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Department of Veterans Affairs VHA HANDBOOK 1100.19 Veterans Health Administration Transmittal Sheet Washington, DC 20420 October 15, 2012

CREDENTIALING AND PRIVILEGING

1. REASON FOR ISSUE. This revised Veterans Health Administration (VHA) Handbook provides VHA procedures regarding credentialing and privileging. AUTHORITY: Title 38 United States Code 7304, 7401, 7402, 7405, 7409, and 7461 through 7464; title 45 Code of Federal Regulations (CFR) Part 60; Public Law (Pub. L.) 106-117, sec. 209, Pub. L. 105-33, sec. 4331(c), Pub. L. 104-191, sec. 221, Pub. L. 99-166, sec. 206, and Pub. L. 99-660, sec. 422 and its revisions; 5 CFR Parts 315, 731, and 752; and 38 CFR Part 46.

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

1100.19 incorporates:

a. Requirement for Clinical Pharmacy Specialists to be credentialed in accordance with this policy;

b. Incorporation of requirements for acceptance of facsimile primary source verification;

c. Reduction of the number of references required for expedited appointment;

d. Specific requirements for verification of previous VA experience;

e. Revision to the credentialing and privileging requirements related to telemedicine and Teleconsultation;

f. Guidance on the privileging process; and

g. Clarification on the due process procedures afforded practitioners for reduction or revocation of clinical privileges.

3. RELATED ISSSUE. VHA Directive 1100.19.

4. RESPONSIBLE OFFICE. The Office of Quality, Safety, and Value (10A4E), is responsible for the contents of this VHA Handbook. Questions may be addressed to 919-474-3905.

5. RESCISSIONS. VHA Handbook 1100.19, dated November 14, 2008, is rescinded.

6. RECERTIFICATION. This VHA Handbook is scheduled for recertification on or before the last working day of October 2017.

Robert A. Petzel, M.D.

Under Secretary for Health

DISTRIBUTION: E-mailed to the VHA Publications Distribution List 10/16/2012

October 15, 2012 VHA HANDBOOK 1100.19 i

CONTENTS

CREDENTIALING AND PRIVILEGING

PARAGRAPH PAGE

1. Purpose

2. Definitions

3. Scope

4. Responsibilities of the Under Secretary for Health

5. Responsibilities of the Principal Deputy Under Secretary for Health

6. Responsibilities of the Deputy Under Secretary for Health for Operations and Management (10N)

7. Responsibilities of the Veterans Integrated Service Network (VISN), Chief Medical Officer (CMO),

8. Responsibilities of the Facility Director

9. Responsibilities of the Facility Chief of Staff (COS)

10. Responsibilities of the Service Chief

11. Responsibilities of the Director, Management Review Service

12. Responsibilities of the Applicant and Practitioner

13. 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) Registration and Controlled

Dangerous Substance (CDS) Certification

i. Employment Histories and Pre-employment References

j. Health Status

k. Malpractice Considerations

VHA HANDBOOK 1100.19 October 15, 2012 ii

CONTENTS Continued

PARAGRAPH PAGE

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

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

n. Credentialing for Telehealth and Teleconsultation

o. Expedited Appointment to the Medical Staff

p. Temporary Medical Staff Appointments for Urgent Patient Care Needs

q. Credentialing for Contracted Services

r. Reappraisal

s. Transfer of Credentials

t. Disposition of Credentialing and Privileging Files

14. 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. Triggered Reviews

i. On-Going Monitoring of Privileges

j. Reappraisal and Re-privileging

k. Denial and Non-renewal of Privileges

l. Reduction and Revocation of Privileges

m. Inactivation of Privileges

n. Deployment and/or Activation Privilege Status

15. Documentation of the Medical Staff Appointment and Clinical Privileges

16. References

APPENDICES

A Standard (Six-Part) 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 iii

CONTENTS Continued

PARAGRAPH PAGE

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 Clinical Privileges........................................................................................................ F–1

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

CREDENTIALING AND PRIVILEGING

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 trainees, including physician residents, except those who function outside the scope of their training program; i.e., Medical Officer of the Day advanced Fellows, or certain Chief Resident positions.

AUTHORITY: Title 38 United States Code 7304, 7401, 7402, 7405, 7409, and 7461 through 7464; title 45 Code of Federal Regulations (CFR) Part 60; Public Law (Pub. L.) 106-117, sec.

