Info You Can Use

Primary & Secondary Source Verification of Credentials

Hospitals are increasingly expected to proactively ensure their clinical staff are meeting the legal requirements of their position, in addition to meeting compliance standards set forth by both HR and The Joint Commission (TJC). Furthermore, TJC standards are placing increasing emphasis on ensuring continual compliance with credential requirements around the year. This adds mounting challenges on growing health organizations:

  • To effectively track, distill and analyze large amounts of staff credential information to determine who is out of compliance today and in the near future, in order to proactively ensure compliance with HR requirements; and
  • To accurately verify the integrity and authenticity of staff credentials to ensure compliance with both legal requirements and TJC standards.

This article clarifies verifying credentials using both primary source verification and secondary source verification methods and when to use each. (If you’re looking for a tool to help with tracking and analyzing staff compliance with HR requirements, consider taking a look at

Primary source verification is verification by the original source of a specific credential to determine the accuracy of the qualification reported by a healthcare professional, both upon hire and when the credential is renewed. For example, for the state of Colorado, one may go to DORA ( to verify the license of a Registered Nurse; for verifying board certifications, one would use the ABMS search site. Both of these sources would be considered acceptable for primary source verification.

Means of obtaining primary source verification include, but are not limited to:

  • Direct written correspondence,
  • Telephone verification,
  • Internet verification, and
  • Reports from the credentialing organization.

Certainly, having to go to the original source for every pertinent credential is time consuming and tedious. So alternatively, a credentials verification organization (CVO) may be employed to provide primary source verification. CVOs are typically accredited by NCQA or URAC and used by both health plans and healthcare organizations’ Medical Staff Offices to provide primary source verification for the credentials of licensed independent practitioners; SourceOne and MedVentive are examples of NCQA-certified CVOs.

To reduce costs and improve efficiency (as CVOs have a normal turnaround time of 30-45 days), many health systems have internal, certified CVOs to provide dedicated, primary source verification services to their respective hospitals and/or clinics.

Secondary source verification is, simply put, verification that is not considered an acceptable form of primary source verification. This may be used to verify credentials when primary source verification is not required. Examples of secondary source verification include the original credential, a notarized copy of the credential, or a copy of the original credential when the copy is made by an approved staff member.

When logging a credential verification, using either a primary or secondary source, the following information should be maintained by the health organization:

  • Credential verified,
  • Name and title of person performing the verification,
  • Date and time of verification,
  • Verification type (e.g., Primary or Secondary),
  • Means of verification (e.g., California’s DCA BreEZe for license verification, notarized copy of original, etc.),
  • Status of verification (e.g., Verified or Invalid), and
  • Written documentation or proof.

As for when to use primary or secondary source verification, it depends on the healthcare professional and the credential being verified. The following table summarizes which credentials require primary or secondary verification for both licensed independent practitioners (LIP) and other licensed or certified practitioners (OLCP).

When to use primary source verification and secondary source verification

It quickly becomes apparent that knowing when to use which type of source verification is as important as the verification process itself! While time consuming and tedious, verifying credentials using the appropriate means and procedures ensures a health organization’s compliance with both legal and HR requirements in addition to meeting TJC standards. But standards and requirements aside, properly verified healthcare professionals improve the overall safety and quality of a heath organization’s ability to care for its patients.

Leave a Comment