TN 4 (10-15)

DI 39569.300 Disability Determination Services Requirements for Ensuring Proper Licensures, Credentials, and Exclusions of Consultative Examination (CE) Providers, CE Provider’s Employees, Medical and Psychological Consultants (MC/PC)

Citations:

20 CFR §§ 404.1519g,

416.919g

A. Policy for Licensures, Credentials and Exclusions of CE providers and CE provider’s employees

1. CE Providers

Use only qualified medical sources to perform CEs. By "qualified," we mean that the medical source:

  • is currently licensed in the State;

  • has the training and experience to perform the type of examination or test we will request;

  • is not barred from participation in Medicare or Medicaid programs or any other Federal or federally-assisted programs; and

  • has the equipment required to provide an adequate assessment and record of existence and level of severity of a claimant’s impairments(s).

NOTE: CE providers must have a current license in the state the provider will perform the examination.

2. CE Provider’s employees

CE providers may use support staff to help perform the CE. All support staff, such as Medical Assistants and Psychological Assistants, reemployed by a CE provider, must meet appropriate licensing or certification requirements of the state. These requirements vary by state.

CE providers must certify that employees who participate in performing CEs:

  • meet the licensing or certification requirements of the state (For information on Selecting a Qualified Medical Source to Perform a Consultative Examination (CE) per DI 22510.010 ); and

  • are not currently excluded, suspended, or otherwise barred from participation in Medicare or Medicaid programs or any other Federal or federally-assisted programs.

B. Using the System for Award Management (SAM) website

Use the System for Award Management (SAM) website to obtain data on medical sources that are:

  • currently excluded, suspended, or barred from participation in federal or federally-assisted programs; and

  • whose license to provide health care is currently lawfully revoked or suspended by any state licensing authority for reasons of fraud, abuse, or professional misconduct.

When to use the System for Award Management (SAM):

  • Review the SAM prior to using the services of a new CE provider.

  • Review SAM, at least annually. Do this to prevent medical sources excluded for improprieties in another Federal program from providing CE services.

  • Review problem medical sources more frequently than once a year.

  • Review your state and the entire country for exclusions.

C. Procedure for Verifying and Documenting Medical Licenses, Credentials, and Exclusions

1. CE providers

a. New CE providers

Prior to using the services of any CE provider (including CE providers who are also treating sources):

  1. check the System of Award Management (SAM);

  2. verify medical licenses, credentials, and certifications with state medical boards, psychology boards, and other state professional certification bodies;

  3. annotate the provider file with the:

    • date and name of the DDS employee verifying the license and the source of verification (e.g., state licensing agency webpage, SAM database); or

    • name of the individual who provided the credential verification.

  4. obtain a signed License and Credentials Certification from the CE provider and retain it in a file. (For information on License and Credentials Certification for Consultative Examination Provider and Certification of All Support Staff, see DI 39569.400.)

NOTE: At the time of an established agreement or contract to work with the DDS, the CE provider must sign the License and Credentials Certification statement. The DDS will obtain a new signed certification:

  • annually, or

  • when there is a change with the CE providers support staff that assists with CEs.

Where possible, subscribe to the state or medical board’s service that provides alerts for sanctions against a license or certificate holder. Consider more frequent tracking if the DDS does not subscribe to alerts.

DDS may require all CE providers to include their professional license numbers with expiration dates on all CE reports.

b. Existing CE providers

Conduct license checks of CE providers (including treating sources) used by the DDS on a rolling basis, including providers who perform CEs near and across the borders of neighboring States, specifically:

  1. Verify license renewals within 30 days of renewal date.

  2. Conduct periodic licensure reviews prior to renewal dates to ensure that licenses are active.

  3. Review the SAM for each CE provider at least annually.

  4. Confirm with the DDS in the neighboring state that the medical source has a current license and not federally excluded.

  5. Annotate the provider file with the:

    • date and name of the DDS employee verifying the license and the source of verification (e.g., state licensing agency webpage, SAM database); or

    • date and name of the individual who provided the credential verification.

NOTE: Where possible, subscribe to the state or medical board’s service that provides alerts for sanctions against a license or certificate holder. Consider more frequent tracking if the DDS does not subscribe to alerts. The DDS may require all CE providers to include their professional license numbers and expiration dates on all CE reports.

c. CE provider’s support staff

Obtain and retain a signed statement from each CE provider certifying that all support staff that assist with CE:

  • meet the licensing or certification requirements of the state; and

  • are not currently excluded, suspended, or otherwise barred from participation in Medicare or Medicaid programs or any other Federal or federally assisted programs.

NOTE: At the time of an established agreement or a contract to work with the DDS, the CE provider must sign the License and Credentials Certification statement. The DDS will obtain a new signed certification:

  • annually. or

  • when there is a change with the CE providers support staff that assists with CEs.

To view the License and Credentials Certification for Consultative Examination Provider and Certification of All Support Staff see DI 39569.400.

2. Medical Consultants and Psychological Consultants (MC/PCs)

a. New MC/PCs

Prior to using the services of any MC/PC:

  1. check the System for Award Management (SAM);

  2. verify medical licenses, credentials, and certifications with state medical boards, psychology boards, and other state professional certification bodies; and

  3. annotate the:

    • date and name of the employee verifying the license and the source of verification (e.g., state licensing agency webpage, SAM database); or

    • date and name of the individual who provided the credential verification.

b. Existing MC/PCs

Conduct license checks for existing MC/PCs on a rolling basis, specifically:

  1. Verify license renewals on the renewal date.

  2. Conduct periodic licensure reviews prior to renewal dates to ensure that licenses are active.

  3. Review the SAM for each MC/PC at least annually.

  4. Annotate the:

    • date and name of the employee verifying the license and the source of verification (e.g., state licensing agency webpage, SAM database); or

    • date and name of the individual who provided the credential verification.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0439569300
DI 39569.300 - Disability Determination Services Requirements for Ensuring Proper Licensures, Credentials, and Exclusions of Consultative Examination (CE) Providers, CE Provider's Employees, Medical and Psychological Consultants (MC/PC) - 01/28/2016
Batch run: 01/28/2016
Rev:01/28/2016