Appendix_H_General_Credentialing_Procedures.docx

General Credentialing Procedures

1. The credentials of all providers shall be reviewed and privileges granted as outlined in AFI 44-119, Medical Quality Operations. The Contractor is responsible to ensure that proposed staff possesses the requisite credentials enabling the granting of privileges by the MTF sufficient to allow for performance of all tasks identified in this PWS.

2. In accordance with Para 4.2.1, AFI 44-119, Medical Quality Operations, 16 Aug 2011, personal services contract personnel providing care in the MTF can be licensed in any US jurisdiction.

3. Instructions for credentialing may vary slightly dependent upon respective MTF. Contractor shall contact the respective MTF for specific, current instructions.

4. Initial applications for clinical privileges, to include credentials action history, malpractice history, and completed copies of the below listed documents, shall be submitted to the MTF at the address below 30 calendar days from notice of contract award, or anytime when requested by the Functional Requirements Evaluator Designee (FRED). Additionally, the Contractor shall make all proposed health care providers available for interview by the MTF during the credentialing process. Below is a list of items required, however, the Contractor shall call the respective MTF to get the latest list of requirements. The MTF can provide copies of forms.

Below is a list of items that may be required:

· Copy of valid, current, unrestricted state medical license and applicable Board Certification.

· Copy of any current background check.

· Healthcare worker education and training.

· Current Basic Life Support (BLS), Pediatric Advanced Life Support (PALS), and Advanced Cardiac Life Support (ACLS) certification.

· Current certification in Neonatal Resuscitation Program (NRP), if applicable.

· A signed consent for release of information.

· Copy of Drug Enforcement Agency (DEA) certificate, if applicable.

· A copy of the proposed contract provider’s professional resume, accompanied by that individual’s sworn affidavit of the truthfulness of same, indicating experience, training, and technical expertise in the type of care to be rendered.

· A list of all states in which contract healthcare worker currently holds or has held a license to practice related services.

· Certification of current physical examination for each employee. The certification shall contain a signed statement by the examining physician stating that the employee is free of any contagious diseases. Physical examination must be current as of 12 months prior to application for privileges.

· Release of Liability

· 21st MDG Bylaws, see Appendix D.

· Sedation Care Memorandum

· Copy of Photo ID

· Unrestricted License Memorandum or Application for Waiver of Administrative Licensure Requirements

· Any training certificates, licenses, etc. listed on your application.

· MD, DO, DDS, DMD, CRNA, RN, LPN, MA or other professional training certificates.

· Internship, residency, fellowship and all other specialty training certificates.

· Copy of Board Certification

· ALL current state licenses.

· National Providers Identification (NPI) number

· Read, complete, and return the following:

· AF Form 1540, Application for Clinical Privileges (Complete Section I through IX and sign. Element Chief and Flight Commander review and complete the application and sign where indicated.)

· AF Form 1 540A, Application for Clinical Privileges Update (Addendum to Form 1540)

· AF Form 1541, Credentials Continuing Health Education Training Record

· AF Form 1562, Credentials Evaluation of Health Care Practitioners: Sign and date each of the AF Forms 1562. These will be sent to the individuals you list as references on your application.

· AF Form 283CC, Clinical Privileges — (Specialty)

· Privilege List (Specialty Specific): Review and complete the privilege list for your specialty by placing # 1, 2, or 4 in the requested column, according to the instructions at the top of the form. DO NOT use “x’s” or check marks. Ensure all equipment is properly Place your signature in the “Provider Signature” space and obtain your clinical supervisor’s recommendation and signature.

5. Applications for privileges will be screened through the National Practitioners Data Bank.

6. Professional staff appointments and clinical privilege actions will be based on review of documents in accordance with AFI 44-119. Re-appointment shall occur not less than every two years, in accordance with AFI 44-119.

7. Applications for clinical privileges for replacement contract providers shall be submitted to the appropriate MTF’s FRED not later than 30 calendar days prior to the healthcare worker assuming duty.

8. The Contractor must submit only complete credentials applications for processing. Incomplete applications (those that do not fully comply with the requirements) will not be accepted by the Government and will be returned without action.

9. The Contractor must take specific action, including Primary Source Verification, to ensure that contract healthcare worker applications have the required prerequisites for privileging and do not have disqualifying impediments for privileges at the MTF. The Contractor cannot delegate this responsibility.

10. The Contractor will submit applications for only those contract healthcare workers who can reasonably be anticipated to render the actual, substantial performance on the contract. The submission of primary contract providers for credentialing who lack the requisite qualifications, or who will not work at all, is unacceptable and will be considered a failure to perform.

11. Team member may not see patients until clinical privileges have been approved.

12. Provide credentialing packages to the appropriate MTF:

CAUTION: READ INSTRUCTION ON ALL FORMS AND FOLLOW THEM. IF ANY PART OF THE APPLICATION PACKAGE IS INCOMPLETE OR MISSING THE ENTIRE PACKAGE WILL BE RETURNED FOR PROPER COMPLETION.

Appendix H