Credentialing is the administrative process for validating the qualifications of licensed professionals and appraising their background. It is used by hospitals and other health care facilities, educational institutions, and insurance companies to ensure the qualification of their clinicians and to grant privileges to provide specific services and perform different medical or dental procedures. This article familiarizes the reader with the credentialing process and the documentation that is needed to be credentialed by certain organizations.
Credentialing is the administrative process for validating the qualifications of licensed professionals and appraising their background. The process generally involves an objective evaluation of a subject’s current licensure, training or experience, competence, and ability to provide particular services or perform particular procedures. It is used by hospitals and other health care facilities, educational institutions, and insurance companies to ensure the qualification of their clinicians and to grant privileges to provide specific services and perform different medical or dental procedures. The process is also used by state dental boards to grant licensure or to decide on whether to accept candidates from other states or jurisdictions for licensure by qualifications only. This article familiarizes the reader with the credentialing process and reviews documentation that is needed to be credentialed by certain organizations.
Standard credentialing information that generally is required after graduation from dental school includes the following:
Dental practice information
Current state dental license
Current Drug Enforcement Administration (DEA) certificate
Current state controlled substance certification
Malpractice coverage summary
Board eligibility or certification verification
National Practitioner Data Bank (NPDB) report
The credentialing process involves initial data gathering, primary source verification, and enhanced data gathering and verification.
Initial data gathering
Initial data gathering is the process of securing a complete application with demographic information and professional credentials. It may be done by an individual institution or a network, the credentialing or peer review department of an insurance company, a professional credentialing specialist, or a regional electronic service. All questions on the credentialing application must be answered. Failure to answer all questions or to provide all requested documentation would force the credentialing committee to withdraw the dentist’s application. Similarly, information provided by the dentist must be held in the strictest confidence.
Primary source verification
Primary source verification is the process of authenticating information provided by the dentist during the initial data gathering. Dentists practicing within a community must comply with all applicable local, state, and federal laws and regulations. This compliance will vary by states or territories and, in addition to state license, may include matters related to disease and infection control, child abuse and domestic violence, infected waste material, and so on. Hospitals also have specific and unique requirements for practicing within their confines. Credentialing committees verify compliance with the necessary regulations for their region and organization. Some of the verification may be done by direct interaction with sources such as state dental boards and the NPDB via secure Internet and digital technologies or by the dentist providing proof such as malpractice certification, basis life support (BLS) or advanced cardiac life support (ACLS) cards, and proof of taking an infection control course. Primary source verification includes all or several of the items discussed in the following sections.
A photocopy of a current state dental license (with the license number and issue date) is always requested. This copy is kept on file along with proof of current registration. The credentialing committee or department will validate that the dentist’s license to practice is active and unencumbered and will confirm whether there are any sanctions against the license. This information can be obtained directly from individual state licensing boards of dentistry.
National practitioner data bank query
The NPDB is a clearinghouse of information relating to medical malpractice payments and adverse actions taken against physicians, dentists, and other licensed health care practitioners in regards to restrictions or limitations of clinical privileges and sanctions by professional associations. Hospitals and other health care entities, including professional societies and state licensing boards, use the information contained in the NPDB in conjunction with information from other sources when granting clinical privileges or in employment, affiliation, or licensure decisions.
The information on the professional competence and conduct of physicians and dentists that is provided by the NPDB is only available to state licensing boards, hospitals and other health care entities, professional societies, certain federal agencies, and other entities specifically named under section 11134(b) of The Health Care Quality Improvement Act of 1986. Hospitals are the only health care entity with federal mandatory requirements for querying the NPDB. Information is not available to the general public, and practitioners may query the NPDB regarding themselves at any time. Several commercial dental insurance companies state on their Web page that they use information from the NPDB when considering participation on their provider panels. Health maintenance organizations (HMOs) that are entering into an affiliation relationship with a dentist who has applied for affiliation may access the information and are mandated to do so in certain localities.
The purpose of the NPDB is to improve the quality of health care by encouraging state licensing boards, hospitals and other health care entities (including insurance companies), and professional societies to identify and discipline persons who engage in unprofessional behavior and to restrict the ability of incompetent physicians, dentists, and other health care practitioners to move from state to state without disclosure or discovery of previous medical malpractice payment and adverse action history. Adverse actions can involve licensure, denial or withdrawal of clinical privileges, expulsion from membership in a professional society, and exclusions from Medicare and Medicaid.
