FAQ Directory: Health Plan Accreditation

Although the National Student Clearinghouse (NSC) is not an approved source for primary source verification, NCQA allows verification of credentials through an agent of an approved source. NSC can serve as an agent for some institutions. 

Before using NSC, the organization must obtain documentation of a contractual relationship between it and the approved source (institutions that work with NSC). The contractual relationship must entitle the agent to provide verification of credentials on behalf of the approved source. 

HP 2022

Yes. Because the board would have primary-source verified education and training before awarding certification, NCQA allows organizations to use expired board certifications to meet the requirements. Education and training information does not change even if board certification expires.

HP 2022

No. NCQA does not accept future dates of program completion as valid verification of completion of education and training.

HP 2022

Yes, if there is a unique electronic signature or identifier and if the organization can demonstrate that the signature/identifier can only be entered by the signatory. NCQA reviews organizations’ security and login policies and procedures to confirm that the signature/identifier can only be entered by the signatory.

HP 2022

NCQA requires organizations to credential practitioners before they provide care to members. NCQA uses the date of the Credentialing Committee or medical director’s decision (in the case of clean files) to determine credentialing timeliness requirements.

HP 2022

For UM Accreditation, 75 files are reviewed per product line.  For CR Accreditation, 75 initial credentialing files and 75 recredentialing files are reviewed. 

Note: For non-health plan organizations, 30 files are reviewed per product line.  

HP 2023

At a minimum, credentialing files must be retained for the period covering the survey look-back period. Otherwise, NCQA does not prescribe a specific time period for retaining credentialing files.

HP 2022

Yes, if the language specifies that the delegate must meet NCQA requirements (UM 12, Elements A and C, 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.

Note: The underlined text is a correction. The previous FAQ referred to the wrong element. 

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

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

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

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