J-6_Credentialing_and_Privileging.pdf

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J-6

J-6 Credentialing and Privileging

Credentialing and Privileging.

4-1. Establishment of Credentials Portfolios

a. The Office of the AMD establishes credentials portfolios for all IHSC staff prior to their working in the clinic.

b. For all contract physicians and behavioral health providers who deliver services on site, IHSC must receive education, training, experience and competency documents, including licensure and certifications, before contracts for services are negotiated or privileges are granted.

c. NOTE: The decision to hire any health care provider will be based on the review of a complete verified credentials portfolio.

4-2. Format. The complete credentials portfolio consists of four sections.

a. Section I – Privileges

(1) IHSC Application/Privileges (see forms below)

(2) Health Statement

(3) Malpractice Insurance

b. Section II – Education

(1) License (ALL state licenses, active/inactive/current/expired/ valid/non-valid) within any U.S. state, territory, commonwealth, possession.

(2) Professional School Diplomas

(3) Internship documents

(4) Residency documents

(5) Preceptorship documents

(6) Board certification

(7) Cardio-Pulmonary Resuscitation (CPR) certification

c. Section III – Experience and Current Competency

(1) References (letters of reference written within the past three months)

(2) Competency Checklist by discipline

(3) Scope of Practice Checklist/Competency Assessment forms for Staff

d. Section IV – Personal Information

(1) Miscellaneous

(2) Curriculum vitae/ Resume

(3) Continuing Professional Education

(4) Letters of Appreciation

(5) Documentation of all personnel actions (letters of counseling, reprimands, etc.)

NOTE: Each section is identified by a cover sheet with the contents under the cover sheet. Each credentials portfolio is labeled with the provider’s name (last name, first name, middle initial) and profession. This is located on the front cover.

4-3. Primary Source Verification. All credentials documents are verified at the primary source for proof of authenticity. This verification is in writing and is included with the referenced document in the credentials portfolio. Interim source verification may be accomplished by telephone. See sections 5-1 and 5-2 below for additional information.

4-4. Maintenance. Maintenance of the credentials portfolio involves:

a. Ensuring all documents are included and up to date.

b. Adding documents as needed.

c. Accepting renewed documents and placing them in the proper section.

d. Verifying any renewed document.

e. Replacing worn portfolio covers.

4-5. Transfer. The credentials portfolio is the property of the government. A credentials portfolio will be transferred for the following reasons only:

a. Transfer of any employee within the contract (portfolio is mailed to the receiving facility).

b. Termination of employment (portfolio is sent to, credentials archives.)

4-6. Storage. Credentials portfolios will be stored in a locked cabinet on-site at all times for the duration of the contract. At the end of the contract, they will be archived as per the COR’s instruction.

4-7. Release of Information. A portfolio will not be transferred to anyone outside of the site without special permission of the employee and concurrence of the COR.

5. PROCEDURES:

5-1. Procedures for Primary Source Verification

a. Obtain a photocopy of the document from the applicant/employee.

b. Obtain a signed and notarized Authorization for Release of Information from applicant/employee.

c. Request, in writing, verification of the document from the primary source. Be sure to obtain addressed of schools, hospitals, etc. from the applicant/ employee.

d. Many primary sources require a processing fee. Each site Administrator, and or his or her designee, will establish a mechanism at the local level for payment of those fees.

5-2. Procedures for Telephonic Primary Source Verification

a. Obtain a photocopy of the document from the applicant/employee.

b. Obtain a signed and notarized Authorization for Release of Information from applicant/employee.

c. For licenses, call the State Board of Examiners (Medical, Dental, Nursing, Physician Assistant). This is usually located in the capital city of the state.

d. For schools, call the Office of the Registrar.

e. For residencies, internships, etc. obtain the name of contact from provider.

f. Upon making contact with the primary source, request verification of the document.

g. Record the following information on front of the photocopy of the document.

(1) Date and time of call

(2) Organization contacted

(3) Name of the verifier (they usually will not give their last name)

(4) What the verifier says (License is current and active with no actions pending or license expired on 3-3-2010.)

(5) Sign your name.

h. Request address for obtaining written verification.

i. Notes:

(1) All telephonic verification must be followed by letter or electronic mail verification.

(2) All non-expiring documents need only to be verified once. All documents that expire (licenses, certification. etc.) will be verified after each renewal.