BOP Program Statement 6027.03 § 9

REQUIREMENTS

The National Credentialing Program Chief and the Bureau’s Medical Director review the NPDB

memorandum of each health care provider and provide guidance to the institution regarding

suitability for appointment, conversion to probationary appointment, or permanent appointments,

as appropriate. The National Credentialing Program Chief and the Medical Director review the

Professional Liability Case Reporting form from individuals with adverse actions in the NPDB

and provide guidance to the institution on appropriate actions to be taken prior to signing the

clearance memorandum.

Bureau staff, including the Warden, are prohibited from entering into express or implied written

or oral agreements not to report a staff member in return for a personnel action such as

resignation, retirement, accepting a reassignment, etc.

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The Bureau Medical Director is the only authorized official to approve and sign any reporting of

a Bureau health care provider or contractor to the NPDB which may be applicable to situations

such as, adverse clinical privileges actions, federal and state licensure and certification actions,

health care related criminal convictions, and more per the NPDB reporting requirements listed on

the U.S. Department of Health and Human Services NPDB website. If the health care provider’s

privileges, practice agreements, or protocols are suspended, denied, restricted, or revoked due to

actions related to professional competence or conduct, for a period longer than 30 days they will

be reported to the NPDB and state licensure or certification boards. The Bureau Medical Director

may delegate authority for technical aspects of the query and reporting processes to the National

Credentialing Program and may delegate authority for review of documents and development of

NPDB recommendations to the National Credentialing Program or to a panel of Bureau

physicians and dentists.

The institution maintains all reports and information in the provider’s credential file.

 NPDB Queries. The Bureau requires a continuous query NPDB before granting initial,

renewed, or revised privileges on every physician, dentist, or other licensed provider providing

professional care in a Bureau institution.

 If NPDB initial screening shows any adverse action, the applicant submits the

Professional Liability Case Reporting form. Central Office verifies the applicant, or staff

member, fully disclosed the related information required and requested by the Bureau in

its pre-employment, credentialing, and clinical privileging procedures. The Medical

Director or designee reviews all reports and provides a decision on whether the applicant

is suitable for employment in the Bureau.

 When during a continuous query, the NPDB report calls into question the professional

competence or conduct of an individual appointed or used by the Bureau, the National

Credentialing Program and the Bureau Medical Director or designee review all reports

and relevant information. The Medical Director or designee provides guidance to the

institution about appropriate necessary actions, which may include no further action,

revision, or removal of clinical privileges. The institution and the individual are required

to submit information regarding the NPDB report during this process.

 The Medical Director or designee will review the provider’s submission and render a

decision via memorandum. This memorandum must be in the credential file before

providing patient care.

 The institution maintains copies of the NPDB results in the credential file for each

provider.

The information on how to submit NPDB queries is located on the HSD Credentialing Section

page of the Bureau’s intranet site.

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