National technical information service
A photocopy of a current DEA certificate will be requested. Validation of the practitioner’s license to prescribe drugs is done through the National Technical Information Service (NTIS). The NTIS is an agency in the Technology Administration of the US Department of Commerce that serves as the US government repository for results of research and development and for other information produced by and for the government as well as a variety of public and private sources. One of the products available from the NTIS is the complete official DEA database of persons and organizations certified to prescribe or handle controlled substances under the Controlled Substances Act. The DEA authorizes the use of this database and the inclusion of any individual or organization in the database as proof of that entity’s registration with the DEA.
General anesthesia permit (if applicable)
Validation of the practitioner’s permit to administer anesthesia is required. A photocopy of the certification for general anesthesia or conscious sedation permit is required if the applicant wishes to use sedation within a hospital or bill for sedation in a private office. Most states require additional permits or licenses for dentists who are trained in the administration of substances that produce general anesthesia, deep sedation, or conscious sedation, or for nitrous oxide sedation in patients being treated by the licensee, although most states omit nitrous oxide. The American Dental Association (ADA) position statement on the use of conscious sedation, deep sedation, and general anesthesia in dentistry advocates that state dental boards have a responsibility to ensure that only dentists who are properly trained, experienced, and competent are allowed to use conscious sedation, deep sedation, and general anesthesia within their jurisdictions .
Current active malpractice coverage is one of the credentialing standards set by nearly all nongovernmental organizations and dental insurance companies, and this information is routinely collected as part of the process. This verification usually requires a photocopy of the current malpractice insurance certificate (with the policy number, levels of individual aggregate coverage, and dates of coverage) or a verification from the insurance carrier itself. Most organizations want an assurance that the dentist carries adequate malpractice insurance, usually $1,000,000 per occurrence and $3,000,000 per aggregate.
To obtain a specialty license, to practice as a specialist within a hospital or an academic institution, or to bill an insurance carrier as a specialist, proof of specialty training is required. To become a specialist, one must be trained in a residency or advanced graduate training program accredited by the ADA. Once the residency is completed, the doctor is granted a certificate of specialty training. Many specialty programs require advanced degrees such as MD (specific to oral and maxillofacial surgery), MS, or PhD.
There are nine recognized dental specialties in the United States : dental public health, endodontics, oral and maxillofacial pathology, oral and maxillofacial radiology, oral and maxillofacial surgery, orthodontics and dentofacial orthopedics, pediatric dentistry, periodontics, and prosthodontics.
Dentists who receive formal education in these fields are designated as being “board eligible” and can advertise exclusive titles such as orthodontist, oral and maxillofacial surgeon, endodontist, pedodontist, periodontist, or prosthodontist and are educationally eligible to sit examinations to become “board certified.” Many insurance companies require board certification after a specific time to remain listed as a specialist on their panels. Hospitals also require board certification.
The specialist designations are registrable titles and in the United States are controlled by the ADA. The Dental Practice Act of most states forbids a licensed and registered dentist to designate in any manner that he or she has limited their practice to one of the specialty areas of dentistry expressly approved by the ADA unless such dentist has completed the required advanced or postgraduate education in the area of such specialty. Some states issue a specialty license or require notification of the state’s dental commission of such limitation of practice. Pseudo-specialists such as a cosmetic dentist, dental implantologist, or temporomandibular joint specialist are not fields that people are generally credentialed in as a specialist, and there are restrictions on allowing these dentists to call themselves specialists in these fields in certain jurisdictions and by some local dental associations. General practitioners can provide services in specialty areas such as oral surgery, endodontics, or periodontics, but they cannot bill as a specialist and may not receive reimbursement at the specialist fees.
Dental Medicaid is fairly limited, and the number of dentists participating in the program is decreasing. Some private insurance carriers, HMOs, and hospitals may try to determine whether sanctions have been imposed on the practitioner by the federal government’s Office of Inspector General or Office of Personnel Management. Exclusion for cause by Medicaid may be used by an insurance company to deny an applicant participation on their closed panel.
Enhanced data gathering
Enhanced data gathering involves research and collection of additional information concerning issues such as criminal convictions, sexual misconduct allegations or investigations, child abuse allegations or investigations, health issues and substance abuse, unprofessional conduct, and inappropriate prescribing practices.
Some of this enhanced data gathering is normally collected by a “yes/no” form on which the applicant is required to sign an affidavit. “Yes” responses require a written detailed explanation. Some jurisdictions will require the applicant to obtain a report from the Criminal Justice Information Services (CJIS) division of the FBI.
