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FAQ Directory: Health Plan Accreditation

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9.15.2022 File Review Scope for NCQA-Accredited Health Plans seeking UM-CR-PN Accreditation How many files are reviewed in a UM-CR-PN Survey for Accredited Health Plans?

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

9.15.2022 Backdating effective dates Can an organization backdate an effective date for a practitioner to the practitioner’s start date in the network?

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

9.15.2022 Electronic signatures Are electronic signatures (e.g., DocuSign) acceptable?

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

9.15.2022 Durable medical equipment in the scope of credentialing Are durable medical equipment entities in the scope of credentialing?

Yes. Durable medical equipment entities are in the scope of CR 7, Element A, to the extent that organizations must have policies and procedures for initial and ongoing assessment of the entities with which it contracts. NCQA’s review of the organization’s assessment of organizational providers is limited to the organizations listed in CR 7, Elements B and C.

HP 2022

9.15.2022 Use of future dates to verify education and training Are future dates acceptable for verifying education and training?

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

HP 2022

9.15.2022 Retaining practitioner records How long should practitioner records be retained?

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

9.15.2022 Use of NSC to verify education and training Can the National Student Clearinghouse be used to verify education and training?

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

5.24.2022 Updated: Boilerplate Language in Delegation Agreements for System Controls May organizations’ delegation agreements contain boilerplate language for system controls delegates?

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

5.15.2022 System Control Requirements Review by Product Line If auditing is used to monitor an organization’s system controls or a delegate’s system controls, is sampling by product line required?

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

5.15.2022 Clarify scope for CR 1, Element C What are the differences in scope for system controls at the factor level in CR 1, Element C?

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

5.15.2022 Clarify scope for new Credentialing System Controls Oversight requirement (CR 1, Element D) How is the new oversight requirement, CR 1, Element D, different from the monitoring requirement in factor 5 in CR 1, Element C?

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

5.15.2022 Clarify scope for new UM System Controls Oversight requirement (UM 12, Elements B and D) How are the new oversight requirements, UM 12 Elements B and D, different from the monitoring requirements in factor 7 in UM 12, Element A and C?

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