FAQ Directory: Credentials Verification Organization

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8.24.2018 What organizations are eligible for CVO Certification?

Any organization that provides credentials verification services can apply for Certification if it:

  • Verifies practitioner credentials for health plans, MBHOs, physician organizations or health care organizations, and
  • Provides verification services for at least six months before application, and 
  • Performs verification activities for at least 50% of contracted practitioners, and
  • Maintains the necessary credentials documentation, policies and procedures for NCQA to conduct the survey, and
  • Obtains errors and omissions insurance for $1M–$2M.

CVO

9.15.2015 Documentation requirements for file review when delegating to a certified CVO What documentation must an NCQA-Certified CVO provide to an organization for an accreditation survey file review?

The organization and the CVO determine the documentation methods for reporting information. Acceptable methods include a checklist, the actual documents and access to electronic credentialing files. When an organization delegates to a certified CVO, NCQA reviews the organization’s credentialing files to assess timeliness and ascertain whether the credentialing decision was made within the specified time limits (i.e., 180 calendar days from verification).

CVO 2013

5.01.2015 Notifying NCQA of Reportable Events How and when must the organization notify NCQA of Reportable Events?

The organization must notify NCQA, in writing, within thirty (30) calendar days of the issuance of the notice of sanctions, issuance of a fine or issuance of a request for corrective action. 

The organization must also complete an annual attestation signed by an officer, or other authorized signatory of the organization, affirming that it has notified NCQA of all Reportable Events specified within the Agreement. NCQA-accredited health plans that reports HEDIS results include the attestation with its submission of the annual IDSS attestation submission for HEDIS® reporting.  Other health plans submit the completed attestation electronically to NCQA-Accreditation@ncqa.org. 

CVO 2013

5.01.2015 Reporting Regulatory Actions Are health plans required to report regulatory actions taken against the organization?

Yes. The Agreement for Health Plan Accreditation Survey (the “Agreement”), specified in the “Organization’s obligations” section of the standards and guidelines, requires the organization to provide NCQA written notice within thirty (30) calendar days of the final determination by a state or federal agency with respect to request for corrective action, imposition of sanctions, changes in licensure or qualification status, if applicable, or violation of any federal or state law that affects the Scope of Review under the Standards and Guidelines. These are termed Reportable Events.

CVO 2013

5.01.2015 Specific Regulatory Actions to be Reported What specific regulatory actions must be reported?

The organization must report the occurrence of any of the following actions by any federal or state regulatory authority:

  • Issuance of Intermediate Sanctions and/or suspension of enrollment by CMS or any other federal or state regulatory authority.
  • Issuance of any fine equal to or exceeding $50,000 related to Organization’s operations by CMS or any other federal or state regulatory authority.
  • Issuance of any request for a corrective action by any federal or state regulatory authority where the substance of such corrective action relates to the Organization’s handling of utilization management decisions, network adequacy, benefit denials, complaints, grievances, appeals or other important patient safety matters. 

The above actions are referred to as the “final determination” within the Agreement.

CVO 2010

1.15.2014 Board Certification as Verification of Education and Training for Nurse Practitioners (NP) and Physician Assistants (PA) Is it acceptable to use ANCC and NCCPA board certification as verification of highest level of education for nurse practitioners and physician assistants?

Yes, if the organization can obtain written confirmation from the ANCC and NCCPA that they perform primary-source verification of the professional school training.

CVO 2013

8.29.2013 NCQA Complaint Review Process Does our current Agreement with NCQA permit NCQA to investigate complaints?

Yes, the current Agreement allows NCQA to investigate complaints relevant to the standards.

CVO 2013

8.29.2013 NCQA Complaint Review Process Are complaints sent to a specific person at an organization?

Yes. Complaints are forwarded to the organizations Accreditation contact.

CVO 2013

8.29.2013 NCQA Complaint Review Process When does the "30 calendar-day" response period begin?

The time period for response begins when the health plan receives the complaint from NCQA.

CVO 2013

8.29.2013 NCQA Complaint Review Process Is the NCQA Complaint Review Process dated March 25, 2013 new?

No, this is not a new process or policy. NCQA has followed this process for handling complaints for more than a decade. In the interest of transparency, NCQA is sharing its policy with organizations.

CVO 2013

8.29.2013 NCQA Complaint Review Process Does NCQA expect the organization to release peer-related information?

This is up to the organization, in conjunction with their legal counsel, if disclosure is permitted. The organization is expected to provide a copy of the response given to the complainant to NCQA.

CVO 2013