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Chapter 1 - Medical Credentials And Privileges Review Process

Part 3 - Professional Services

Title Section
Introduction 3-1.1
    Purpose 3-1.1A
    Background 3-1.1B
    Policy 3-1.1C
    Definitions 3-1.1D
Responsibilities 3-1.2
    Clinical Director 3-1.2A
    Governing Body 3-1.2B
    Applicant 3-1.2C
Medical Staff 3-1.3
    Medical Staff 3-1.3A
    Medical Staff Categories 3-1.3B
Procedures 3-1.4
    Verification 3-1.4A
    Documentation 3-1.4B
    Required Elements for Review 3-1.4C
    Attestation and Release 3-1.4D
    Renewal of Membership and Clinical Privileges 3-1.4E
    Clinical Privileges 3-1.4F
    Temporary Medical Staff 3-1.4G
    Disaster Privileges 3-1.4H
Medical Staff Credential Files 3-1.5
    Records Management 3-1.5A
    System File Managers 3-1.5B
    Records Retention 3-1.5C
    Privacy Act Consideration 3-1.5D

Exhibit Description
Manual Exhibit 3-1-A Indian Health Service Application for Medical Staff Appointment and/or Privileges


  1. Purpose.  This chapter updates the policy and procedures for the credentialing and clinical privileging of medical staff working in Indian Health Service (IHS) facilities.
  2. Background.  The IHS is a comprehensive national health care system composed of a very diverse group of health care providers and clinical settings.  The size and scope of the medical services they can provide also varies ranging from a single individual providing limited ambulatory care services, to a medical staff of several hundred providing comprehensive medical services including sub-specialty care.  While the policy guidelines and procedures for the credentialing and clinical privileging of medical staff are same in each IHS facility, the medical staff organization and staffing to support this function are often very different.  Despite this diversity, the principal purposes and the intended results of this oversight are as follows:
    1. to ensure that all IHS health care providers are appropriately screened, credentialed, and privileged,
    2. to provide quality health care to American Indian and Alaska Native patients; and to avoid exposing patients and facilities from unnecessary risks from unprofessional, unethical, or incompetent health care providers.

      Additionally, it is intended to ensure that all IHS health care providers meet the requirements of billing third-party payers for the medical services they provide.

      The medical staff credentialing and privileging process for health care providers is one of the critical tasks of the Agency and is directly related to the provision of quality medical care that is provided in these facilities.  An ineffective credentialing and privileging process has a negative effect on the quality of health care provided to patients treated at the facilities.  It can increase the potential for financial risk to the Federal Government because of the cost of litigation and to IHS facilities when a provider?s competence or conduct affects a facility?s accreditation status, which is tied to the billing of third-party payers for medical services provided.

  3. Policy.  It is the policy of the IHS that all licensed independent practitioners and other practitioners who provide direct patient care shall be credentialed and privileged through the medical staff.
  4. Definitions.
    1. Credentialing.  A ongoing process whereby a facility?s medical staff obtains, verifies, and assesses an individual?s professional credentials.  This information is utilized by the medical staff and governing body to evaluate competency and appropriately grant medical staff membership and/or clinical privileges.
    2. Credentials.  Credentials are the attestation of qualification, competence, or authority issued to an individual by a third party with the authority or assumed competence to do so.  Examples of credentials include the documents that constitute evidence of practitioner training, licensure, experience, and expertise.
    3. Clinical Privileges.  The listing of the specific clinical privileges an organization?s staff member is permitted to perform in the facility, e.g., diagnostic services, procedures, prescribe medications.  Clinical privileges are based on the review of an individual practitioner?s professional training, licensure, experience, and expertise.
    4. Licensed Independent Practitioners.  Fully licensed individuals permitted by law to provide patient care services independently and without concurrent professional direction or supervision, within the scope of his/her license and in accordance with individually granted clinical privileges.
    5. Verification.  Verification is the process of validating all credentials and other information provided by an applicant for medical staff privileges.  Primary source verification is the process of validating all credentials and other information provided by the applicant with the original sources of the credential.  Secondary source verification is the process of validating credentials and other information provided by the applicant through a third-party database and/or credentialing source.


  1. Clinical Director.  The Clinical Director (or medical staff official in charge) of each IHS facility is responsible for ensuring that the credentials review process is completed for every individual granted clinical privileges through the medical staff.  The Clinical Director may designate individuals to assist in the credentials review process.
  2. Governing Body.  The governing body is the only authority that can grant full medical staff membership and/or clinical privileges.  Clinical privileges are granted through procedures outlined in local medical staff bylaws.  A reference resource, ?Medical Staff Credentialing and Privileging Guide,? can be found on the National Council of Chief Clinical Consultants Web site

  3. The governing body has the ultimate authority and responsibility for the initial and ongoing oversight and delivery of health care rendered by licensed independent practitioners and other practitioners who are credentialed and privileged through the medical staff process.

