A Summary of What NCQA Looks for When It Reviews an Organization

Note:  Some standards found within other NCQA programs are not a part of Organization Certification.  Standard numbers that have been are not a part of Organization Certification. RR 5 listed below is RR 6 in the 2007 Standards and Guidelines for Certification in UM.

Credentialing and Recredentialing (CR)

1.    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?

2.    Credentialing Committee (CR 2)

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

3.    Initial 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?

4.    Application and Attestation (CR 4)

• 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?

5.    Initial Sanction Information (CR 5)

• 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 Verification (CR 7)

• Does the organization reevaluate practitioners’ qualifications every 36 months?
• Before reevaluating its decision on a practitioner’s qualifications, does the organization receive information from third parties, such as information about disciplinary actions?

8.    Recredentialing Cycle Length (CR 8)

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

9.    Ongoing Monitoring (CR 9)

• 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 10)

• 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.    Assessment of Organizational Providers (CR 11)

• Does the organization confirm that hospitals, home health care agencies, skilled nursing facilities, nursing homes and behavioral health facilities are in good standing with state and federal agencies and accrediting organizations?
• Does the organization re-review these standings at least every three years?

12.    Delegation of Credentialing (CR 12)

• 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?

Quality Management and Improvement (QI)

1.    QI Program Structure (QI 1)

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

3.    Health Services Contracting (QI 3)

• Are participating practitioners required to cooperate with QI activities, provide access to their medical records and protect the confidentiality of enrollee information?
• Do contracts with practitioners assure their free communication with patients about treatment?

4.    Availability of Practitioners (QI 4)

• Are practitioners located throughout the organization’s service area?
• Does the organization take steps to ensure that there are sufficient numbers of practitioners available to its enrollees?
• Does the plan measure its performance in these areas and make improvements when needed?

5.    Accessibility of Services (QI 5)

• Does the organization provide and maintain appropriate access to medical care, behavioral healthcare?

Privacy and Confidentiality (PC)

1.    Protecting Credentialing Information (PC 1)

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