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OVERCOMING THE CHALLENGES
OF CREDENTIALING AND
PRIVILEGING
Michelle Layton BSN, MBA
Infidium Healthcare Solutions, LLC
michellel@infidiumhs.com
Disclaimers
 This presentation is not endorsed by Management Strategists
Consulting Group (MSCG).
 This presentation is not endorsed by Health Resources Services
Administration (HRSA) or the Bureau of Primary Health Care
(BPHC).
 Not employed by MSCG or BPHC.
 Independent Consultant who is contracted to conduct Operational
SiteVisits (OSV), provideTechnical Assistance and assist health
centers prepare for their OSV.
Confidentiality Notice: This document is confidential and contains proprietary information and
intellectual property of Infidium Healthcare Solutions, LLC. Neither this document nor any of the
information contained herein may be reproduced or disclosed under any circumstances without the
express written permission of Infidium Healthcare Solutions, LLC.
Agenda
 Back to Basics
◦ Differences between Credentialing and Privileging
 Compliance Manual Changes
 How Credentialing and Privileging relates to Scope of
Project
 Peer Review
 Credentialing and Privileging During COVID-19
 Updates/Question and Answer Session

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Back to Basics
Back to Basics
Credentialing and
privileging…
Oh… I thought they were
the same thing?
Definitions
Credentialing
The process of assessing and confirming the
qualifications of a licensed or certified health care
practitioner
Privileging/Competency
The process of authorizing a licensed or certified
health practitioner’s specific scope and content of
patient care services

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Definitions
Licensed Independent Practitioner (LIP)
Physician, Dentist, Nurse Practitioner and Nurse
Midwife or “ any other individual permitted by law and
the organization to provide care and services without
supervision, within the scope of the individual’s
license and consistent with individually granted
clinical privileges
Definitions
Other Licensed or Certified Health Care
Practitioner (OLCP)
An individual who is licensed, registered or certified but is not
permitted by law to provide patient care services without
direction or supervision. Examples include:
• Laboratory Technicians
• Medical Assistants
• Registered Nurses
• Dental Hygienists
Definitions
Other Clinical Staff
A clinical staff member that performs services in a state,
territory or other jurisdiction that does not require licensure or
certification. Examples include:
• Medical Assistants
• Dental Assistants
• Community Health Workers

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Definitions
Primary Source Verification
Verification by the original source of a specific
credential to determine the accuracy of a qualification
reported by an individual health care practitioner.
Examples include:
• Internet verification (i.e., state database)
• Direct correspondence
• Reports from Credentials Verification Organization
Definitions
Primary Source Verification
Possible sources for PSV of verification of education
and residency for physicians include:
• American Medical Association (AMA) Masterfile
• American Board of Medical Specialties
• American Osteopathic Association Physician
Profiles
• Education Commission for Foreign Medical
Graduates (ECFMG) – International graduates
licensed after 1986
Definitions
Primary Source Verification
Possible sources for PSV of verification of
certifications for other LIPs (i.e., PA, NP, etc.) include:
• American Nurses Credentialing Center
• American Midwifery Certifying Board
• National Commission on Certification of Physician
Assistants

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Definitions
Secondary Source Verification
Methods of verifying a credential that are not
considered an acceptable form of primary source
verification. Examples include:
• Notarized copy of the credential
• Copy of the credential that is made from an
original by approved staff
Definitions
Reappointment
The process of verifying expired credentials and re-
privileging of a licensed or certified health care
practitioner on a recurring basis
Credentialing and Privileging Activities
Credentialing and Recredentialing activities for
LIPs include:
• Verification of identity – Initial only
• Verification of current licensure, registration or
certification – Primary source
• Verification of education and training – Primary source,
initial only
• National Practitioner Data Bank Query
• Verification of DEA Registration
• Verification of basic life support training

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Credentialing and Privileging Activities
Credentialing and Recredentialing activities for
OLCPs include:
• Verification of identity – Initial only
• Verification of current licensure, registration or
certification – Primary source
• Verification of education and training – Primary or
Secondary Source, initial only
• National Practitioner Data Bank Query
• Verification of DEA Registration (if applicable)
• Verification of basic life support training
Credentialing and Privileging Activities
Privileging and Reprivileging activities for LIPs
include:
• Verification of fitness for duty
• Verification of immunization and communicable disease
status
• Verification of current clinical competence
• Initial – Verification via training, education, reference reviews
• Renewal – Verification via peer review, performance improvement
activities
Credentialing and Privileging Activities
Privileging and Reprivileging activities for OLCPs
include:
• Verification of fitness for duty
• Verification of immunization and communicable disease
status
• Verification of current clinical competence
• Based on Supervisory evaluation of clinical competence per the job
description

