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Understanding Primary Source Verification

Understanding Primary Source Verification

September 7, 2021
September 7, 2021

Primary Source Verification (PSV) is a required step in confirming whether a physician can legally practice in an institution. PSV is an integral part of the credentialing process and it is important for every organization to fully understand what it is, the acceptable forms of primary sources, and the items that must be verified.


What is PSV?

The Centers for Medicare & Medicaid Services (CMS) regulations require that a healthcare facility’s governing body confirms that both new physicians and those renewing their membership and/or privileges meet the organization’s criteria for medical staff membership. PSV uses “primary sources” to verify certain credentials, including medical school diplomas, specialty training or residency certificates, licenses to practice, registration with a medical or dental council or any other credential required by law, regulation or hospital policy.


What is a primary source?

A primary source is the original source of a specific credential that can verify the accuracy of a credential reported by an individual health care professional, which means verification is received directly from the issuing source. An example of Primary Source Verification would be when an organization receives information on medical school graduation directly from the medical school, not a copy of the medical school diploma from a provider.


How is PSV performed?

Primary source verifications can be performed in several ways. Some organizations complete the process manually. Letters requesting the appropriate information are written, faxed, or emailed directly to the primary source, and responses are received directly from that source. In some cases, PSV can also be completed via telephone, as long as the information listed below is properly documented:


  • Name of organization 
  • Date collected
  • Name and title of the person contacted
  • The questions asked and responses received
  • The name and title of the person receiving the responses

As technology continues to grow and improve, more organizations are beginning to complete PSV electronically. In fact, in a recent study 83% of healthcare organizations have fully or partially automated their PSV processes. Primary sources now provide internet portals and/or web access to credentials verifications making the process a little easier. Solutions like CredentialStream integrate with these resources to provide access to multiple primary sources via a single solution.

It's important to note that all accrediting organizations that require primary source verifications have their own standards and timeframes. In addition, bylaws for different organizations can also dictate what is considered to be acceptable within their accreditation standards.


What are Designated Equivalent Sources (DES) and how do they pertain to PSV?

The Joint Commission defines a Designated Equivalent Source (DES) as “selected agencies that have been determined to maintain a specific item(s) of credential(s) information that is identical to the information at the primary source.” In fact, a primary source may designate another organization as its agent in providing information to verify credentials. This other organization is then considered a DES, which permits them to serve as the primary source during the verification process. However, all accrediting organizations have specific requirements regarding DES for individuals to be verified.


What are Commonly Used Designated Equivalent Sources (DES)?

There are a variety of DES options, such as:


  • Education Commission for Foreign Medical Graduates (ECFMG)
  • American Medical Association (AMA) Physician Masterfile
  • National Practitioner Data Bank (NPDB)
  • American Osteopathic Association (AOA) Physician Database
  • Federation of State Medical Boards (FSMB)
  • American Academy for Physician Assistants (AAPA)

What needs to be verified?

Specific categories of content that are required for verification include:


  • Demographics
  • Education
  • Training
  • Professional Experience
    • Work History
    • Hospital Affiliations
  • Board Certification
  • Licensure & Other Certifications
  • Drug Enforcement Administration (DEA)
  • Liability History
    • Proof of Insurance
  • National Practitioner Data Bank Report
  • Criminal Background Checks
  • Health Status/Ability to Perform
  • Peer References & Competency
  • Medicare/Medicaid Sanctions/Exclusions
  • Continuing Medical Education – Recorded but not validated via PSV

Some accrediting bodies allow exceptions, eliminating the need to verify each record. For example, some state licensing boards perform PSV for education and graduated medical education (GME) prior to issuing licensure. Because of that, the state licensing board is considered a DES, eliminating the need for organizations practicing in those states to validate Education and GME as long as they are able to validate the state licensure. Other accrediting bodies only require that organizations verify the highest level of education completed if not board certified.


How can I simplify PSV?

Managing PSV in-house can be challenging, time-consuming, and expensive.HealthStream's Credentialing solutions can simplify the process through automation. HealthStream's NCQA-Certified CVO Services can also assist acting as an extension to your team. We provide credentialing services as an ongoing or overflow capacity covering a variety of services including initial and re-credentialing, expirables management, and sanctions monitoring. Reach out today for a demo, and let’s improve patient care, together.