The CJIS is a computerized criminal justice information system within the FBI that provides timely and relevant criminal justice information concerning individuals to qualified law enforcement bodies as well as civilians and academic, employment, and licensing agencies. The database of the CJIS is, for the most part, supplied to the FBI on a monthly basis by federal, state, and local law enforcement agencies. The FBI assembles the data and distributes it to law enforcement organizations and civilian entities interested in this information. To obtain the identification record, each applicant must submit in writing to the FBI [CJIS Division, ATTN: SCU, Mod. D-2, 1000 Custer Hollow Road, Clarksburg, WV 26306, phone (304) 625-3878] a signed letter stating the reason for requesting the identification record (licensure application), a completed fingerprint card, and a certified check or money order for $18.00 (2007) made payable to the Treasure of the United States. The fingerprint form may be downloaded from the FBI Web site at www.fbi.gov/hq/cjisd/pdf/fpcardb.pdf .
Other information can be obtained from the Division of Professional Conduct of each state.
Credentialing by specific organizations
State board of dentistry
A state board of dentistry will most likely be the first to credential a dentist for the purpose of granting a license to practice dentistry. The qualifications to obtain a dental license in a particular state are controlled by the Dental Practice Act of the individual state. Documentation required by all 50 states includes the following:
A written application for a license must be signed by the applicant.
Proof of age of at least 21 years and of good moral character must be provided.
A diploma from a dental college accredited by the ADA conferring a dental degree (DDS or DMD) must be provided.
Successful completion of an examination authorized or given by the state board in the theory and practice of the science of dentistry must be achieved. All 50 states recognize the certificate granted by the National Board of Dental Examiners; however, passing scores may be established by the individual state boards.
Successful completion of a clinical examination conducted by the state dental board of examiners or by an approved regional testing service in lieu of the state examination must be achieved. Successful completion means that the applicant has achieved a minimum passing score on the regional examinations as determined by the regional testing service. New York State now requires the successful completion of a 1 year general practice residency.
Payment of a fee is required.
Other items that may be required are an infection control course certification, documentation of having attended a child abuse recognition course, a BLS certificate, and a jurisprudence test.
Dentists are re-credentialed for renewal of their license every 2 or 3 years as mandated by their state. This process usually involves an update in biographic data, criminal convictions, sexual misconduct, substance abuse, the suspension by state professional associations, unprofessional conduct, DEA violations, and current infection control and child abuse certificates. This data gathering is collected by a “yes/no” form on which the applicant is required to sign an affidavit. “Yes” responses require a written detailed explanation.
Mandatory continuing education (CE) is an almost universal requirement for relicensure of dentists in the United States. A survey in 2005 found that 45 states and the District of Columbia mandated CE for relicensure . The number of hours, period of time, and the types of CE vary by state. Some state dental boards have made distinctions about the acceptability of CE credits. For instance, some state dental boards set minimums, maximums, or both for clinical and nonclinical credit hours. Others require a minimum number of credit hours on certain subjects, such as infection control, child abuse, HIV/AIDS, and BLS. Another categorization divides CE credits into those earned through independent study and on-site courses .
Reporting of CE credits earned over the mandated time span is most often done by an affidavit indicating that the applicant has completed the required minimum number of hours of CE in approved courses as required by the state. The affidavit rarely requires a listing of courses. The affidavit is considered to be prima facie evidence that the applicant has obtained the minimum number of required CE hours in approved courses. In these cases, verification is done by random audits. Another method of recording CE credits is through a state agency or an organization such as the state dental society or the Academy of General Dentistry. Clinicians should keep their own log of courses taken along with the documentation of attendance.
Licensure by credentials (also known as licensure by recognition)
Licensure by recognition is a process by which a state board of dentistry grants a dental license to an individual based on its determination that the candidate has previously met requirements for initial licensure in another jurisdiction, holds a current state license to practice in another state of the United States, and has practiced for a minimum specified amount of time before application (usually 5 years) in a state that has licensure standards equivalent to the one where licensure by credentials is being sought. If the candidate meets all of the required criteria, a license is granted upon payment of the fee. The purpose of this credentialing is to prevent dentists who are inept, addicted to drugs, or convicted of a crime from going state-to-state undetected.
Unlike in medicine, dentistry does not have a national credentialing system that would allow dentists to practice in any US state; therefore, dentists must go through a system of state-by-state licensure. Although the process of obtaining a license by credentialing varies by state, common documents that may be requested are as follows:
Some state boards may require a report from all states or territories of the United States or District of Columbia where the applicant has ever held or currently holds a dental license to verify a current active license. The license must be “active” (not under suspension), and there should be no sanctions against the license. Reasons for surrendering a license may be requested.
Continuing dental education credits that meet the requirements for the state to which the candidate is applying will need to be provided. The applicant will need to submit the certification of attendance.
A letter attesting to the “good character” of the applicant from the state dental society or association may need to be provided.