  4. Applicant.  An applicant for initial medical staff membership and/or clinical privileges must complete a comprehensive credentials review before delivering any health care services to any patient in an IHS facility.  Initial applicants must complete the ?Indian Health Service Application for Medical Staff Appointment and/or Privileges? form (see Manual Exhibit 3-1-A).  Completion of this form applies to initial applicants only.  Ordinarily, individuals who are applying for medical staff membership and clinical privileges in anticipation of obtaining Federal employment should not be required to complete this form until the appropriate Agency hiring official has made a bona fide offer of Federal employment.  The employment offer may be conditional and may be contingent on the applicant subsequently obtaining the necessary medical staff membership status and all clinical privileges required for the particular position.  If medical staff membership and clinical privileges are not obtained upon initial hire or continuously maintained during employment, the employee may be subject to an adverse action, up to and including removal from the Federal service.  All 5 sections of the IHS Application for Medical Staff Appointment and/or Privileges must be completed:
    1. IHS Application for Medical Staff Appointment and/or Privileges
    2. IHS Health Screen/Immunizations
    3. IHS Statement of Understanding and Release
    4. IHS Statement of Health
    5. IHS Confidential Malpractice Claims Information Report

    NOTE:  After the Director, IHS, signs the Transmittal Notice No. 2008-19 and this chapter becomes effective, Manual Exhibit 3-1-A will be placed on the IHS Web site as a writable or write-enabled electronic PDF document that can be downloaded by the prospective applicant, completed electronically, printed, signed, and transmitted to the respective site or sites where the applicant is seeking privileges.  Specific privileging forms must be provided separately to the applicant at the appropriate time by the IHS site and/or sites where the applicant will be providing medical services.


  1. Medical Staff.  The medical staff shall include physicians (medical doctors and doctors of osteopathy) and dentists, and other categories of providers as determined by the local medical staff and its governing body, and defined in its policies and procedures manual and bylaws.  Each medical staff member who provides medical services must meet the medical staff credentialing and privileging standards of a nationally recognized accrediting/certifying body such as the Joint Commission, the American Association for Ambulatory Health Care (AAAHC), or the Centers for Medicare and Medicaid Services.
  2. Medical Staff Categories.  The following medical staff categories are to be used as a guide, but are not restrictive:
    1. Provisional.  New members of the medical staff who are serving a 1-year mandatory probationary period as specified in the local medical staff bylaws.  During this time their qualifications and clinical skills are being assessed.
    2. Active.  Members of the medical staff who are Federal employees and/or spend at least 50 percent (or an amount specified in the local medical staff bylaws) of their professional time providing direct patient care services in a facility.
    3. Temporary.  Members of the medical staff assigned to this category are those who generally provide medical services on a short-term time-limited basis or have applied for active medical staff membership but have not had their credentials completely reviewed.
    4. Consultant, Courtesy, or Associate.  Those members who generally provide medical services on a periodic or episodic basis, e.g., hold specialty clinics or provide clinical consultation.


  1. Verification.  Several methods (written and oral) may be used to obtain verification of medical credentials, e.g., letters, phone calls, or State licensing board computer printouts.  Primary source credentials verification, e.g., professional education, post-graduate training, all current professional licensure, and current competence, will be completed to maintain compliance with the Joint Commission and/or the AAAHC standards.  This function may be performed by Service Unit personnel, a centralized verification organization, or other mechanisms permitted by a nationally recognized accrediting body.
  2. Documentation.  Documentation of an initial applicant's ability to perform (health status) should be confirmed.  The American Medical Association physician profile and the American Osteopathic physician profile can be utilized as secondary source verification for many physician credentials as per current Joint Commission/AAAHC standards.  Every applicant requesting clinical privileges will be checked against the National Practitioner Data Bank and the Healthcare Integrity and Protection Data Bank.  A query will be done on each provider at least every 2 years and when specified actions are requested by the applicant (e.g., reappointment to the medical staff, changes in privileges).
  3. Required Elements for Review.  The credentials review process must, at a minimum, require verification of:
    1. Professional Education.  Medical staff members and other practitioners subject to the medical staff credentialing and privileging process must possess a valid diploma certifying them as a graduate of a professional school, accredited by a nationally-recognized accrediting body appropriate to the member?s professional discipline.  A foreign graduate must possess a diploma as a graduate of a professional school and documentation of having successfully completed appropriate certifying requirements, e.g., Education Commission for Foreign Medical Graduates for physicians, as applicable to the specific profession.
    2. Post-Graduate Training.
      1. Physicians and other practitioners whose professional disciplines require post-graduate clinical training must possess certification of such training through a program accredited by a nationally recognized accrediting body.
      2. Any internship, residency, fellowship, or other organized professional training which has been completed should be specified, including dates of participation, location, type of program, and the name of the program director.
    3. Experience.  Time since graduation from professional school should be accounted for, with a summary of jobs or medical staff memberships, dates, locations, and types of clinical activities or privileges.
    4. Board Certification and Professional Affiliations.  Board certification(s) held by an applicant should be verified and professional association(s) to which an applicant belongs should be noted.
    5. Licensure.  Members of the medical staff and others who must apply for clinical privileges must hold an active and unrestricted State license, certification, or registration, as applicable, to practice in their professional field.  The term ?unrestricted? means that there are no restrictions, special considerations, periods of monitoring, or probationary requirements associated with license, certification, or registration that restricts or inhibits the ability of the practitioner to practice his/her profession in the specialty or clinical area for which the practitioner is being hired.  This includes any stipulations that may have a potentially significant adverse impact on patients, the medical staff, or the efficiency of the facility.

