.

(2) Completing training identified in subparagraph 4c(3) and ensuring that appropriate staff in direct line of authority complete the training.

f. Service Chiefs

(1) Service chiefs are responsible for:

(a) Recommending the criteria for clinical privileges that are relevant to the care provided in the service;

(b) Reviewing all credentials and requested clinical privileges, and for making recommendations regarding appointment and privileging action; and

(c) A continuous surveillance of the professional performance of those who provide patient care services with delineated clinical privileges. NOTE: The title Service Chief applies to Service Line Directors, Product Line Chiefs, and any other equivalent titles.

https://www.lms.va.gov/ http://vaww.ees.lrn.va.gov/mandatorytraining

(2) Service Chiefs involved in the credentialing and privileging process are responsible for completing training identified in subparagraph 4c(3) and ensuring that appropriate staff in direct line of authority complete the training.

g. VISN CMO. The VISN CMO is responsible for oversight of the credentialing and privileging process of the facilities within the VISN.

h. Director, Management Review Service (10B5). The Director, Management Review Service (10B5), is responsible for evaluating progress towards the implementation of recommendations made by external reviewers, such as Office of Inspector General (OIG) and Government Accountability Office (GAO).

i. Applicant and Practitioner. Applicants and appointed practitioners must provide evidence of licensure, registration, certification, and/or other relevant credentials, for verification prior to appointment and throughout the appointment process, as requested. They must agree to accept the professional obligations delineated in the Medical Staff Bylaws, Rules, and Regulations provided to them. They are responsible for keeping VA apprised of anything that would adversely affect, or otherwise limit, their clinical privileges.

NOTE: Failure to keep VA fully informed on these matters may result in administrative or disciplinary action.

5. CREDENTIALING (i.e., the Initial Appointment, Reappointment, or Reappointment after a Break in Service)

a. Provisions. Health care professionals must be fully credentialed and privileged prior to initial appointment or reappointment, except as identified in subparagraphs 5o, 5p, 6e, and 6f.

b. Procedures. Credentialing is required to ensure an applicant has the required education, training, experience, physical and mental health, and skill to fulfill the requirements of the position and to support the requested clinical privileges. This paragraph contains the administrative requirements and procedures related to the initial credentialing and reappraisal of practitioners who plan to apply for clinical privileges.

(1) The credentialing process includes verification, through the appropriate primary sources, of the individual's professional education; training; licensure; certification and review of health status; previous experience, including any gaps (greater than 30 days) in training and employment; clinical privileges; professional references; malpractice history and adverse actions; or criminal violations, as appropriate. Except as identified in subparagraph 5a., medical staff and employment commitments must not be made until the credentialing process is completed, including screening through the appropriate State Licensing Board (SLB), FSMB, and the NPDB-HIPDB. All information obtained through the credentialing process must be carefully considered before appointment and privileging decision actions are made.

(2) The applicable service chief reviews the credentialing folder and requested privileges and make recommendations regarding appointment. The folder and recommendations are reviewed by the credentialing committee and then submitted with recommendations to the medical staff’s Executive Committee.

(3) All applicants applying for clinical privileges must be provided with a copy of the Medical Staff Bylaws, Rules, and Regulations and must agree in writing to accept the professional obligations reflected therein.

(4) The applicant has the burden of obtaining and producing all needed information for a proper evaluation of professional competence, character, ethics, and other qualifications. The information must be complete and verifiable. The applicant has the responsibility for furnishing information that will help resolve any questions concerning these qualifications. Failure to provide necessary information, in a reasonable time, may serve as a basis for denial of medical staff appointment and/or privileges, as defined in the facility Medical Staff Bylaws.

c. Application Forms. Candidates seeking appointment or reappointment must complete the appropriate forms for the position for which they are applying.

(1) All candidates, requiring credentialing in accordance with this policy, must complete an electronic submission of VetPro. VetPro's supplemental information form requests applicants to answer questions to meet TJC and VHA requirements. This supplemental information form requires the applicant to provide information concerning malpractice, adverse actions against licensure, privileges, hospital membership, research, etc.

(2) The "Sign and Submit" screen in VetPro addresses the applicant's agreement to provide continuous care and to accept the professional obligations defined in the Medical Staff Bylaws, Rules, and Regulations for the facility(ies) to which the application is being made, as well as attesting to the accuracy and completeness of the information submitted.

(3) Applicants are required to provide information on all educational, training, and employment experiences, including all gaps greater than 30 days in the candidate’s history.