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Temporary Privileges
• Privileges SHOULD:
• Be granted in accordance with FTCA Guidelines
• Be approved by the CEO upon the recommendation of
appropriate department head
• Privileges SHOULD NOT:
• Exceed more than 90 days
• Be renewed
• Be granted in lieu of expired credentials
Credentialing and Privileging Activities
Initial Privileging and Reappointment
 Privileging is completed after the health center has verified all
necessary credentials for a practitioner
 Re-appointment is completed on a recurring basis (i.e., every
two years), as determined by the health center
 Re-appointment involves the verification of expired
credentials and re-privileging of practitioners
 The health center determines who has approval authority for
Credentialing and Privileging
Credentialing and Privileging Activities
Delineation of Privileges (Clinical Services)
• Subsequent to credentials verification, the practitioner
submits a request for clinical privileges, which includes
completion of a Delineation of Clinical Services Form.
• The Delineation of Clinical Services Form:
• Includes only services and sites listed in the health center’s
approved scope of project
• Is specific to each specialty within the health center (i.e., Dental,
Behavioral Health, Family Practice, Obstetrics)
• Outlines Requested Services, Non-Requested Services,
Approved Services and Non-Approved Services

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Compliance Manual Changes
Compliance Manual Changes
 The Compliance Manual supersedes the following Policy
Information Notices:
◦ 2001-16: Credentialing and Privileging of Health Care Practitioners
◦ 2002-22: Clarification of BPHC Credentialing and Privileging Policy Outlined in
PIN 2001-16
 Do NOT include any references to the above PINs in the
Credentialing and Privileging Policy
 Ensure the Credentialing and Privileging Policy demonstrates a
clear understanding of the difference between credentialing and
privileging, as well as the associated activities
 Ensure the Credentialing and Privileging Policy is reflective of
current practice
◦ Board approval or not, reference to CVO
Compliance Manual Changes
 The Credentialing and Privileging Policy does NOT require board
approval
 Credentialing and Privileging of clinical staff does NOT require
board approval
 The health center must have documented procedures in place to
ensure competency of Other Clinical Staff
◦ The health center determines what aspects of the credentialing and privileging
process apply
◦ None required if the health center does not utilize Other Clinical Staff
 The health center determines the timeframe for recurring
credentialing and renewal of privileges
◦ Exercise caution!! Certain credentials have specific recurring timeframes

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Compliance Manual Changes
 The health center must ensure contracted and referral providers
are appropriately credentialed and privileged
◦ Contracts/referral arrangements must include provisions to support
credentialing and privileging of contracted/referral providers
◦ Review of the contracted organization’s credentialing and privileging
process
 Reappointment of Licensed Independent Practitioners requires the
consider of Peer Review results or performance improvement
activities
 There MUST be a process in place for denial, modification or
revocation of privileges based on performance. Reference it in
your policy!!!
Compliance Manual Changes
As a reminder……..
 The Compliance Manual is the minimum standard for credentialing
and privileging of clinical staff
 FederalTort Claims Act (FTCA) regulations are the highest
standard for credentialing and privileging of clinical staff
 Utilize the HRSA Credentialing and Privileging File Review
Resource (updated 2/2020) as a guideline for primary and
secondary source verification
 Categorization of providers as LIPs and OLCPs may vary from
state to state based on the specific licensure and certification
requirements and scope of practice prescribed by the state
Scope of Project

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What is Scope of Project?
A health center’s scope of project defines the activities
supported by the Health Center Program project
budget. Specifically, scope of project defines the
approved service sites, services, providers, service
area(s) and target population(s).
https://bphc.hrsa.gov/programrequirements/scope.html
What is Scope of Project?
 Form 5A defines the service being provided, as well as the
method of service delivery.
 Form 5B identifies the sites where the services on Form
5A are being provided.
 Form 5C identifies other activities the health center may
be conducting such as hospital admitting and health fairs.