      In general, providers with any restrictions on any State license, certification, or registration will not be granted medical staff membership or clinical privileges.  However, exceptions may be granted on a case-by-case basis by the Area Director.

    6. Other Information.  Additional information required for membership and/or granting clinical privileges should also be provided.  All individuals requesting medical staff appointment and/or clinical privileges (either initial or renewal) must furnish verifiable information pertaining to the following:
      1. Professional Liability Claims, Suits, and/or Judgments.  Previous, pending, or current professional liability claims, suits, and/or judgments made against them.
      2. Denial or Revocation of Medical Staff Membership.  Previous or pending denial or revocation of medical staff membership.
      3. Reduction, Suspension, Revocation, Relinquishment, or Non-renewal of Clinical Privileges.  Previous or pending reduction; suspension, revocation, voluntary or involuntary relinquishment; or non-renewal of clinical privileges.
      4. Drug Use.  Current or past use of illegal drugs.
      5. Loss, Suspension, Restriction. Denial, or Relinquishment of Professional Licensure or Professional Society Membership.  Previous or pending loss, suspension, restriction, denial, or voluntary or involuntary relinquishment of professional licensure or professional society membership.
      6. Sanctions or Current Investigations.  Previous, pending, or current Medicare or Medicaid sanctions or current investigation.
      7. Convictions Involving Crimes Against Children.  Unfavorable information which may affect suitability for Federal employment, (e.g., convictions involving crimes against children), must be provided by the Service Unit Chief Executive Officer (CEO) to the Area or Regional IHS Human Resources Office.  All applicants for reappointment must also have similar suitability criteria verification.
      8. References.  All applicants for initial membership and/or clinical privileges must provide a minimum of two letters of reference from persons who can attest to the applicant?s current professional and clinical judgment, competence, and character.  These references must meet the definition of ?peer? (e.g., from providers in the same professional disciple as the applicant).  For applicants who have recently completed or are just completing professional school or post-graduate clinical training, one letter of reference must be from the training program.  For all other applicants, who are currently members of one or more medical staffs, one letter must be from the chief of staff or departmental chairperson from each hospital or medical facility where the applicant is on the active medical staff (as defined in this policy).
      9. Heath Status.  All applicants, whether seeking initial appointment or reappointment, must be physically able (with or without reasonable accommodation) and mentally capable of performing the required functions of their medical staff role and the privileges they are requesting.  (See Manual Exhibit 3-1-A.)
  4. Attestation and Release.  Each applicant for an initial appointment must sign the ?Statement of Understanding and Release? form found on page 11 in Manual Exhibit 3-1-A.
  5. Renewal of Membership and Clinical Privileges.  Initial medical staff membership and/or clinical privileges are for a provisional 1-year period.  Credentials and performance are to be reviewed near the end of this 1-year period, after which medical staff appointments and/or clinical privileges may be granted for no more than a 2-year period.  Renewal is neither automatic nor guaranteed.
  6. Clinical Privileges.  Clinical privileges are granted by the governing body after consultation with discipline-specific staff or consultants, as appropriate.  This is done at the time of initial application or reapplication and at any time that modification of privileges is indicated or requested.  The granting of privileges must reflect the training, experience, and qualifications of the applicant as they relate to the staffing, facilities, and capabilities of the facility.  Recommendation of privileges should be made by the Executive Committee of the Medical Staff or its equivalent (as defined in the medical staff bylaws) to the chairperson of the governing body.  This recommendation should be routed through the Clinical Director and the CEO (or designee) to the governing body.
  7. Temporary Medical Staff.  Applicants for temporary medical staff membership and/or temporary clinical privileges are subject to the same review as other applicants.  However, carrying out a full credentials review may not be possible due to the immediate need to fulfill an important patient care or service need.  Therefore the applicant may provide services prior to a complete review as long as, at a minimum, the following has occurred:
    1. a medical staff application form has been fully completed;
    2. clinical privileges have been requested;
    3. both (1) and (2) have been reviewed by the Clinical Director and found to be in conformance with IHS standards;
    4. primary source verification of licensure, training, and education has been performed;
    5. ability to perform (health status) has been assessed;
    6. current competence has been verified;
    7. a National Practitioner Data Bank - Healthcare Integrity and Protection Data Bank query has been evaluated; and
    8. the Clinical Director or the CEO has granted temporary privileges.  Time limits for temporary membership/privileges will vary depending on the circumstances and will be at the discretion of the Clinical Director or CEO, but should not exceed 120 days.
  8. Disaster Privileges.  During any disaster in which the emergency management plan has been activated, the Clinical Director or the CEO has the option to grant disaster privileges when the medical staff is unable to handle the immediate patient needs.  The Clinical Director or the CEO may grant disaster privileges upon presentation of any of the following:  a current picture hospital identification (ID) card; a current license to practice and a valid picture ID card issued by a State, Federal, or regulatory agency; identification indicating the individual is a member of a Disaster Medical Assistance Team; identification indicating that the individual has been granted authority to render patient care in disaster circumstances (such as authority having been granted by a Federal, State, or municipal entity); or attestation by current hospital or medical staff member(s) with personal knowledge of the practitioner?s identity.  As soon as the immediate situation is under control, the medical staff begins the credentials verification process for individuals who received disaster privileges.


