BOP Program Statement 6027.03 § 3

After the initial credentialing process is finalized, specific items within the credential file will

require routine maintenance. Some of the components requiring maintenance include, but are not

limited to:

a. License(s). According to this program statement, licenses must be maintained as current and

primary source verified initially and upon renewal. If the health care provider elects to allow a

non-essential license (e.g., held in more than one state or other profession) to be inactive, the

health care provider must notify the credentialing authority in writing of their decision. Primary

source verification of the inactive license is required, one time.

b. Certifications and Registrations (as applicable). Certifications and registrations must be

maintained as current and primary source verified upon renewal if an expiration date is present.

If they do not have an expiration date, they are primary source verified within 90 days of

renewing privileges or practice agreements. If the health care provider elects to allow a non-essential certification to be inactive, the health care provider must notify the credentialing

authority in writing of their decision. Primary source verification of the inactive certification/

registration is required, one time.

c. Competencies. Competencies should be completed initially, and then every two years, at a

minimum, except for certain disciplines at Federal Medical Centers (FMCs). See Section 5 for

further requirements regarding competencies.

d. Peer Review. All health care providers who are providing direct medical care, and working

under privileges or practice agreements must have a peer review. A peer review must be

performed by a professional peer prior to the renewal of privileges or practice agreements. See

Section 6 for further requirements regarding peer reviews.

e. Protocols. Protocols vary from institution to institution and will be reviewed and signed

annually by the Clinical Director (CD) or their designee. Proof of the health care provider’s

authorization to utilize specific protocols will be placed in the local credential file. Signed

competency training for staff who work under protocols is required; this includes, but is not

limited to clinical nurses, paramedics, medication technicians, medical assistants, etc.

f. Privileging. All LIPs must have current privileging that reflects their current standardized

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PD. The privileging date is the date in which the privileges were signed by the privilege granting

authority. The timelines that follow apply to providers who are providing safe medical care, and

run successful programs:

 The initial privileges are signed and may not exceed six months.

 The first peer review will be conducted prior to the expiration date of privileges (within

six months) and based on the results, privileges are renewed for a second period, not to

exceed 12 months.

 A second peer review will then be completed prior to the expiration date of privileges

(within 12 months). Based on the results from this peer review, privileges can

be renewed on a two-year cycle.

 More aggressive timelines or higher-level reviews will be triggered when a peer review

highlights gaps in clinical knowledge, poor decision making, or trends in care that has or

is likely to result in poor patient outcomes. Section 6 gives more detail into more

aggressive timelines for peer reviews and Section 8 describes higher-level reviews.

g. Practice Agreements. All APPs, dental hygienists, clinical pharmacists, and other clinical

positions with expanded functions, must have a current practice agreement that reflects their

current standardized PD, and applicable advanced functions. Providers with advanced training or

certification, such as physical therapists, occupational therapists, clinical nurse specialists, or

others with appropriate advanced education/licensure, must have practice agreements for their

advanced functions if they are in a position providing direct medical care. The practice

agreement date is the date in which the practice agreement was signed by the privilege granting

authority.

 The first peer review will be conducted prior to the expiration date of practice agreements

(within six months) and based on the results, renewed for a second period, not to exceed

12 months.

 A second peer review will then be completed prior to the expiration date of practice

agreements (within 12 months). Based on the results from this peer review, practice

agreements can be renewed on a two-year cycle.

 More aggressive timelines or higher-level reviews will be triggered when a peer review

highlights gaps in clinical knowledge, poor decision making, or trends in care that have

or are likely to result in poor patient outcomes. Section 6 provides more detail into more

aggressive timelines for peer reviews and Section 8 describes higher-level reviews.

h. NPDB. After the Bureau has obtained an initial query for all licensed providers; also

including onsite contractors, onsite consultants, and Bureau telehealth providers; a continuous

query is acceptable for ongoing NPDB information. A new query is not required for renewal of

privileges or practice agreements; however, continuous query quarterly reports received from the

CVO or designee, should be reviewed by the institution credentialing officer designee, to verify

the health care provider is undergoing a continuous query.

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i. Proof of Current BLS Certification. All healthcare providers are required to maintain BLS

certification. In the event that a healthcare provider’s BLS certification lapses or expires, the

provider must immediately notify the HSA. Failure to maintain current certification will result in

restriction or suspension of clinical duties until compliance is restored.

j. Additional Credential File Components. It is the provider’s responsibility to provide a copy

of renewed professional licenses, registrations, or certifications (or evidence of application to

renew) to the credentialing officer before the date the current license, registration, or certification

expires. It is the credentialing officer’s responsibility to verify the submitted information is

primary source verified according to this program statement. The verification needs to occur on

or before the expiration date.