FAQ Directory: Health Plan Accreditation

No. If the organization provides evidence of advanced system controls capabilities, it must submit policies and procedures for UM 12, Elements A and C and for CR 1, Element C. Policies and procedures must address all factors regarding advanced system control capabilities.

Organizations are only eligible to receive a score of Met for UM 12, Elements B and D, and for CR 1, Element D if they provide evidence of advanced system control capabilities that both automatically record dates and prevent changes that do not meet the organization’s policies and procedures.

HP 2022

No. Although the organization may set a monitoring goal, NCQA does not require it for UM 12, Elements B and D, factor 2 and CR 1, Element D, factor 2. The intent is that the organization reviews all instances of modifications that did not meet its policies and procedures.

HP 2022

For CR 1, Element C:

• Factor 1 applies to verification source information from credentialing and recredentialing cycles, covered in CR 3, Elements A–C.
• Factor 2 applies to modified credentialing verification information from initial credentialing and recredentialing cycles, covered in CR 3, elements A–C.
• Factors 3–4 apply to all information associated with credentialing/recredentialing of practitioners, covered in CR 2–CR 5.

Factor 5 requires a monitoring process that covers compliance with all policies and procedures described in factors 1–4.

HP 2022

For UM 12, Elements A and C:

• Factors 1–5 apply to receipt and notification dates, covered in UM 5 and UM 8–UM 9.
• Factor 6 applies to all UM system data for managing denials and appeals (not only the dates specified in factors 1–5), covered in UM 4–UM 7 and UM 8–UM 9.

Factor 7 requires a monitoring process that covers compliance with all policies and procedures described in factors 1–6.

HP 2022

UM 12, Elements A and C, factor 7 require organizations to have a process for monitoring that policies and procedures are followed for all other factors (factors 1–6) in this element at least annually. Policies and procedures must describe the monitoring process for factor 7.

For UM 12, Elements B and D, the organization submits evidence that it identified, analyzed and acted only on modifications to receipt and notification dates (UM 5) that did not meet the organization’s policies and procedures.

HP 2022

CR 1, Element C, factor 5 requires organizations to have a process for monitoring that policies and procedures are followed for all other factors (factors 1–4) in this element at least annually. Policies and procedures must describe the monitoring process for factor 5.

For CR 1, Element D, the organization submits evidence that it identified, analyzed and acted only on modifications to credentialing/recredentialing information (CR 2 – CR 5) that did not meet the organization’s policies and procedures.

HP 2022

Yes, if the language specifies that the delegate must meet NCQA requirements (UM 12, Elements A and B, factor 6; UM 13, Element C, factor 5; CR 1, Element C, factor 4; CR 8, Element C, factor 5), template language may be used in the delegation agreement. Language specific to each delegate is not required.

HP 2022

Both the organization and delegate must monitor the delegate’s system security controls as part of the delegation oversight requirements and may choose audit as the monitoring method. If auditing is the chosen method, the delegate provides an audit report of modifications that did not comply with its policies and procedures or with the delegation agreement.

The organization is not required to conduct an audit if it determines that the delegate adequately monitored and reported noncompliant modifications, but must provide documentation (a report, meeting minutes or other evidence) that it reviewed and agreed with the delegate’s findings. If the organization determines that the delegate did not adequately monitor noncompliant modifications, it must conduct its own audit of the delegate’s system controls.

The organization must submit its documentation and the delegate’s documentation as part of the survey.
 

HP 2022

No. Sampling is not required by product line if the product lines are managed the same (a single system is used to manage all product lines).

HP 2022

For Maryland practitioners credentialed between December 2021 and February 2022, NCQA will not penalize organizations on inability to verify licensure due to the MDH network security incident. NCQA accepts the MDH’s grace period on licensure expirations and accepts temporary licenses issued by the MDH and will consider them current and valid. Organizations should adhere to guidance provided by MDH and document the guidance in the affected practitioners’ credentialing files.

HP 2022

No. Delegate files may be audited using one of the following methods as described in the factor explanation and noted below:

• 5 percent or 50 of its files, whichever is less, to ensure that information is verified appropriately.
  • At a minimum, the sample includes at least 10 credentialing files and 10 recredentialing files. If fewer than 10 practitioners were credentialed or recredentialed since the last annual audit, the organization audits the universe of files rather than a sample.
• The NCQA “8/30 methodology” available at https://www.ncqa.org/programs/health-plans/policy-accreditation-and-certification/

Either methodology is allowed, for consistency with other Delegation Oversight requirements for annual file audits.

HP 2022

No. Delegate files may be audited using one of the following methods as described in the factor explanation and noted below:

• 5 percent or 50 of its files, whichever is less, to ensure that information is verified appropriately.
• The NCQA “8/30 methodology” available at https://www.ncqa.org/programs/health-plans/policy-accreditation-and-certification/

Either methodology is allowed, for consistency with other Delegation Oversight requirements for annual file audits.

HP 2022