DEPARTMENT: Clinical Services Group / POLICY DESCRIPTION: Licensure and Certification
PAGE:1 of 9 / REPLACES POLICY DATED: 1/1/01, 4/1/01, 2/15/02, 8/1/02, 3/15/03, 11/1/05, 3/1/06, 7/1/06, 8/1/08, 1/24/09, 7/1/09, 11/1/09
EFFECTIVE DATE: February 1, 2011 / REFERENCE NUMBER:CSG.QS.002 (formerly QM.002)
APPROVED BY: Ethics and Compliance Policy Committee
SCOPE: Hospitals, ambulatory surgery centers, home health agencies, and physician practices. Specifically, the following departments:

Administration Shared ServicesCenter

Medical Staff Services MedicareServiceCenter

Admitting/Registration

PURPOSE: To ensure that Company affiliates, physicians, privileged practitioners and independent or dependent practitioners or contractors who provide and/or order services which require licensure, certification or other credentials have valid licenses, certificates or credentials and are not ineligible persons or persons who are excluded from participation in an applicable state healthcare program.
To ensure that no Federal health care program payment is sought for any items or services directed or prescribed by a physician, privileged practitioner or independent or dependent practitioner or contractor who provides and/or orders services who is an ineligible person.
To ensure that each Company-affiliated facility conduct appropriate checks as to licensure and exclusion status for both privileged and non-privileged practitioners at the intervals outlined in the procedure section of this policy.
POLICY:
1.All Company-affiliated facilities must have written policies and procedures that address issues related to licensure, certification, registration, or other credentials of affiliates, physicians, privileged practitioners, and independent or dependent practitioners or contractors providing and/or ordering services which require a license, certificate, registration, and/or other credentials.
2.All privileged practitioners and independent or dependent practitioners or contractors providing services at Company-affiliated facilities must comply at all times with Federal, State and professional requirements applicable to their respective discipline.
3.Each Company-affiliated facility must:
  1. Maintain documentation to demonstrate proof of valid licenses and certificates as appropriate;
  2. Require notice from each colleague, affiliate, physician, privileged practitioner and independent or dependent practitioner or contractor of any revocation, suspension or investigation of licensure and/or credential status or his/her status as an ineligible person; and
  3. Comply with the Records Management Policy, EC.014, to ensure that Company-affiliated facilities do not contract with any Ineligible Person;
4.A colleague, affiliate, physician, privileged practitioner, or independent or dependent practitioner or contractor who provides and/or orders services in a Company-affiliated facility must have valid, current licenses or credentials in the state in which the facility is located, unless otherwise authorized by applicable state law and identified on the Company’s intranet at:
or the licensed healthcare professional is a member of the Armed Forces. A licensed healthcare professional who is a member of the Armed Forces may practice the member’s profession in any state, regardless of whether the practice occurs in a healthcare facility of the Department of Defense, a civilian facility affiliated with the Department of Defense, or any other authorized location as long as the individual is practicing within the scope of Federal duties.
Note: The referenced intranet site includes summaries of state laws that permit some latitude with regard to licensure issues. It also includes guidelines for facilities in states with such laws.
5.Each Company-affiliated facility must ensure that Federal Health Programs are not billed for any services, tests or treatments rendered based upon the order or direction of a physician or other practitioner who is an ineligible person.
  1. At the intervals noted in the procedure of this policy, each Company-affiliated facility must search the HHS/OIG List of Excluded Individuals/Entities (the “OIG Sanction Report”) and the General Service Administration’s List of Parties Excluded from Federal Programs (the “GSA List”) data to ensure that no affiliate, physician, privileged practitioner, or independent or dependent practitioner or contractor is an Ineligible Person or any individual or entity currently excluded on a state exclusion list.

