BOP Program Statement 6027.03 § 2

a. Applicant Responsibility. Applicants are required to provide the necessary documentation

for the credentialing process. A complete credential file is required prior to providing care for

patients. The applicant must provide the following, to include but not limited to:

 Documentation of qualifying professional education

 Post-graduate training (internship, residency, and/or fellowship if applicable)

 All active and inactive professional licensures

 Professional active certifications and registrations as applicable to the job description

 All past and pending actions taken against an active or inactive license in any or every

state or registration, such as:

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 Drug Enforcement Administration

 Clinical privileges

 Voluntary relinquishment of license or registration

 Complete details of any malpractice history

 Release of information

 LIPs and APPs need to provide contact information for two professional references

within the same field of practice

 Initial curriculum vitae/resume for LIPs that includes the names and addresses of

affiliations (work history, hospital affiliations, etc.) for the past 10 years or since

completing residency or fellowship

b. Institution Credentialing Officer Designee Responsibility.

 Primary source verification. Documentation of relevant education, post-graduate

training, licenses, and applicable certifications must be primary source verified.

 Verification from the primary source can be completed through telephonic, written, or

web-based sources listed on the verification resources on the Bureau’s intranet

site. Regardless of method of primary source verification, documents require a

printed or typed name and signature of the verifier and will include date of

verification. Indicate the document is primary source verified.

 For those with privileges or practice agreements, primary source verification of

licensure and certifications need to occur within 90 days of initial privileges or

practice agreements signed by the privilege granting authority. After initial issuance

of privileges or practice agreements, the primary source verification of license(s)

and/or certification(s) will only be required at the time of the health care providers’

license(s) and/or certification(s) being reissued or renewed by the organization. The

documents will not require reverification before the renewal of privileges or practice

agreements.

 Examples of verification of credentials through written forms and web-based sources

include official transcript in a sealed envelope, email from registrar’s office, transcript

clearing house, education hospitals, etc.

 Verification of credentials by telephone should be done when such verifications are

needed on a short-term notice (if other avenues are not available). When verifying a

credential by phone, in addition to the requirements above, an annotation will be

made on the credential indicating:

 The date of the phone call

 The agency contacted

 The agency phone number

 The name of the agency representative who verified the information

 The National Credential Verification Officer (CVO), or designee, will complete the

initial primary source verification for non-contracted physicians, RNs, APPs,

pharmacists, and dentists.

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 The institution credentialing officer designee will complete the primary source

verification requirements of health care disciplines not listed.

 After initial credentialing, the institution credentialing officer designee, is also

responsible for primary source verifying any renewed or changed information for all

disciplines.

 Primary source verified, current, non-expired, license(s) and/or certification(s) must

be present in the credential file. The health care provider is responsible for ensuring

these requirements do not lapse, and the local credentialing designee is responsible

for ensuring appropriate file maintenance and accuracy.

 National Practitioner Data Bank process. An initial query must be completed before

being hired and then continuously maintained for all health care and independently

licensed qualified mental health providers; including onsite contractors, onsite

consultants, and Bureau telehealth providers; regardless of their licensure, certification,

or education. The information from the NPDB must be reviewed prior to providing

patient care. All initial health care provider NPDB requests for positions other than

physicians, APPs, RNs, pharmacists, and dentists, which are done by the National CVO,

must be completed by the institution credentialing officer designee, and submitted to the

CVO using the fillable form on the Bureau’s intranet site. All sections of the form need to

be completed and sent via email with the subject heading stating Initial NPDB. The HSA

may designate credentialing duties as appropriate within the institutions.

 Initial NPDB match process. When there is an NPDB match or hit, a Professional

Liability Case Reporting form (located on the Health Services Division Credentialing

page of the Bureau’s intranet site), along with any supporting documentation, must be

completed by the applicant if any past or pending actions have been taken against the

provider’s license(s). All documents must be reviewed and sent to the CVO. The Medical

Director or designee will review the applicant’s submission and render a decision via

memorandum. Only staff with applicable fully unrestricted licenses in all states will be

approved to render patient care. This memorandum must be in the credential file. Even

applicants with fully unrestricted licenses may be found to be unsuitable for Bureau

employment if past professional conduct and NPDB findings are sufficiently serious or

show trends in behavior that are likely to be repeated in a carceral setting.

 File formats. Credential files will be maintained in digital or paper form, unless

otherwise specified by the Health Services Division’s (HSD) Credentialing Section.

