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Credentialing and privileging: Common pitfalls

Credentialing and privileging: Common pitfalls

By Candace Kugel, FNP, CNM, Specialist in Clinical Systems and Women’s Health, Migrant Clinicians Network
Claire Hutkins Seda, Writer, Migrant Clinicians Network, Managing Editor, Streamline

Credentialing and privileging can be challenging for many health centers, though it is a significant risk management issue.  What’s the difference between the two processes in the oft-uttered word pair?  Credentialing is verifying the qualifications of a health care professional who provides care, while privileging is defining the scope of clinical practice for that professional within a given organization.  When a new nurse practitioner is hired, for example, health center staff credentials the NP through verification of that individual’s professional background by contacting the NP’s alma mater(s), the state licensing board and the national certification organization. The NP then requests privileges -- a list of skills and services she or he can perform for patients -- and the health center is then tasked with assuring the NP is qualified and trained for those services before granting privileges. In most cases, initial verification comes through documentation of training or from references from colleagues and faculty who have worked closely with the practitioner. Or privileges may be granted as “under review,” indicating that the practitioner may perform the tasks under observation or guidance until the medical director or other clinical supervisor feels sufficient skill has been demonstrated to grant the privileges to perform those tasks.

Credentialing and privileging processes assure that the right practitioner is doing the right job, so that patients receive skilled and knowledgeable care. It also protects the health center from liability claims that may result from improper care provided by practitioners performing tasks that they haven’t been properly trained and approved to do. Re-privileging at least every two years also assures that a health center’s practitioners remain up-to-date on their skills and advancements in their field. 

Credentialing and privileging isn’t just a good practice -- it’s a requirement for health centers. Credentialing and privileging is a major component to the staffing requirement, the third of the 19 program requirements established by the Health Resources and Services Administration (HRSA), which oversees the Health Center Program.  HRSA has issued two Policy Information Notices (PINs) which specifically outline the credentialing and privileging requirements for health centers. (See resources below.)  And yet, health centers experience challenges in this area. Here are some of the common credentialing and privileging pitfalls for health centers:

1. Credentialing and privileging policies and the real-life process aren’t aligned.

Both credentialing and privileging are ongoing processes, and should be reviewed and updated at least every two years. While many health centers have policies and procedures in place to assure that this regular upkeep is documented, health centers may lag in completion.  Maintaining the many pieces in a credentialing file can be challenging. When a practitioner’s license expires between the two year intervals, for example, health center staff must verify the new license. Additionally, sometimes health centers are doing the credentialing appropriately -- but they aren’t doing the privileging. At least every two years, health centers must review that list of privileges that the practitioner was granted when first hired, and either re-approve the list, or add to (or subtract from) it as needed.

2.  The policies and procedures aren’t approved at the board level.

Even if the correct policies are in place and are implemented properly, some health centers miss the critical step of including the board of directors. The board has final approval authority on credentialing and privileging, and if a health center’s board approves a practitioner’s credentials and privileges, the approval needs to be documented, preferably in both the board minutes and the practitioner’s credentialing and privileging file. In addition, the credentialing and privileging policy must be approved by the board.

3. Primary source is confused with secondary source.

HRSA requires primary source verification for certain elements of a practitioner’s credentialing.  Some health centers are using secondary source verification in places where HRSA requires the use of primary source verification.  Primary source verification means health center staff goes to the original source of the credential, like contacting the university that issued a practitioner’s diploma and documenting confirmation from the university. Secondary source verification is less direct, like receiving the practitioner’s diploma and photocopying it. 

4. Licensed practitioners who practice with supervision are overlooked for credentialing.

There are two categories of clinical staff: Licensed Independent Practitioners (LIPs) and “other licensed or certified health care practitioners.” LIPs practice independently, like doctors, nurse practitioners, nurse-midwives, and dentists. Non-LIPs are licensed clinical staff that do not work independently, like registered nurses, licensed practical nurses, medical assistants, and dental hygienists. Although the credentialing and privileging requirements for these two groups are different, both categories of workers need regular credentialing, which some health centers overlook.


Health centers are encouraged to assess their policies and processes to assure full compliance with HRSA’s specific requirements regarding credentialing and privileging.  Many resources are available to assist health centers in strengthening credentialing and privileging policies and procedures:

1. HRSA has issued two Policy Information Notices (PINs) specifically outlining its credentialing and privileging requirements.

2. The ECRI Institute provides a credentialing toolkit available to its members at

3. Credentialing and privileging is outlined in the third of HRSA’s 19 Health Center Program requirements. Read a short description here:

Read a more detailed description in HRSA’s Health Center Program Site Visit Guide for fiscal year 2015:

4. MCN’s online toolbox includes sample policies, procedures, and documents useful to health centers in performing credentialing and privileging: