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Credentialing and Recredentialing (CR)

1.  Internal Quality Improvement Process (CRC 1)

  • Does the organization have the QI infrastructure needed to improve its credentialing process?

2.    Agreement and Collaboration with Clients (CRC 2)

  • Has the organization worked with the client to develop a mutually agreed-upon document that describes each party’s responsibilities, delegated activities, frequency of reporting to client, process by which the client evaluates the organization and the remedies available to the client if the client does not fulfill its obligations?
  • Has the organization provided the client with the client’s efforts to implement quality improvement and other activities?
  • Has the organization given the client access to its medical records?

3.    Protecting Credentialing Information (CRC 3)

  • Does the organization protect the confidentiality and integrity of credentialing files?

4.    Credentialing Policies (CR 1)

  • Does the organization have clearly defined and documented procedures for assessing its practitioners’ qualifications and practice history?
  • Does the organization identify which types of practitioners must be credentialed?
  • Does the organization have policies and procedures that define practitioner rights to review and correct credentialing information?

5.    Credentialing Committee (CR 2)

  • Has the organization designated a committee to make recommendations regarding decisions about practitioners’ credentials?

6.    Credentialing Verification (CR 3)

  • Prior to allowing network participation, does the organization verify practitioners’ credentials, including a valid license to practice medicine; education and training, malpractice history; and work history within the timeframes specified within NCQA standards and guidelines? Do practitioners applications to the organization include a current and signed attestation about why they cannot perform certain tasks; a history of loss of medical license and felony convictions; a history of limitation of privileges or disciplinary actions; and current malpractice insurance coverage? Before making a decision on a practitioner’s qualifications, does the organization receive and review information from third parties, such as information about any disciplinary actions?

7.    Recredentialing Cycle Length (CR 4)

  • Does the organization reevaluate practitioners’ qualifications every 36 months?

8.    Practitioner Office Site Quality (CR 5)

  • Does the organization set thresholds for office-site criteria and medical/treatment record-keeping practices?
  • Does the organization visit practice sites that reach its member complaint threshold?
  • Does the organization take necessary steps when an office does not meet its standards, and does it evaluate those steps regularly until the office improves?

9.    Ongoing Monitoring (CR 6)

  • Between recredentialing cycles, does the organization conduct ongoing monitoring of practitioner sanctions, complaints and quality issues?
  • Does the organization take appropriate action when issues are identified?


10.    Notification to Authorities and Practitioner Appeal Rights (CR 7)

  • Does the organization have a process for discontinuing the contracts of practitioners who demonstrate poor performance?
  • Is there a process in place by which the practitioner can appeal the organization’s decision?
  • Does the organization report to appropriate authorities when it suspends or terminates practitioners?

11.    Delegation of Credentialing (CR 8)

  • If the organization delegates to a third party decisions on evaluating or reevaluating a provider’s qualifications, is the decision-making process—including the responsibilities of the organization and delegated party—clearly documented?
  • Does the organization evaluate and approve the delegated party’s plan on a regular basis?

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UM/CR Report Card

View the Utilization Management/Credentialing Certification Report Card.

 

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