Definitions

Allied Health Practitioner – Any non-physician practitioner permitted by law to provide care and services within the scope of the individual’s license and consistent with individually granted clinical privileges by the Board of Trustees. For example, certified nurse-midwives, certified registered nurse anesthetists, clinical psychologists, clinical social workers, physician assistants, nurse practitioners, and clinical nurse specialists.
Certification – The procedure and action by which a duly authorized body evaluates and recognizes (certifies) an individual as meeting predetermined requirements.
Department of Health and Human Services (HHS)/OIG List of Excluded Individuals/Entities– The Department of Health and Human Services' Office of Inspector General's (OIG) List of Excluded Individuals/Entities provides information to health care providers, patients, and others regarding individuals and entities that are excluded from participation in Medicare, Medicaid, and other Federal health care programs.
Dependent Practitioner – An individual who is permitted by law and the Company-affiliated facility in which he/she practices to provide patient care services under the direction or supervision of an independent practitioner, within the scope of the individual's license and in accordance with individually granted clinical privileges.
Federal Health Care Program – Any plan or program that provides health benefits, whether directly, through insurance, or otherwise, which is funded directly, in whole or in part, by the United States Government or a State health care program (with the exception of the Federal Employees Health Benefits Program) (section 1128B(f) of the Social Security Act). The most significant Federal health care programs are Medicare, Medicaid,Blue Cross Federal Employee Program (FEP)/ Tricare/Champus and the Veterans programs.
General Service Administration’s List of Parties Excluded from Federal Programs – The List of Parties Excluded from Federal Procurement and Nonprocurement Programs ("List of Parties") identifies those parties excluded throughout the U.S. Government (unless otherwise noted) from receiving Federal contracts or certain subcontracts and from certain types of Federal financial and nonfinancial assistance and benefits. The List of Parties is maintained by the U.S. General Services Administration (GSA) for the use of Federal programs and activities.
Independent Practitioner – An individual who is permitted by law and by a Company-affiliated facility in which he/she practices to provide patient care services without direction or supervision, within the scope of the individual's license and in accordance with individually granted clinical privileges.
Ineligible Person – Any individual who: (1) is currently excluded, suspended, debarred, or otherwise ineligible to participate in Federal health care programs; (2) has been convicted of a criminal offense related to the provision of health care items or services but has not yet been excluded, debarred, or otherwise declared ineligible; or (3) is currently excluded on a state exclusion list.
License – An official or a legal permission, granted by competent authority, usually public, to an individual to engage in a practice, an occupation or an activity otherwise unlawful.
Licensure – A legal right that is granted by a governmental agency in compliance with a statute governing the activities of a profession.
Non-Privileged Practitioner – Those individuals who are licensed in the state of the Company-affiliated facility to order specific tests and services but who are not medical staff members or privileged practitioners by the Company-affiliated facility.
Physician – A doctor; a person who has been educated, trained, and licensed to practice the art and science of medicine.
Privileged Practitioner – A person who practices medicine (physician) or one of the allied health professions who has been granted by an appropriate authority of a Company-affiliated facility, such as the board of trustees, the authority to provide specific patient services within defined limits.
Privileges – Authorization granted by an appropriate authority, such as the board of trustees in a Company-affiliated facility, to a practitioner to provide specific patient services in the facility within defined limits, based on an individual practitioner's license, education, training, experience, competence, health status, and judgement.
Registration – The process in which a person licensed to practice by a state authority has such license recorded or registered.
SanctionCheck.com– The Compliance Concepts, Inc. (CCI) website ( that enables Company-affiliated facilities to verify provider exclusions using a batch file of multiple providers that is processed against the OIG Sanction Report and the GSA List at the same time. Instructions for using the CCI website are on the Company’s Intranet.
PROCEDURE:
  1. Each facility must establish policies, bylaws or contractual agreements defining licensure and certification requirements for the facility, departments and services, colleague positions, physicians, privileged practitioner and independent and dependent practitioners or contractors (i.e., Allied Health Professional policies, Medical Staff credentialing policies).
