Requirements for Approval of Credentialing and Privileging by the Board of Directors

Prior to the initial release of the Health Resources and Services Administration (HRSA) Health Center Compliance Manual, health centers were required to present providers to the Board of Directors for the approval of credentialing and privileging. Likewise, health centers were required to have the organization’s Credentialing and Privileging Policy approved by the Board of Directors. 

Chapter Five, Clinical Staffing, of the HRSA Health Center Compliance Manual requires health centers to implement the following for all clinical staff members, including Licensed Independent Practitioners (LIP), Other Licensed and Certified Practitioners (OLCPS) and Other Clinical Staff (OCS).  These requirements apply to all employees, individual contractors, volunteers and locum tenens (HRSA Compliance Manual, Chapter Five).

  • Maintain credentialing and privileging procedures for the initial and recurring review of credentials, as well as privileges/verification of competency.
  • Ensure credentialing and privileging information is stored in a secure location.
  • Take into consideration the results of peer review and/or performance improvement activities in the reappointment process.
  • Maintain formal written contracts and formal written referral arrangements for Column II and Column III services with providers and organizations who are credentialed and privileged. 

 

The “Related Considerations” section of Chapter Five, Clinical Staffing, of the HRSA Health Center Compliance Manual now allows for flexibility, as it relates to the requirements for credentialing and privileging of clinical staff.  For example:

  • The health center determines who has approval authority for credentialing and privileging of its clinical staff.  Approval is no longer required by the Board of Directors.
  • The health center determines how credentialing and privileging will be implemented, as well as whether to have a separate process for LIPs versus OLCPs and OCS. 
  • The health center determines how clinical competence and fitness for duty will be verified.
  • The health center decides whether to deny, modify or remove the privileges of staff; whether to utilize an appeals process and whether to implement corrective action plans associated with the denial, modification, or removal of privileges.
  • The health center decides whether to prohibit providers/organizations from providing services on behalf of the health center.

 

Although the health center is no longer required to present providers to the Board of Directors, industry standards support the continuation of this practice to keep the Board of Directors informed and mitigate the risk of malpractice.  Additionally, although the health center is no longer required to obtain board approval for the Credentialing and Privileging Policy, it is important to remember the policy and any associated procedures must be reflective of current practice. 

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