It used to be very commonplace for health centers to describe in their Credentialing and Privileging Policy how they might grant “temporary privileges”. Recently, in the absence of guidance from a HRSA Compliance perspective, some reviewers have begun marking such policies as “non-compliant”. As the COVID-19 global pandemic begins to hobble health center staff, health centers are taking a hard look at their “temporary privileging” policies in case they need to bring in additional staff on a short-term basis. Though both the HRSA Compliance Manual and HRSA Site Visit Protocol are silent in regard to granting “temporary privileges”, HRSA PAL 2017-07 does provide some guidance.

The PAL states that:

  • Temporary credentialing and privileging may be provided to clinical providers in response to certain “declared emergency situations”.
  • A “declared emergency situation” is defined in the PAL as, “an event affecting the overall health center target population and/or the health center’s community at large, which precipitates the declaration of a state of emergency at a local, state, regional, or national level by an authorized public official such as a governor, the Secretary of the Department of Health and Human Services, or the President of the United States”. The PAL gives examples including, “hurricanes, floods, earthquakes, tornadoes, widespread fires, and other natural/environmental disasters; civil disturbances; terrorist attacks; collapses of significant structures within the community (e.g., buildings, bridges); and infectious disease outbreaks or other public health threats”. It goes on to state that in situations where there has not been an official emergency declaration, HRSA will, “…evaluate on a case-by-case basis whether extraordinary circumstances justify a determination that the situation faced by the health center constitutes an “emergency” for purposes of FTCA coverage during a declared emergency”.
  • Temporary privileges “may be granted by the CEO or Executive Director of the impacted health center, upon expedited review and verification of the professional credentials, references, claims history, fitness, professional review organization findings, and license status of providers. Such expedited review and verification may take into account signed, written findings of the impacted health center’s applicable clinical department head and/or the Chief Medical Officer, as to the following items:

    • Identity: This may be done by verifying the individual’s government issued ID. This may include state or federal ID (i.e., driver’s license, passport).
    • Professional Credentials: Licensure verification must be done by primary source verification. “Primary Source Verification” is the process of verifying a credential by directly contacting or obtaining documentation from the original source that issued the specific credential to determine the accuracy of a qualification reported by an individual health care practitioner. For example, primary source verification of medical licensure could be obtained by a health center staff member requesting a copy of the provider’s medical license directly from the Board of Medical Licensing of that state. In the event that primary source cannot be obtained, the health center must document its attempts to obtain primary source verification and may accept a secondary source document (i.e., a copy from the provider). These references should also include information related to any negative professional organization findings, if applicable. Please note that during an emergency, all individuals must adhere to all state licensing laws and requirements when performing services in jurisdictions or states.
    • Claims History: This may be done by obtaining a secondary source copy from the applicant of the most recent National Practitioner Data Bank (NPDB) query. If not possible, the applicant may attest that they have had no claims within the last 12 months, or if such claims exist, the applicant should provide information for each.
    • Fitness/References: This must be assessed by reviewing privileging forms and/or at least one reference from the current or most recent employer, which demonstrates the individual can perform the duties and services that will be requested. The reference may be provided in the form of an email or other electronic correspondence that clearly states the individual can perform the duties that are requested. If an individual cannot produce privileging forms from a current or recent employer (for example, if the individual is a recent graduate), the applicant may provide secondary sources such as a statement or other documentation from the degree issuing institution.
  • Temporary privileges can be granted for no more than 90 days. After the 90-day period, the impacted health center should have completed all the necessary verification for standard credentialing and privileging and granted full privileges based on that information.

Though the HRSA Compliance Manual does not explicitly promote or condemn the use of temporary provider privileges, we recommend health centers align their policies with the guidance offered in PAL 2017-07. The FTCA Health Center Policy Manual also may provide guidance on coverage for temporary sites and providers.

If you would like our RegLantern team of HRSA Compliance experts take a look at your Credentialing and Privileging policy or if you’d like us to perform a remote mock HRSA compliance review, contact us today at