The applicant may need to pass a written jurisprudence examination on the Dental Practice Act of the state.
Proof of successfully passing the dental National Boards I and II, administered by the Council of National Board of Dental Examiners, must be provided.
The applicant may be asked to personally appear before the credentialing committee of the board for an interview.
A search for a criminal background record may be performed.
A review of the applicant’s practice history may be requested.
Private insurance carriers assemble a panel of participating dentists who agree to accept the fees established by the insurance companies. Because these agreements are dictated by the insurance companies, “business criteria” become a part of the credentialing process, and the payee will first verify whether the provider falls within their business criteria for network participation.
The credentialing process of HMOs, unions, and other insurance companies is intended to evaluate the qualifications of dentists who provide care to their members but often becomes a process designed to find dentists that meet the requirements necessary to be a participating provider. With more reputable insurance companies, the process will involve the data gathering and verification steps discussed previously. The following is a checklist of documents that are needed when an application is made to participate on an insurance panel:
A photocopy must be provided of the current state dental license (with the license number, issue date, and expiration date). This information is verified with the state dental board.
A photocopy must be provided of a current DEA certificate. The dentist must be able to prescribe medications, specifically antibiotics and analgesics.
A photocopy must be provided of the current malpractice insurance certificate (with the policy number, levels of individual aggregate coverage, and dates of coverage). This certificate is one of the credentialing standards set by nearly all dental insurers, and this information is routinely collected as part of the process. The insurers want to guarantee their members that the dentists who participate in their programs carry adequate malpractice insurance.
A photocopy must be provided of specialty certifications or general anesthesia or conscious sedation permits, if applicable.
Some of the more selective health insurance companies will query the NPDB before accepting applicants to their panel, and they can (and some will) conduct peer and performance reviews of existing participating practitioners. Because participating dentists are independent practitioners in private or group practice and are neither agents nor employees of insurance companies or HMOs, their credentialing process cannot guarantee any level of quality or the type of service provided to their members by the participating dentists.
Hospital staff membership
The process of applying for and obtaining hospital privileges can be long and arduous and is the most involved credentialing process that a dentist will undergo. This process is somewhat similar to what has been mentioned previously. The applicant will need to fill out a biographic form that often includes details of clinical experience such as residency or internships, previous hospital privileges, any previous denial, suspension, or revocation of privileges, and any involvement in malpractice suits or college investigations. Additional items that are often requested are a resume, ACLS and advanced trauma life support certificates, evidence of successful completion of clinical procedures relevant to clinical practice, reference letters, and a recent photograph.
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) specifies four core criteria that should be met when credentialing licensed independent practitioners: (1) current licensure, (2) relevant training or experience, (3) current competence (defined as letters from authoritative sources attesting to the applicant’s scope and level of performance), and (4) the ability to perform privileges requested.
The terms credential s and privileges define separate entities that are determined independently, and appropriate documentation will be required for each. The credentialing criteria for appointment to the medical staff are the general requirements that must be met by all applicants for medical staff appointment and by all medical professionals currently practicing in the hospital. The criteria for delineation of clinical privileges, on the other hand, specify the certification or specific training and experience needed to be eligible for specific clinical privileges. The ruling body that accredits hospitals—the JCAHO—requires that “All individuals who are permitted by law and by the hospital to provide patient care services independently in the hospital have delineated clinical privileges.” For clinical privileges, documentation will be required to determine competence, relevant education, training, and experience with respect to the particular procedures that he or she seeks to perform.
It is the duty of the hospital and its medical staff office to ensure that the physicians (the term physician also includes dentists) on staff are qualified and competent to deliver care. A primary purpose is not only to evaluate the qualifications of the physician but also to determine the clinical competence, experience, and judgment of that physician. Because one of the main purposes of credentialing in the hospital is to ensure a high quality of care, competency becomes an important factor. Granting hospital privileges to a physician or dentist with inadequate clinical qualifications will obviously have important patient care and legal implications. In the current litigious climate, hospitals have implemented stringent privileging processes to protect against malpractice suits. The medical staff office of the hospital must determine whether the applicant for privileges has the training and experience needed to ensure competence in the procedures in which he or she is seeking privileges and must translate the information gained into an appropriate course of action (ie, to grant or deny privileges).