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Why is Scope of Project Important?
 Scope demonstrates the health center’s commitment to
HRSA
 Scope is reflective of the operations of the health
center
 Scope must be accurate for purposes of:
◦ Medicare/Medicaid FQHC Reimbursement
◦ FTCA Coverage
◦ 340B Drug Pricing Program Benefits

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Why is Scope of Project Important?
 The health center’s Scope of Services MUST be accurate to reduce the risk
associated with FTCA malpractice claims
 Credentialing and privileging is required to ensure appropriate FTCA coverage
 Services provided by FTCA covered individuals must be within the approved Scope
of Project and outlined on a “Delineation of Privileges” form
 In the event of a malpractice claim, FTCA will do a review of the health center’s
Scope of Services to determine the accuracy
 Health center’s that have an outstanding condition in the areas of Credentialing and
Privileging or Quality Improvement/Assurance are at risk for denial of FTCA
deeming status
Peer Review
Peer Review – Basic Concepts
Peer Review must be completed:
 On a “routine and regular basis”
◦ Considered a quarterly QI Assessment per the Site Visit Protocol
 Between providers within the same specialty who are similarly
credentialed
 In all clinical areas within the health center’s scope of project (Family
Medicine, Obstetrics, Dental, Behavioral Health)
 Using an industry standard tool that clearly evaluates the quality of
services provided and does not only perform administrative review
 Using a blinded methodology that ensures confidentiality of patient
information

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Peer Review – Basic Concepts
The results of Peer Review must be part of the
health center’s Quality Improvement Program and
incorporated into the LIP reappointment process,
which is evidenced by documentation in:
• Credentialing and Privileging Policy
• Peer Review Policy
• Quality Improvement Plan
• Credentialing and Privileging files
Credentialing and Privileging
During COVID-19
Compliance During COVID-19
 Health centers are still expected to maintain compliance with HRSA’s Credentialing
and Privileging Requirements, as well as FTCA Requirements
 HRSA recognizes the impact of COVID-19 may impact a health center’s ability to
demonstrate compliance within the specific time frame or specific manner as outlined
by the Compliance Manual
◦ Basic Life Support Training
◦ Patient Satisfaction Survey
 HRSA will consider the impact of COVID-19 on the ability of health centers to
maintain compliance when making future compliance determinations
◦ The level and/or areas of leniency have not yet been determined
Updated 3/30/20 – Program Oversight and Monitoring
https://bphc.hrsa.gov/emergency-response/coronavirus-frequently-asked-
questions.html#faqs

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Compliance During COVID-19
Compliance with FederalTort Claims Act Requirements
 Temporary Privileges
◦ Utilize Program Assistance Letter (PAL) 2017-07: Temporary Privileging of Clinical
Providers by FTCA Deemed Health Centers in Response to Certain Declared
Emergency Situations
https://bphc.hrsa.gov/sites/default/files/bphc/ftca/pdf/pal-2017-07.pdf
 Temporary Service Sites
◦ Utilize PAL 2020-05: Requesting a Change in Scope to AddTemporary
Service Sites in Response to Emergency Events
https://bphc.hrsa.gov/sites/default/files/bphc/programrequirements/pdf/pal202
005.pdf
Updates
Updates
 Deadline for submission of 2021 FTCA Health Center
Deeming Applications for health center and volunteer
health professionals – Extended to Monday, 7/13/20 at
11:59pm
◦ PAL 2020-02
◦ PAL 2020-03
 NPDB Query fees are waived
◦ Includes one time and continuous query
◦ Retroactive from March 1, 2020 – May 31, 2020
◦ Credit will be given for those queries conducted on or after
March 1 and prior to implementation of the waiver

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Updates
 Project periods for most health centers scheduled to
complete a SAC in FY2021 have been extended. Those
with a current 2- or 3-year project period ending in
FY2021 will:
◦ Receive a 12-month extension with funds
◦ Complete a BPR instead of a SAC
◦ Health centers in a one-year project period will still complete
SAC
 Release of FY2021 SACs, BPRs, LAL Renewal
Designation and Annual Certifications has been delayed
◦ Projected Release June 2020
Additional Resources
Additional Resources
• Compliatric
https://www.compliatric.com/
• Health Resources and Services Administration
https://www.hrsa.gov/coronavirus
https://bphc.hrsa.gov/emergency-response/coronavirus-
frequently-asked-questions.html#faqs
https://bphc.hrsa.gov/programrequirements/scope.html
https://bphc.hrsa.gov/sites/default/files/bphc/programrequirem
ents/pdf/c_and_p_file_review_resource.pdf

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Additional Resources
• National Practitioner Data Bank
https://www.npdb.hrsa.gov/coronavirus.jsp
• FTCA
https://bphc.hrsa.gov/sites/default/files/bphc/ftca/pdf/pal-2017-
07.pdf
https://bphc.hrsa.gov/sites/default/files/bphc/ftca/pdf/pal-2020-
02.pdf
https://bphc.hrsa.gov/sites/default/files/bphc/ftca/pdf/pal-2020-
03.pdf
Questions & Answers
Michelle Layton BSN, MBA
Infidium Healthcare Solutions, LLC
michellel@infidiumhs.com