Board Approval of Credentialing Documents

Can you please tell me if it is a HRSA requirement to obtain board approval of credentialing and privileging documents?

No, the Health Resources and Services Administration (HRSA) no longer requires health centers to obtain board approval of credentialing and privileging documents.  Although HRSA has never required health centers to present Other Licensed and Certified Practitioners (OLCPs) and Other Clinical Staff (OCS) to the Board of Directors for approval, with the release of the Health Resources and Services Administration (HRSA) Compliance Manual (HRSA Compliance Manual), the requirement to obtain board approval for credentialing and privileging of Licensed Independent Practitioners (LIPs) was lifted.  As outlined in the “Related Considerations” section of Chapter 5 of the HRSA Health Center Compliance Manual (Compliance Manual Chapter 5 – Clinical Staffing), “The health center determines who has approval authority for credentialing and privileging of its clinical staff.”

In addition to credentialing and privileging documents, the Credentialing and Privileging Policy and Procedure no longer requires board approval.  As outlined in the “Demonstrating Compliance” section of Chapter 19 (Compliance Manual Chapter 19 – Board Authority), the only clinical policies requiring board approval are those associated with Quality Improvement/Assurance.

Although not required, many health centers implement industry standard best practices and continue to require board approval of LIPs, as well as other categories of staff, and approval of the Credentialing and Privileging Policy.  The guidance provided in the HRSA Compliance Manual provides the minimum standards for compliance, as it relates to credentialing and privileging.  Health Centers with Federal Tort Claims Act (FTCA) Deemed status must ensure compliance with FTCA requirements, in accordance with the Federal Tort Claims Act Health Center Policy Manual (FTCA Manual), as they define the highest standards for compliance.  

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