1. Quarterly Review Process: The Compliance Committee of the Board will continue to review provider credentialing and privileging files at least quarterly. These reviews will be documented in committee meeting minutes and retained for audit readiness.
1. Quarterly Review Process: The Compliance Committee of the Board will continue to review provider credentialing and privileging files at least quarterly. These reviews will be documented in committee meeting minutes and retained for audit readiness.
2. Policy Review and Revision: SCMRC will re-evaluate its Credentialing and Privileging Policy during the next scheduled policy review cycle to determine whether full Board approval should be incorporated in alignment with HRSA best practices.
2. Policy Review and Revision: SCMRC will re-evaluate its Credentialing and Privileging Policy during the next scheduled policy review cycle to determine whether full Board approval should be incorporated in alignment with HRSA best practices.
3. Credentialing Log Maintenance: The Compliance Officer will maintain a centralized credentialing and privileging log that includes primary source verifications, privilege grant dates, and expiration tracking.
3. Credentialing Log Maintenance: The Compliance Officer will maintain a centralized credentialing and privileging log that includes primary source verifications, privilege grant dates, and expiration tracking.
4. Internal Audit and Quality Checks: SCMRC will conduct semi-annual internal audits of credentialing files to ensure documentation accuracy and compliance with HRSA Chapter 5 requirements.
4. Internal Audit and Quality Checks: SCMRC will conduct semi-annual internal audits of credentialing files to ensure documentation accuracy and compliance with HRSA Chapter 5 requirements.
5. Board Training: The Compliance Committee and Board members will receive annual refresher training on credentialing oversight responsibilities, file requirements, and regulatory expectations.
5. Board Training: The Compliance Committee and Board members will receive annual refresher training on credentialing oversight responsibilities, file requirements, and regulatory expectations.
2. SCMRC updated its Medicare compliance protocols in 2025 and established centralized tracking of required federal reports in the CEO’s compliance calendar.
2. SCMRC updated its Medicare compliance protocols in 2025 and established centralized tracking of required federal reports in the CEO’s compliance calendar.
3. Ongoing Medicare reporting oversight has been assigned to the Controller, with CEO review and incorporation into Board-level financial and compliance workplans.
3. Ongoing Medicare reporting oversight has been assigned to the Controller, with CEO review and incorporation into Board-level financial and compliance workplans.
7. SCMRC’s updated compliance tracking system was reviewed during the 2025 HRSA Verification Site Visit, contributing to the clearance of Chapter 18 conditions.
7. SCMRC’s updated compliance tracking system was reviewed during the 2025 HRSA Verification Site Visit, contributing to the clearance of Chapter 18 conditions.