 File components. Each credential file must contain the following documents prior to

delivering patient care. These initial documents must be retained based on the current

Records and Information Disposition Schedule (RIDS):

 Initial Curriculum vitae/resume to include:

 Names and addresses of affiliations (e.g., work history, hospital affiliations) for

the past 10 years or since completing residency or fellowship

 Documentation of relevant professional education – primary source verified

 Documentation of post-graduate training (if indicated) – primary source verified

 Contact information from two professional peers

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 Active and inactive professional licenses – all primary source verified within 90 days

of initial issuance of privileges, practice agreements, and protocols. The file must

always contain a current valid license.

 Professional certifications and registrations as applicable to job description such as

board certifications and National Commission on Certification of Physician Assistants

(NCCPA) certification for Physician Assistant – Certified (PA-C), which is required –

primary source verified

 NPDB query

 NPDB match memorandum (if indicated)

 Complete details of any malpractice history must be included in the credential file

along with a memorandum from the Medical Director.

 Current position description (PD) for Bureau staff or statement of work for

contractors

 Authorization for release of information

 Proof of current Basic Life Support (BLS) certification

 Privileges, practice agreement, or protocols (if applicable)

 Orientation packet

 Competencies

Verified credentials are maintained through an electronic monitoring system, at the institution or

office of record, by the HSA or designee. Each staff member has the right to review, or receive a

copy of, any information in their credential file.

c. Initial Credentialing – From Contracted Hospital or Other Credential Verification

Organization. Local primary source verification of onsite contract health care providers’

personnel credentials (e.g., license, certification, registration, education) will not be required

when the contractor is employed by an entity (contract company, integrated health system,

hospitals, ambulatory clinic groups) that is accredited by a health care accreditation body (e.g.,

Accreditation Association for Ambulatory Health Care (AAAHC), Joint Commission,

Accreditation Commission for Health Care (ACHC), National Committee for Quality Assurance

(NCQA), National Commission on Correctional Health Care (NCCHC), or other entity deemed

appropriate by the Bureau’s Medical Director). A letter of assurance from the contracting

company attesting the clinician is credentialed, the primary source verification of required

documents has been completed, and the clinician holds the appropriate unrestricted license(s),

certification(s), or education and training to perform the contracted service is sufficient.

The letter of assurance should stay current, being reissued to the institution at a minimum, every

two years, or sooner if a contractor works under privileges, practice agreements, or protocols and

would require verification sooner. Each institution is required to maintain an onsite copy of the

contracted organization’s credentialing policy.

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 Contractors from an accredited entity. For onsite contract health care providers, the

local institution will be responsible for maintaining a credential file. The credential file

will include:

 Orientation

 NPDB

 NPDB match memorandum (if indicated)

 Two professional peer references’ contact information for LIPs and APPs

 Proof of current BLS certification (can be included within letter of assurance)

 Statement of work

 Letter of assurance (current and updated with privilege, practice agreement, and

protocol renewals)

 Privileges, practice agreement, or protocols as indicated

 Competencies

 Contractors from a nonaccredited entity. For onsite contract health care providers, the

local institution will be responsible for maintaining a credential file. The credential file

will include all components as outlined under File Components in Section 2.b.

d. Central Office Clinicians Credentialing and Privileging. All Central Office staff in a

health care provider PD will have an active credential file which includes licensure, NPDB, and

BLS certification. Only those providing individualized patient care that require privileges or

practice agreements will undergo a peer review. Privileges and practice agreements are indicated

at the discretion of the Medical Director.

Commissioned Corps of the U.S. Public Health Service (USPHS) clinicians who require annual

clinical hours and do so within the Bureau, are required to complete temporary privileges or

practice agreements prior to completing clinical hours and will undergo an abbreviated peer

review following the temporary duty assignment.

e. Temporary Privileges/Practice Agreements During Emergencies/Critical Staffing

Needs. Regional and Central office health care providers, who are in non-clinical PDs currently

(e.g. Health Services Analysts, Health Service Administrators, etc.), may be granted temporary

privileges or practice agreements by their respective privilege-granting authority (Bureau

Medical Director, National Chief Dentist, or their designee), in the event of critical patient care

needs. Temporary privileges or practice agreements may be granted prior to a temporary duty

assignment upon completion of the appropriate credentialing. The privileges must be based on

primary source verification of a current state license, an NPDB report that is clear of licensure

action and has no malpractice history triggering a review of the Medical Director, BLS

certification, and a signed temporary privilege or practice agreement. The request for temporary

privileges or practice agreement must come from the health care providers themselves, with

supervisor approval. The temporary privileges or practice agreement may not be granted for

more than 120 consecutive days. If an individual works longer than 120 consecutive days, a

transition to non-temporary privileges or practice agreement must be completed before the end of

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the 120 days. Following a temporary duty assignment, and upon expiration of the 120-day period

from the date temporary privileges or practice agreement were granted, an abbreviated peer

review must be completed within 60 days. The temporary privileges and abbreviated peer

reviews must be maintained in their credential file.