209, Pub. L. 105-33, sec. 4331(c), Pub. L. 104-191, sec. 221, Pub. L. 99-166, sec. 206, and Pub.

L. 99-660, sec. 422 and its revisions; 5 CFR Parts 315, 731, and 752; and 38 CFR Part 46.

2. 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 Department of Veterans Affairs (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 be used as primary source verification, if the authenticity of the facsimile is independently verified; there is verification of the identity of the creator, when it was created; and that it is an accurate reproduction of the original documented in writing.

d. Credentialing. The term "credentialing" refers to the systematic process of screening and evaluating qualifications and other credentials, including, but not limited to: 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, practitioner-specific, and within available resources.

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

f. Competency. The term “competency” is a 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) Continuous Query (CQ) annual registration, and other credentials with expirations.

h. Independent Practitioner. The term "independent practitioner" is any individual permitted by law (the statute that defines the terms and conditions of the practitioner’s practice in the State of licensure) 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 an occupation, as evidenced by documentation issued by a State, Territory, Commonwealth, or the District of Columbia (hereafter referred to as “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 must be the same regardless of whether they are performed by more than one service, more than one type of practitioner, or in more than one location.

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

l. Primary Source Verification. Primary source verification is the 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 subpar.

14p(3)(b) for additional information on reduction of privileges).

n. Teleconsulting. Teleconsulting is the provision of advice on a diagnosis, prognosis, and/or therapy from a licensed independent practitioner to another licensed independent practitioner using electronic communication 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 LIP.

o. Telemedicine. Telemedicine is the provision of care by a LIP that directs, diagnoses, or otherwise provides clinical treatment delivered using electronic communications and information technology when distance separates the practitioner 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 practitioner 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. Unless noted otherwise in this Handbook, a Medical Staff appointment is required if the practitioner 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 practitioners that facilitates completion of a uniform, accurate, and complete credentials file.

3. 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 LIPs 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 those Advanced Practice Registered Nurses (APRN), Physician Assistants (PA), and clinical pharmacy specialists who do 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, that are 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 practitioners 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 or local policy 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 the 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. The VHA credentialing and privileging 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, APRNs, PAs, and clinical pharmacy specialists.

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

(2) 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 facility Medical Staff Bylaws, Rules, and Regulations can be inconsistent with the law, Department of Veterans Affairs (VA) regulations, this Handbook’s policies and procedures, or other VA policies.

4. RESPONSIBILITIES OF THE 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.

5. RESPONSIBILITIES OF THE 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 facilities.

6. RESPONSIBILITIES OF THE DEPUTY UNDER SECRETARY FOR HEALTH

FOR OPERATIONS AND MANAGEMENT (10N)

The Deputy Under Secretary for Health for Operations and Management (10N), is responsible for:

a. Ensuring that VISN Directors maintain an appropriate credentialing and privileging process consistent with the VHA policy.

b. Ensuring uniform prototype performance standards are issued for key VHA medical facility managers, such as Directors, Associate or Assistant Directors, Human Resource Management Officers, and COS.

c. Continuing the monitoring of credentialing and privileging through periodic TJC consultative site visits and other reviews, as applicable.

7. RESPONSIBILITIES OF THE VISN CHIEF MEDICAL OFFICER (CMO)

The VISN CMO is responsible for oversight of the credentialing and privileging process of the facilities within the VISN using a standardized assessment tool as directed by the Deputy Under Secretary for Health for Operations and Management when completing oversight activities.

8. RESPONSIBILITIES OF THE 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:

a. The labor-management obligations are met prior to implementing a Credentialing and Privileging Program that involves Title 5 or Hybrid Title 38 LIPs who are represented by a professional bargaining unit.

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

c. 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).

(1) Training must be completed within 3 months of assuming this position.

(2) This training may be accessed through the VA Learning Management System at https://www.tms.va.gov .

(3) This target audience includes: Medical Staff and Credentialing Professionals; Clinical Service and Product Line Chiefs; Credentials Committee Members (Professional Standards Boards); Executive Committee of the Medical Staff members; COSs and medical facility Directors; Quality and Performance Improvement professionals; and Risk Managers. NOTE:

Additional information may be found at the Employees Education Service (EES) Mandatory Training website at http://vaww.ees.lrn.va.gov/mandatorytraining.

d. Securing all credentialing and privileging documents.