(4) If the delay between the candidate’s application and reporting for duty is greater than 180 calendar days, the candidate must update all time-limited credentials and information including, but not limited to licensure, current competence, and supplemental questions. The updated information must be verified prior to the candidate reporting for duty. Verification of a time-limited credential cannot be greater than 120 days old at the time a practitioner reports for duty.

This requirement includes a response from the NPDB–HIPDB. NOTE: Delays between a candidate’s application and reporting for duty most frequently occur in the case of an individual for whom special waivers (i.e., visa waiver) may be required. Since these processes can be time consuming, information on the candidate’s practice or non-practice during the period of delay must be obtained in order to ensure the most appropriate placement of the candidate.

NOTE: A copy of the appropriate application form and any supplemental form(s) are maintained electronically in VetPro and may be filed in Section I of the credentialing and privileging folder. If the applicant provides a resume or curriculum vitae, this is also filed in Section I.

d. Documentation Requirements

(1) Each privileged health care practitioner must have a Credentialing and Privileging file established electronically in VetPro with any paper documents maintained according to the requirements of the standardized folder identified in Appendix A. Other credentialed health care providers have a credentials file maintained in the same system of records even though they may not be granted clinical privileges. NOTE: Duplication of information documented and maintained in the electronic VetPro file for filing in the paper Credentialing and Privileging file is not necessary and is discouraged.

(2) Information obtained, to be used in the credentialing process, must be primary source verified (unless otherwise noted) and documented in writing, either by letter, report of contact, or web verification. Facilities are expected to secure all credentialing and privileging documents.

Any facsimile copy must be followed up with an original document. NOTE: When using an Internet source for verification, the following criteria must be considered in determining appropriateness as primary source verification: (a) The web site disclaimer needs to be reviewed to determine the organization’s attestation to the accuracy and timeliness of the information. If there is no disclaimer, the web verification needs to seriously be considered as not adequate for verification. (b) There must be evidence that the site is maintained by the verifying entity and that the verification data cannot be modified by outside sources. If not maintained by the verifying entity, the site must include an endorsement by the entity that the site is a primary source verification or the transmission is in an encrypted format. (c) The site must provide information on the status of license and adverse action information. (d) To avoid issues arising with surveyors, it's advisable to print the disclaimer when the verification is printed.

Sites are constantly changing.

(3) There must be follow-up of any discrepancy found in information obtained during the verification process. The practitioner has the right to correct any information that is factually incorrect by documenting the new information with a comment that the previously-provided information was not correct. Follow-up with the verifying entity is necessary to determine the reason for the discrepancy if the practitioner says the information provided is factually incorrect.

(4) Health care professionals with multiple licenses, registrations, and/or certifications are responsible for maintaining these credentials in good standing and of informing the facility Director, Program Chief Officer, or designee, of any changes in the status of these credentials.

The Director, Program Chief Officer, or designee, is responsible for establishing a mechanism to ensure that multiple licenses, registrations, and/or certifications are consistently held in good standing or, if allowed to lapse, are relinquished in good standing. The practitioner is required to provide a written explanation for any credentials that were held previously, but which are no longer held or no longer full and unrestricted. The verifying official must contact the State board(s) or issuing organization(s) to verify information provided regarding the change. NOTE:

There are circumstances when verification from a foreign country is not possible or could prove harmful to the practitioner and/or family. In these instances, full documentation of efforts and circumstances, including a statement of justification, is to be made in the form of a report of contact and filed in the Credentialing and Privileging file in lieu of the document sought.

(5) If the search for documents is unsuccessful or the primary source documents are not received, after a minimum of two requests, full written documentation of these efforts, in the form of a report of contact, must be placed in the folder in lieu of the document sought. It is suggested that no more than 30 days elapse before the attempt is deemed unsuccessful. The practitioner needs to be notified and to assist in obtaining the necessary documentation through a secondary source.

e. Educational Credentials

(1) Verification of Educational Credentials

(a) For health care professionals who are requesting clinical privileges, primary source verification of all residencies, fellowships, advanced education, clinical practice programs, etc., from the appropriate program director or school is required. If a physician or dentist participated in an internship(s) equivalent to the current residency years PG 1, 2, and 3, it is necessary to obtain primary source verification of the internship(s). Any fees charged by institutions to verify education credentials are to be paid by the facility.