  1. Each facility shall work with its Medical Executive Committee to develop enforcement remedies and disciplinary procedures that address infractions of the facility’s Licensure Verification and Certification policy.
  1. Each facility should require processes to review and validate licensure, certification or other credentials for privileged practitioners based upon issues such as the following:
  • Licensure or certification maintenance requirements such as:
  • Mandatory continuing education
  • State specific minimal census requirements
  • Maintenance of required minimum limits of professional liability coverage
  • Ongoing professional practice evaluations/competency assessments
  • Voluntary or involuntary relinquishment or reduction of credentials
  • Licensure or certification expiration dates
  • Previously successful or currently pending challenges to any licensure or certification
4.Licensure Checks
Each Company-affiliated facility must conduct appropriate checks as to licensure for:
  1. Privileged practitioners:
  2. at the time of appointment;
  3. at the time of reappointment; and
  4. prior to licensure expiration dates.
  1. Non-privileged practitioners:
  2. when the practitioner initially orders tests or services; and
  3. at the time of licensure expiration if the non-privileged practitioner has continued to order tests or services within the previous two (2) years.
If a non-privileged practitioner has not ordered tests or services for two (2) years, licensure checks are no longer required for that individual. If orders are not obtained, the practitioner’s name should be removed from the MIS Dictionary. If, after ceasing licensure checks on a non-privileged practitioner, that practitioner orders again, that order must be treated as an initial order.
  1. Following the procedures in Attachment A, each Company-affiliated facility must verify that the practitioner has a valid license, certificate or other legally-required credential. Should an individual not have a valid license, certificate or other legally-required credential, the facility must follow the applicable procedures as defined by the Medical Staff Bylaws, Rules and Regulations for discontinuing credentialing or canceling privileges.
  1. Following the procedures in Attachment A, each Company-affiliated facility must verify that the ordering practitioner has a valid license, certificate or other legally-required credential. Should an individual not have a valid license, certificate or other legally-required credential, the facility must follow the steps outlined in Attachment A for prohibiting such individual from ordering further services.
5.Exclusion Checks
Each Company-affiliated facility must conduct appropriate checks as to exclusion status for:
  1. Privileged practitioners:
  2. at the time of appointment;
  3. at the time of reappointment;
  4. at least every 30 days for
  5. the GSA List;.
  6. the OIG Sanction Report; and
  7. the State exclusion list, if applicable.
  1. Non-privileged practitioners:
  2. at the initial time of ordering tests or services and;
  3. at least every 30 days for
  4. the GSA List;
  5. the OIG Sanction Report; and
  6. the State exclusion list, if applicable.
If a non-privileged practitioner has not ordered tests or services for two (2) years, exclusion status checks are no longer required for that individual and the practitioner’s name should be removed from the MIS Dictionary. If, after ceasing exclusion status checks on a non-privileged practitioner, that practitioner orders again, that order must be treated as an initial order.
The exclusion checks or batch reports must be signed and dated on the date reviewed by the staff member responsible for ensuring that there are no matches.
  1. Each facility must check exclusion status as follows:
Following the procedures in Attachment A, each Company-affiliated facility must compare the name and address of each colleague, affiliate, physician, privileged practitioner and independent or dependent practitioner or contractor providing and/or ordering services at the facility to the OIG Sanction Report and the GSA List to ensure that those individuals are not ineligible persons. The OIG Sanction Report and the GSA List are available in searchable formats on the Internet at, respectively: and The data on the OIG Sanction Report and GSA List has been combined by Compliance Concepts, Inc. (CCI) and is available at the CCI website at: This is the recommended method of conducting ineligible persons searches. The OIG/GSA Sanction check should be signed and dated on the date reviewed.
a.Facilities located in states which maintain a state exclusion list must also search the applicable state exclusion list to ensure thatno colleague, affiliate, physician, privileged practitioner, or independent or dependent practitioner or contractor is an ineligible person. A list of states with exclusion lists is available on Atlas.
b.Should an individual appear on the OIG Sanction Report, the GSA List, or a state exclusion list, the facility may not grant or renew privileges for that individual.