9. RESPONSIBILITIES OF THE FACILITY CHIEF OF STAFF (COS)

The facility COS is responsible for:

a. Maintaining the Credentialing and Privileging system.

b. Ensuring that all health care professionals applying for clinical privileges agree to provide continuous care to the patients assigned to them.

c. Ensuring that all health care professionals applying for clinical privileges are provided with a copy of, and agree to abide by, the Medical Staff Bylaws, Rules, and Regulations.

d. Ensuring that the Medical Staff Bylaws are consistent with this Handbook and any other VHA policy related to Medical Staff Bylaws.

e. Ensuring training appropriate staff in direct line of authority complete the training identified in subparagraph 8c.

10. RESPONSIBILITIES OF THE SERVICE CHIEF

Each Service Chief‘s is 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; documenting these recommendations in VetPro; and

c. Monitoring and surveillance of the professional competency and performance of those who provide patient care services with delineated clinical privileges. This includes both the focused professional practice evaluation for new privileges (practitioners new to the facility as well as practitioners requesting new privileges) and the ongoing monitoring and continued surveillance over time. NOTE: The title applies to Service Line Directors, Product Line Chiefs, and any other equivalent titles.

d. Ensuring that appropriate staff in direct line of authority complete the training identified in subparagraph 8c. Service Chiefs involved in the credentialing and privileging process are responsible for completing the same training.

11. RESPONSIBILITIES OF DIRECTOR, MANAGEMENT REVIEW SERVICE

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).

12. RESPONSIBILITIES OF THE APPLICANT AND PRACTITIONER

Applicants and appointed practitioners are responsible for:

a. Providing evidence of licensure, registration, certification, and/or other relevant credentials, for verification prior to appointment and throughout the appointment process, as requested.

b. Agreeing to accept the professional obligations delineated in the Medical Staff Bylaws, Rules, and Regulations provided to them. NOTE: There may be practitioners who by the nature of their position may not be located in Central Office. These practitioners are credentialed in accordance with this Handbook, but are not agreeing to accept the professional obligations delineated in the Medical Staff Bylaws since this is not applicable. These practitioners are only agreeing to the completeness and accuracy of the application as well understanding that their professional obligations can be compromised by financial conflicts of interest; and they will therefore avoid conflicts or seek guidance in their management.

c. Keeping VA apprised of anything that would adversely affect, or otherwise limit, their clinical privileges at the earliest date after notification is received by the practitioner, but no later than 15 days. This includes not only final actions, but also pending and proposed actions.

d. Maintaining licenses, registrations, and certification in good standing and informing the Director, or designee, of any changes in the status of these credentials at the earliest date after notification is received by the practitioner, but no later than 15 days, including, but not limited to any pending or proposed actions.

e. 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 keep VA fully informed on these matters may result in administrative or disciplinary action.

13. 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 13o, 13p, 14e, and 14f.

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 13a., 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 file and requested privileges and make recommendations regarding the 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 Facility Medical Staff Bylaws, Rules, and Regulations and must agree in writing or via electronic signature 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 Handbook, must complete an electronic submission of VetPro. VetPro's supplemental attestation questions require applicants to answer questions concerning malpractice, adverse action against licensure, privileges, research, etc., in accordance with TJC and VHA requirements.

(2) The "Sign and Submit" screen in VetPro meets the requirement for the applicant's agreement to provide continuous care and to accept the professional obligations defined in the facility 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. NOTE: For those individuals who are not members of the medical staff, this attestation is still required since all practitioners delivering care at a facility are subject to the Medical Staff Bylaws, Rules and Regulations whether practicing independently, in collaboration with an independent practitioner or under the supervision of such.

(3) Applicants are required to provide information on all educational, training, and employment experiences, accounting for all gaps greater than 30 days in the candidate’s history from date of graduation for the qualifying degree to the date of submission of the application.

(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, personal history and competence, and supplemental attestation questions. The updated information must be verified prior to the candidate reporting for duty.

The primary source verification of a time-limited credential cannot be greater than 120 days old at the time a practitioner reports for duty. This requirement includes enrollment in the NPDB– HIPDB CQ. 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. A copy of the appropriate application form and any supplemental form(s) are maintained electronically in VetPro. If the applicant provides a resume or curriculum vitae, this is filed in Section I of the credentialing and privileging file.