(b) For foreign medical school graduates, facility officials must verify with the Educational Commission for Foreign Medical Graduates (ECFMG) that the applicant has met requirements for certification, if claimed. The ECFMG is not applicable for graduates from Canadian or Puerto Rican medical schools. Documentation of completion of a “Fifth Pathway” may be substituted for ECFMG certification. Additionally, TJC accepts the primary source verification of ECFMG for foreign medical school graduation. Documentation of this verification must meet the requirements of this policy.

(c) All efforts to verify education must be documented if it is not possible to verify education, e.g., the school has closed, the school is in a foreign country and no response can be obtained, or for other reasons. In any case, facility officials must verify and document that candidates meet appropriate VA qualification standard educational requirements prior to appointment as an employee. NOTE: VA medical treatment facilities are encouraged to consider additional information concerning the education of the applicant from other authoritative sources.

(d) Applicants are required to provide information on all educational and training experiences, including all gaps greater than 30 days in educational history. Primary source verification must be sought on medical, dental, professional school graduation, and all residency(ies) and fellowship(s) training, as well as internships for non-physician and non-dentist applicants.

(e) An educational institution may designate an organization as its agent for primary source verification for the purposes of credentialing. The verification from the agent is acceptable (e.g., National Student Clearinghouse). Documentation of this designation needs to be on file.

(f) For other health care providers, at a minimum, the level of education that is the entry level for the profession or permits licensure must be verified, as well as all other advanced education used to support the granting of clinical privileges, if applicable (e.g., for an APRN, the qualifying degree for the registered nurse (RN) and the advanced APRN education must be verified).

(g) Primary source verification of other advanced educational and clinical practice program is required if the applicant offers this credential(s) as a primary support for requested specialized clinical privileges.

(2) Educational Profile for Physicians. Facilities may obtain, from the American Medical Association (AMA) or the American Osteopathic Association (AOA) Physician Database, a profile listing of all medical education a physician candidate has received in this country. These data sources contain other information for follow-up, as necessary. The AMA Physician Masterfile is a TJC-designated equivalent for primary source verification requirements for physicians’ and osteopaths’ education and completion of residency training. NOTE: The AOA Physician Database is a designated equivalent for: pre-doctoral education accredited by the AOA Bureau of Professional Education, post-doctoral education approved by the AOA Council on Postdoctoral Training, and Osteopathic Board certification. In instances where these profiles do not stipulate primary source verification was obtained, the facility must pursue that verification, if required by this policy. If a VA facility elects to use the profile, any associated fee is borne by the facility. Nothing in this Handbook regarding the AMA Physician Profile or AOA Osteopathic Physician Profile alters Human Resources Management’s documentation requirements for employment.

(3) Filing. Verification of all education and training is filed in Section III of the Credentialing and Privileging Folder and in the appropriate portion of VetPro.

f. Verifying Specialty Certification

(1) Physician Service Chiefs

(a) Physician service chiefs must be certified by an appropriate specialty board or possess comparable competence. For candidates not board-certified, or board certified in a specialty(ies) not appropriate for the assignment, the medical staff’s Executive Committee affirmatively establishes and documents, through the privilege delineation process, that the person possesses comparable competence. If the service chief is not board certified, the Credentialing and Privileging file must contain documentation that the individual has been determined to be equally qualified based on experience and provider specific data. Appointment of service chiefs without board certification must comply with the VHA policy for these appointments as appropriate.

(b) Verification must be from the primary source by direct contact or other means of communication with the primary source, such as by the use of a public listing of specialists in a book or Web site, or other electronic medium as long as the listing is maintained by the primary source and there is no disclaimer regarding authenticity. If listings of specialists are used to verify specialty certification, they must be from recently issued copies of the publication(s), and include authentic copies of the cover page indicating publication date and the page listing the practitioner. This information must be included in the practitioner's folder (electronic or paper) as follows:

1. Physicians. Board certification may be verified through the Official ABMS Directory of Board Certified Medical Specialists, published by the American Board of Medical Specialists (ABMS), or acceptable Internet verification, or by direct communication with officials of the appropriate board. A letter from the board addressed to the facility is acceptable for those recently certified. The electronic matching through VetPro is primary source verification because it is performed through an electronic version of Official ABMS Directory of Board Certified Medical Specialists. Osteopathic board certification may be verified through the AOA Physician Database. Copies of documents used to verify certification are to be filed in the Official Personnel Folder and in the credentialing and privileging file. NOTE: The address and telephone number of the board may be obtained from the latest Directory of Approved Residency Programs published by the Accreditation Council for Graduate Medical Education.