The medical staff credentials files are distinct and separate from any employment or contract files, representing instead the professional relationship and responsibility aspects of the members of the medical staff.  The information in the credentials files may be derived from employment or contractual files and data.  Quality assurance profiles are to be stored and maintained separately from the medical staff credentials files.

  1. Records Management.
    1. The medical staff credentials files are to be located in the Service Unit; parts or all of this information may also be located in the Area Office.
    2. Access to the medical staff credentials files is limited to authorized personnel for use in the performance of their official duties.
  2. Systems File Managers.  The Area Director and the Clinical Director of each facility are designated as the ?Systems File Managers? for the Medical Staff Credentials and Privileges Records system of records.  Systems File Managers will:
    1. develop and maintain a list of personnel who are authorized to access the medical staff credentials files;
    2. maintain a log of any disclosures of information from the medical staff credentials files; and
    3. ensure the medical staff credentials records are confidential and secured at all times.
  3. Record Retention.  All medical staff credentials files and related documents will be maintained in accordance with the IHS Records Disposition Schedule and the Privacy Act System of Records, 09-17-0003, dated June 15, 2006.
    1. Medical staff credential files and related documents must be retained at least 10 years after an individual?s termination from the medical staff.

      NOTE:  The 10-year time frame will become effective once the disposition authority for medical staff credentialing files gets approved by the Archivist of the United States.

    2. Applications for medical staff membership that were denied will be retained for 3 years.  NOTE:  The 3-year time frame will become effective once the disposition authority for medical staff credentialing files gets approved by the Archivist of the United States.
  4. Privacy Act Considerations.  All medical staff credentials files and related documents are to be maintained in conformance with the IHS Privacy Act System of Records, published in the Federal Register (FR), March 31, 2006, (Volume 71, Number 62) Pages 16320-16324; and June 15, 2006 (Volume 71, Number 115) Pages 34626-34630.  These requirements adhere to the rules, laws, and regulations of the Privacy Act of 1974, Title 5 United States Code §552a, as amended, and the ?Health Insurance Portability and Accountability Act of 1996,? Public Law No. 104-191, as amended.  Based on the specifications outlined in the March 31, 2006, and the June 15, 2006, FR Notices, medical staff credentials files must maintain, at a minimum, the data that follows:  The name and location of the system; the categories of individuals on whom records are maintained in the system; the categories of records maintained in the system; each routine use of the records contained in the system, including the categories of users and the purpose of such use; the policies and practices of the IHS regarding storage, retrievability, access controls, retention, and disposal of records; the title and business address of the IHS official who is responsible for the system of records; the IHS procedures whereby individuals can be notified at their request, if the system of records contains a record pertaining to them; the IHS procedures whereby, individuals can be notified at their request, how to access any record pertaining to them that may be contained in the system of records, and how they can contest information in their record; and the categories of sources of records in the system.

* NOTE: For more information see IHM Circular Circular 20-05 Assuring Quality in Medical Staff Membership.