Like their medical counterparts, dentists wishing to provide patient care in the hospital must seek delineation of their clinical privileges. Delineation is the process by which the hospital determines what specific procedures may be performed by each medical staff applicant and appointee in the hospital. The criteria for granting clinical privileges are outlined in the medical staff bylaws and differ between institutions. Clinical privileges granted to a dentist must be consistent with all applicable state laws and regulations, and the services provided must be within the scope of practice. This criterion has presented some difficulties to oral and maxillofacial surgeons who do not have a medical license and who seek privileges to provide an expanded scope of care. Hospitals that grant privileges to a dentist will first verify that the individual is properly licensed (dental, medical, or both [ie, a double-degree oral surgeon]) and is currently registered by the state. They will also query the NPDB and all of the other agencies previously mentioned before granting privileges.
Privilege and competency
The term clinical privilege defines an authorization granted to a practitioner by a local institution to perform a particular procedure or clinical service within the confines of the institution and is among the stickiest of all credentialing issues. The clinician must show that his or her training and experience qualifies him or her for the privileges being requested. A formal process for delineating privileges will be spelled out by the medical staff and departmental bylaws, policies, rules, or regulations, as well as by a program of peer review that evaluates the clinical performance on reappointments. The JCAHO accreditation manual specifically indicates that one of the responsibilities of a departmental chairperson or a chief of division is “recommending to the medical staff the criteria for clinical privileges in the department.”
The term competence is used to define a standardized requirement for an individual to properly perform a specific task. It is the skill set that is essential for a dentist to begin independent unsupervised dental practice. Competency includes knowledge, experience, critical thinking and problem-solving skills, and technical and procedural skills that become an integral whole during the rendering of patient care .
In 1997 the American Dental Educators Association (formerly The American Association of Dental Schools) issued a document containing 63 competency statements that have been used by dental schools as the educational goal of the predoctoral curriculum in the United States. The competency statements standardize expected learning outcomes and are the tool used by the curriculum developers and content experts of each dental school to select instructional strategies, provide relevancy of context, and ensure the most relevant and up to date dental content for their 4-year DDS/DMD curriculum that will result in the expected learning outcomes. The Committee on Dental Accreditation monitors each dental school for the quality of their educational standards. All dentists who graduate from an ADA-accredited dental school and who are licensed by a state will possess competency in certain basic clinical skills and diagnostic knowledge. These basic competencies can be used throughout the United States for granting privileges.
Hospital administrators and the JCAHO have considered the delineation of privileges to be the ultimate in establishing and guaranteeing high standards for patient care. To maintain this “guarantee” and to protect themselves from malpractice suits, hospitals have turned to core privileging. The core privileging approach uses predefined criteria established by the medical staff association and the departmental chairperson to set minimum standards of clinical activities that any appropriately trained and licensed practitioner would be competent to perform and then verifies the qualifications of the applicant against these criteria. Core privileges cover the range of clinical expertise gained through dental school education, training (residency and other postgraduate activity), and ongoing clinical practice. These skills endure throughout an active professional career. These criteria apply to a specialty or procedure and not to a specific department. They should allow for all qualified physicians to perform a basic procedure or treatment for which they are trained and should take away the “turf war.” To gain more extensive privileges (referred to as special privileges), the applicant must prove evidence of education, training, and experience, and demonstrated current competence, ability, and judgment. Special privileges refer to certain operative or invasive procedures and clinical conditions for which training or expertise is not expected to have been achieved in dental school or, in general, is not routinely offered in the DDS/DMD curriculum or in every residency program. For special privileges, it is often expected that one must perform a minimum number of procedures each year to maintain clinical competency.
What happens if your request for privileges has been denied or restricted? The JCAHO stipulates that there must be an appeal process; however, this process may be long, because medical credential committees may only meet annually, biannually, or quarterly, and sometimes documents may have to go through more than one committee. The applicant should ensure that the specific information regarding the decision is obtained in writing, and that the letter explicitly states the reasons why privileges have been denied or restricted. If there are questions regarding training or documentation, the applicant should find out from the department chairperson under what circumstances these privileges may be obtained. Are there reasons other than those that have been stated in writing, such as other practitioners and not enough patients or questions regarding the scope of practice? Were privileges for cosmetic surgery denied because the applicant was a dentist? The applicant should keep written notes on any conversations related to his or her attempts to obtain privileges. Try to work with the department chairperson before seeking legal channels. A legal challenge should be the last resort.
If denial seems inevitable, it may be in one’s best interest to remove an application from consideration before a negative vote. Managed care applications or future hospital staff applications may ask, “Have you ever been denied hospital privileges?” Answering “yes” may indicate that there is a problem with your credentials or a worse situation, that is, you were trying to obtain privileges for procedures that you were not qualified to perform. This discovery would harm the dentist’s credibility with further hospital applications and may even end up in the NPDB. A withdrawn application may be resubmitted with more documentation to demonstrate that the dentist’s training and experience qualify him or her for the privileges requested.