2. Dentists. Board certification may be verified by contacting the appropriate Dental Specialty Board. NOTE: Addresses of these boards may be obtained from the American Dental Association (ADA).

3. Podiatrists. The following three specialties are currently recognized by the House of Delegates, American Podiatric Medical Association, and VA: the American Board of Podiatric Surgery, the American Board of Podiatric Orthopedics, and the American Board of Podiatric Public Health. NOTE: Addresses of these boards may be obtained from the latest American Podiatric Directory.

4. Other Occupations. Board certification and other specialty certificates must be primary source verified by contacting the appropriate board or certifying organization.

(2) Evidence of Continuing Certification. Board certification and other specialty certificates, which are time-limited or carry an expiration date, must be reviewed and documented prior to expiration.

(3) Filing. Verification of specialty certification is filed in Section III of the Credentialing and Privileging folder and in the Board Certification portion of VetPro.

g. Licensure

(1) Requirement for Full, Active, Current, and Unrestricted Licensure. Applicants being credentialed in preparation for applying for clinical privileges must possess at least one full, active, current, and unrestricted license that authorizes the licensee to practice in the state of licensure and outside VA without any change being needed in the status of the license.

NOTE: For new appointments after a break in service, all licenses active at the time of separation need to be primary source verified for any change in status.

(2) Qualification Requirements of Title 38 United States Code (U.S.C.) Section 7402(f).

Applicants being credentialed for a position identified in 38 U.S.C. Section 7402(b) (other than a Director) for whom State licensure, registration, or certification is required and who possess or have possessed more than one license (as applicable to the position) are subject to the following provisions:

(a) Applicants and individuals appointed on or after November 30, 1999, who have been licensed, registered, or certified (as applicable to such position) in more than one State and who had such license, registration, or certification revoked for professional misconduct, professional incompetence, or substandard care by any of those States, or voluntarily relinquished a license, registration or certification in any of those States after being notified in writing by that State of potential termination for professional misconduct, professional incompetence, or substandard care, are not eligible for appointment, unless the revoked or surrendered license, registration, or certification is restored to a full and unrestricted status.

NOTE: Covered licensure actions are based on the date the credential was required by statute or the position’s qualification standards. For example, if VA first required the credential in 1972, the individual lost the credential in 1983, and the individual applies, or was appointed, to VA after November 30, 1999, the individual is not eligible for VA employment in the covered position, unless the lost or surrendered credential is restored to a full and unrestricted status.

However, if the individual lost the credential in 1970, before it was a VA requirement, eligibility for VA employment would not be affected provided the individual possesses one full and unrestricted license as applicable to the position (see App. B for list of occupations, job series, type of credential, and date first required by VA).

(b) Individuals who were appointed before November 30, 1999, who have maintained continuous appointment since that date and who are identified as having been licensed, registered, or certified (as applicable to such position) in more than one State and, on or after November 30, 1999, who have had such revoked for professional misconduct, professional incompetence, or substandard care by any of those States, or voluntarily relinquished a license, registration. or certification in any of those States after being notified in writing by that State of potential termination for professional misconduct, professional incompetence, or substandard care, are not eligible for continued employment in such position, unless the revoked or surrendered license, registration, or certification is restored to a full and unrestricted status.

NOTE: Individuals who were appointed prior to November 30, 1999, and have been on continuous appointment since that date are not disqualified for employment by any license, registration, or certification revocations or voluntary surrenders that predate November 30, 1999, provided they possess one full and unrestricted license as applicable to the position.

(c) Where a license, registration, or certification (as applicable to the position) has been surrendered, confirmation must be obtained from the primary source that the individual was notified in writing of the potential for termination for professional misconduct, professional incompetence, or substandard care. If the entity does verify written notification was provided, the individual is not eligible for employment unless the surrendered credential is fully restored.

(d) Where the State licensing, registration, or certifying entity fully restores the revoked or surrendered credential, the eligibility of the provider for employment is restored. These individuals would be subject to the same employment process that applies to all individuals in the same job category who are entering the VA employment process. In addition to the credentialing requirements for the position, there must be a complete review of the facts and circumstances concerning the action taken against the State license, registration, or certification and the impact of the action on the professional conduct of the applicant. This review must be documented in the licensure section of the credentials file.

(e) This policy applies to licensure, registration, or certification required, as applicable, to the position subsequent to the publication of this policy and required by statute or VA qualification standards, effective with the date the credential is required.