c.Following the procedures in Attachment A, each Company-affiliated facility also must compare the name and address of each physician or other practitioner who does not possess facility privileges, but who orders services from the facility, against the OIG Sanction Report, the GSA List data and state exclusion list, if applicable, to ensure that such physicians or other practitioners are not ineligible persons. Should such a physician or other practitioner appear on the OIG Sanction Report, the GSA List data, or state exclusion list, if applicable, the facility shall no longer permit such physician or other practitioner to order services from the facility. Should an individual be unwilling to provide his/her social security number (SSN) for verification purposes or should GSA not be able to use an SSN to verify an individual’s identity, the individual may submit the attached affidavit indicating that he/she is not the individual that appears on the GSA List, and the process for granting privileges may continue for that individual.
d.Each incident of a physician’s or other practitioner’s confirmation as an Ineligible Person must be reported to the facility Ethics and Compliance Officer (ECO) and Division Reimbursement Manager to address potential cost reporting issues. The ECO will report each such incidence to the Director, Internal Compliance Reporting.
e.Documentation for searches performed directly on the OIG Sanction Report and GSA List websites, and state exclusion list, if applicable:
  1. Checks prior to granting (or renewing) privileges or initially accepting orders for tests or services from non-privileged practitioners: The Search Results screens must be printed and copies must be maintained by the facility, whether or not the results indicate a match. Such copies may be maintained in the hospital’s physician file or in a master exclusion verification file, filed by year and alphabetized. The Sanction check reviewer must sign and date the reports on the date reviewed. The search results must be documented (e.g., on a checklist of physicians) and should be maintained in a master exclusion verification file.
  2. Employed physicians: Documentation of periodic search results of employed physicians (done by Corporate IT&S monthly in the search against the Company employee database) is maintained by IT&S. The facility is required to maintain documentation as required by the Limitations on Employment Policy, HR.OP.019.
  3. Electronic Storage:Electronic storage is also an acceptable storage option provided the documents are readily available on demand. A procedure for backing up documents in the event of system malfunction should be established to ensure accessibility.
v.Document retention: All records regarding ineligible persons search results must be maintained according to the Company’s record retention schedules (i.e., five (5) years).
  1. Documentation required for searches performed on the CCI website (for detailed printing instructions, please use the “HCA Instructions for Using CCI’S Website” document that is available on the Company’s Intranet.
  2. Documentation required when batch file results from CCI’s website indicates a possible OIG or GSA List match:
  • A Batch Summary Report must be printed.
  • A provider certificate summary must be printed for all “Positive Matches Only” (both OIG and GSA positive matches).
  • The batch report reviewer must sign and date the report on the date it is reviewed.
  1. Documentation required regardless of batch file results from CCI’s website:
  • The “All Names Submitted” file must be downloaded when the Batch Results page displays.
  • The Provider Exclusions NPR download report file that was run for the facility or facilities must be printed and saved. This report file has all selected MIS Provider Dictionary names and information regarding formatting and spacing.
iii.All records regarding ineligible persons search results must be maintained according to the Company’s record retention schedules (i.e., five (5) years).
  1. Each facility must retain the documentation generated as a result of the procedures regarding licensure, certification or other credentials set forth herein in accordance with records retention schedules developed pursuant to the Company’s Records Management Policy, EC.014.
It is the responsibility of the facility CEO or facility Administrator to ensure adherence to this policy.
REFERENCES:
1.LEXICON, Dictionary of Health Care Terms, Joint Commission on Accreditation of Healthcare Organizations (“JCAHO”), One Renaissance Boulevard, Oakbrook Terrace, Illinois, 1994
2.Steadman’s Concise Medical & Allied Health Dictionary, 1997
3.Comprehensive Accreditation Manual for Hospitals, The Joint Commission, 2009
4.42 U.S.C. § 1320a-7a(a)(6)
5.42 C.F.R. § 1003
6.63 Fed. Reg. 46676
7.Limitations on Employment Policy, HR.OP.019
8.Prohibition Against Contracting with Any Ineligible Person Policy, MM.001
9.Records Management Policy, EC.014
10.American Medical Association Physician Licensure: An Update of Trends,
11.Compliance Concepts, Inc. (CCI) website:
12.List of states with exclusion lists on Atlas

12/2010