Primary Source Verification Policy
PURPOSE: To confirm that all personnel are qualified and properly credentialed. This policy has been adopted to establish a process for verifying credentials of all medical and technical staff directly from the organizations that originally conferred or issued the credential or certification to the practitioner.
Procedure:
1. This policy applies to all medical and technical staff in regular or temporary (per diem) positions.
2. The practice manager/hiring manager will be responsible for verifying all credentials reported by an individual prior to employment being finalized or within 30 days of employment.
3. Credential verification must be from the organization that originally issued the credential or certification.
4. Primary source verification must occur for all licenses, certifications, and registries as reported by the staff member.
5. Examples of primary source verification include, but are not limited to:
a. Direct written correspondence
b. Telephone verification
c. Internet verification
d. Reports from the credentialing organization
6. Examples of sources for verification:
a. Licenses – Issuing state
b. Medical staff board certification – Example: American Board of Internal Medicine (www.abim.org), American Osteopathic Board of Internal Medicine (www.aobim.org), American Board of Thoracic Surgery (www.abts.org), American Board of Surgery (www.absurgery.org), International Board of Heart Rhythm Examiners (www.ibhre.org)
c. Nursing staff registry/certification – Example: American Nurses Association (www.nursingworld.org), American Nurses Credentialing Center (www.nursecredentialing.org), (American Association of Nurse Practitioners (www.aanp.org) , International Board of Heart Rhythm Examiners (www.ibhre.org)
d. Technical staff registry/certification – Example: Cardiovascular Credentialing International (www.cci-online.org), American Association of Radiologic Technologists (www.arrt.org), Canadian Association of Medical Radiation Technologists (www.camrt.ca), International Board of Heart Rhythm Examiners (www.ibhre.org)
7. Falsification or misrepresentation of credentials shall be grounds for immediate termination of employment.
8. Records of primary source verification will be retained as part of the individual’s permanent employment record. Documentation shall include:
a. Credential verified
b. Name of personnel completing the verification
c. Date of the verification
d. Status of the verification/check
e. Written documentation/proof
9. Primary source verification is to be repeated every two years while employed in the facility.
Primary Source Verification Policy (SAMPLE) 1