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 allowed.

(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. All credentialing and privileging documents must be secured. Facsimile copies may be used as primary source verification with appropriate authentication of the source providing the information. The source of the facsimile needs to be independently authenticated and the authentication needs to be documented in writing by the authenticator, e.g., entry into comments section of VetPro. A coversheet by itself is not considered independent authentication, but it may be scanned as the last page of the document, not the first, as well as documentation of the independent verification of the sender’s source. If independent authentication of the source cannot be made, the facsimile copy must be followed up with an original document.

(a) Authentication of the source of the facsimile requires the recipient to document knowledge that the appropriate source that owed the verification information transmitted the facsimile. For example, if the recipient of the facsimile confirmed with the verifying entity that the facsimile was indeed transmitted by the verifying entity, then this confirmation should be documented on the facsimile coversheet, signed and dated by the individual completing the independent authentication, as well as the name and title of the confirming individual and the date of confirmation.

(b) When using an Internet source for verification, the following criteria must be considered in determining appropriateness as primary source verification:

1. 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 be considered as not adequate for verification.

2. 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.

3. The site must provide information on the status of the credential and pending or final adverse action information as of the date of verification.

4. 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, the Deputy Under Secretary for Health, the Program Chief Officer, or designee, of any changes in the status of these credentials at the earliest date after notification is received by the practitioner, but no later than 15 days. to include, but not limited to, final actions as well as pending or proposed actions. The Deputy Under Secretary for Health, the facility Director, the 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 SLBs 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 the 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, is to be filed in the credentialing file in lieu of the document sought.

It is suggested that at least 15 days be provided for requests made in the continental United States, and no more than 30 days for other locations, before the attempt is deemed unsuccessful.

The practitioner needs to be notified and needs to assist VA in obtaining the necessary documentation through a secondary source. Examples of secondary sources include, but are not limited to: web verifications sources that do not meet appropriate guidelines; documentation from another source that claims to have verified the credential; and, as a final effort, an authenticated copy of the credential.

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, other clinical training 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). Enrollment in any portion of an accredited training program (even if incomplete) must be reported. If an accredited stand-alone internship was completed before entering into the additional years of a residency program, both the internship and residency program must be separately verified. 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) If it is not possible to verify education, all efforts to verify education must be documented, 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, since graduation from the qualifying education degree. 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 practitioners, 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, both the qualifying degree for the registered nurse (RN) and the advanced education must be verified).

(g) Primary source verification of other advanced educational and clinical practice programs 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.

(a) The AMA Physician Masterfile is a TJC-designated equivalent for primary source verification requirements for physicians’ and osteopaths’ United States education, residency, and fellowship training.

(b) The AOA Physician Database is a designated equivalent for:

1. Pre-doctoral education accredited by the AOA Bureau of Professional Education,

2. Post-doctoral education approved by the AOA Council on Postdoctoral Training, and

3. Osteopathic Board certification.

(c) In instances where these profiles do not stipulate primary source verification was obtained, the facility must pursue that verification, if required by this Handbook.

(d) 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 the appropriate portion of VetPro.

f. Verifying Specialty Certification

(1) Physician Service Chiefs. 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 consistent with the assignment, the medical staff’s Executive Committee of the Medical Staff 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 practitioner specific data. Appointment of Service Chiefs without board certification must comply with VA Handbook 5005 for these appointments, as appropriate.

(2) 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:

(a) Physicians. Board certification may be verified through the Official American Board of Medical Specialists (ABMS) Directory of Board Certified Medical Specialists, an 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.

(b) 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).

(c) Podiatrists. The following three organizations 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.

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

(3) 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.

(4) Filing. Verification of specialty certification is filed 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.) 7402(f).

Applicants being credentialed for a position identified in 38 U.S.C. 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, have had such license, registration, or certification revoked for professional misconduct, professional incompetence, or substandard care by any of those States, or who 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 verifies that a 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 practitioner 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 portion of VetPro.

(e) This Handbook applies to licensure, registration, or certification requirements, as applicable, to any practitioner credentialed in accordance with this Handbook.

(3) When a practitioner enters into an agreement (disciplinary or non-disciplinary) with a SLB 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.