(3) When a practitioner enters into an agreement (disciplinary or non-disciplinary) with a State licensing board to not practice the occupation in a State, the practitioner is required to notify VA of the agreement. VA must obtain information concerning the circumstances surrounding the agreement. This includes information from the primary source of the specific written notification provided to the practitioner, including, but not limited to: notice of the potential for termination of licensure for professional misconduct, professional incompetence, or substandard care. If the entity does verify written notification was provided, all associated documentation must be obtained and incorporated into the credentialing and privileging file and VetPro. The practitioner must be afforded an opportunity to explain in writing, the circumstances leading to the agreement. Facility officials must evaluate the primary source information and the individual’s explanation of the specific circumstances, documenting this review in the credentialing and privileging file and VetPro.

NOTE: It may be necessary to obtain a signed VA Form 10-0459, Credentialing Release of Information Authorization request from the practitioner, requesting the State licensing board to disclose to VA all malpractice judgments and disciplinary actions as well as all open investigations and outstanding allegations and investigations. Failure by the practitioner to sign VA Form 10-0459 may be grounds for disciplinary action or decision not to appoint.

(4) There may be instances where actions have been taken against an applicant’s license for a clinically-diagnosed illness. Those applicants are eligible for appointment where they are acknowledged by the licensing, registering, or certifying entity as stable, the licensure action did not involve substandard care, professional misconduct, or professional incompetence, and the license, certificate, or registration is fully restored. A thorough analysis of the information obtained from the entity must be documented, signed by the appropriate reviewers and approving officials, and filed in the licensure section of the Credentialing and Privileging Folder.

NOTE: Questions concerning applicants who may qualify for appointment under the Rehabilitation Act of 1974, need to be referred to Regional Counsel.

(5) Exceptions to Licensure. As part of the credentialing process, the status of an applicant's licensure and that of any required or claimed certifications must be reviewed and primary source verified. Except as provided in VA Handbook 5005, Part II, Chapter 3, subparagraph 14b, all LIPs must have a full, active, current, and unrestricted license to practice in any State, Territory, or Commonwealth of the United States, or in the District of Columbia.

The only exceptions provided in VA Handbook 5005 are:

(a) An individual who has met all the professional requirements for admission to the State licensure examination and has passed the examination, but who has been issued a State license which is limited on the basis of non-citizenship or not meeting the residence requirements of the State.

(b) An individual who has been granted an institutional license by the State which permits faculty appointment and full, unrestricted clinical practice at a specified educational institution and its affiliates, including the VA health care facility; or, an institutional license which permits full, unrestricted clinical practice at the VA health care facility. This exception is only used to appoint an individual who is a well-qualified, recognized expert in the individual’s field, such as a visiting scholar, clinician, and/or research scientist, and only under authority of 38 U.S.C.

7405. It may not be used to appoint an individual whose institutional license is based on action taken by a SLB.

(c) An individual who has met all the professional requirements for admission to the State licensure examination and has passed the examination, but who has been issued a time-limited or temporary State license or permit pending a meeting of the SLB to give final approval to the candidate’s request for licensure. The license must be active, current, and permit a full, unrestricted practice. Appointments of health care professionals with such licenses must be made under the authority of 38 U.S.C. 7405 and are time-limited, not to exceed the expiration date of licensure.

(d) A resident who holds a license which geographically limits the area in which practice is permitted or which limits a resident to practice only in specific health care facilities, but which authorizes the individual to independently exercise all the professional and therapeutic prerogatives of the occupation. In some States, such a license may be issued to residents in order to permit them to engage in outside professional employment during the period of residency training. The exception does not permit the employment of a resident who holds a license which is issued solely to allow the individual to participate in residency training.

NOTE: There may be changes in State licensure requirements and administrative delay by SLBs in processing renewal applications for licensure. For information on these items see VA Handbook 5005, Part II, Chapter 3, Section A, subparagraphs 13f and 13g.

(6) SLBs may restrict the license of a practitioner for a variety of reasons. Among other restrictions, an SLB may suspend the licensee's ability to independently prescribe controlled substances or other drugs; selectively limit one's authority to prescribe a particular type or schedule of drugs; or accept one's offer or voluntary agreement to limit the authority to prescribe, or provide an “inactive” category of licensure. NOTE: In such cases, the license must be considered restricted for VA purposes, regardless of the official SLB status.

(7) Some states authorize a grace period after the licensure and/or registration expiration date, during which an individual is considered to be fully licensed and/or registered whether or not the individual has applied for renewal on a timely basis.