FAQ Directory

No. Organizations coming through for NCQA HIP or WHP Certification may not use a vendor or delegate for any functions or activities required by the HIP/WHP certification standards and guidelines.

WHP 2013

Core elements are requirements that an organization must meet even if it has no clients.

Structural elements are requirements that the organization must meet even if it delegates 100% of the function. If an organization delegates the functions associated with a structural requirement, it must provide NCQA with its own programs or policies and procedures and evidence of approval of the delegates documentation.

UM-CR 2013

Yes. Organizations being surveyed for the Exchange product line are scored NA for all MED elements.

Yes. The language should read, "where the organization can confirm that the visit was in an outpatient setting (POS 53 is not specific to setting)." The intent is to include only codes where the organization can confirm that the visit was in an outpatient setting.

HEDIS 2014

Yes. The language should read, "where the organization can confirm that the visit was in an outpatient setting (POS 53 is not specific to setting)." The intent is to include only codes where the organization can confirm that the visit was in an outpatient setting.

HEDIS 2014

The CVO must provide NCQA with evidence of a practitioners current or continuous enrollment in the NPDB-PDS Databank, and of review and reporting of databank activity to the organizations client within 120 calendar days.

If no malpractice history is reported by the databank, the CVO must document this in the file and must report to clients that no malpractice settlements were reported. NCQA does not prescribe how the organization documents this information.

Yes, if such mechanisms can legitimately access, retrieve and share the data from approved/recognized sources. All credentialing documentation requirements must be met, and there must be clear documentation that the organizations staff reviewed the credentialing information.

If the medical board does not provide the expiration date for a practitioner's board certification, the organization must verify that the board certification is current. Verification must be documented 180 calendar days prior to the recredentialing decision date.

No. The review of work history may be documented on the application, CV or a checklist. Documentation must include the signature or initials of the staff person who reviewed the history and the date of the review.It must be clear that the signature or initials and date apply to the work history review.

No. NCQA does not require board certification for practitioners to be included within its network.

No. With the exception of ABMS or AOA sponsored boards, NCQA requires organizations to determine and list specialty boards they accept within their credentialing policies and procedures. At a minimum, at least annually, organizations must obtain confirmation from specialty boards that they perform primary-source verification of education and training. A specialty board that provides annual written confirmation that it conducts primary source verification of education and training can be used as an acceptable source for verification of education and training if the organization names the specialty board in its policies and procedures.

The organization must verify board certification status for any practitioner claiming to be certified by an ABMS or AOA sponsored boards, or by a specialty board recognized by the organization.

If the medical board does not provide the expiration date for a practitioner's board certification, the organization must verify and document that the board certification is current within 180 calendar days of the credentialing decision date.