FAQ Directory: Health Plan Accreditation

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6.15.2023 Use of Delegate's Self-Service Portal for Delegation Reporting Is it acceptable for organizations to pull reports from a delegate’s system for the delegation agreement reporting requirement?

Yes, if the delegation agreement addresses the required information in the Explanation (e.g., CR 8, Element A, factor 3 for credentialing). The delegation agreement must specify:

  • How often the organization accesses the reports (i.e., must be at least semiannually). The frequency must be specified. Stating “on demand” or “as needed” does not meet the requirement.
  • What information is reported by the delegate in the delegate's system about the delegated activities.
  • How the organization will access the delegate’s system, and to whom information is reported (i.e., to appropriate committees or individuals in the organization).

HP 2023

5.15.2023 Definition of Annual Does NCQA’s definition of “annual” allow for a 2-month grace period?

As noted in the Glossary appendix, NCQA’s long-standing definition of “annual” is 12 months plus a 2-month grace period (12–14 months). “Grace period” refers to allowing organizations to complete an activity after it is due and not before it is due.

HP 2023

5.15.2023 Applicable Standards for Mail Service Organizations Considered Delegates What standards are considered a delegation relationship if an organization uses a mail service organization to meet the distribution requirements?

NCQA considers the following standards to be a delegation relationship if an organization uses a mail service organization to meet the distribution requirements:

  • NET 4, Element A: Notification of Termination
  • NET 4, Element B: Continued Access to Practitioners
  • UM 5, Elements A, B, C: Timeliness of UM Decisions
  • UM 7, Elements B, C, E, F, H, I: Denial Notices
  • UM 9, Elements B, D: Appropriate Handling of Appeals
  • UM 11, Element B: Pharmaceutical Restrictions/Preferences
  • UM 11, Element C: Pharmaceutical Patient Safety Issues

HP 2023

2.15.2023 Use of software to collect credentialing information Is it considered delegation if an organization uses software to only collect credentialing information?

No. The use of another entity’s software to collect credentialing information is not considered delegation unless the other entity also reviews the information on the organization's behalf. NCQA standards allow organizations to use software to collect credentialing information from approved sources, as long as organization staff document that the information was reviewed and verified.

HP 2023

2.15.2023 Use of software for evidence-based clinical guidelines for PHM 5, Element B For PHM 5, Element B, factor 1, is it considered delegation if an organization uses evidenced-based clinical content licensed for use in their own case management system?

No. The use of another entity’s evidence-based content within the organization’s case management system is not considered delegation if the organization maintains control over how the content is used and can customize it as needed. The evidence used to support the content must be cited.

HP 2023

2.15.2023 Recent updates to the MA Deeming Module NCQA updated the 2023 Medicare Advantage (MA) Deeming Module to incorporate changes mandated by the Bipartisan Budget Act of 2018 and as codified in the January 2021 Part C and D final rule. Do these changes apply to the 2022 MA Deeming Module?

Yes. The following changes apply to the 2022 MA Deeming Module:

  • MA 19, Element A:
    • Clarified that the organization’s delegation agreements for MA standards must include a statement requiring delegates to adhere to MA regulations.
  • SNP 2, Element A:
    • Revised factor 3 to reference both initial and annual health risk assessments (HRAs).
    • Clarified in the explanation that the organization must conduct an initial and annual HRA using a comprehensive HRA tool and ensure that results are addressed in the member’s individualized care plan, as required under 422.101(f)(1)(ii).
  • SNP 2, Element C:
    • Added factor 2: “The organization annually, and within the first 12 months of enrollment, conducts face-to-face encounters between the member and their care team.” The face-for-face encounter must be either in person or through visual, real-time, interactive telehealth.
    • Adjusted the scoring to reflect the new factor.
    • Revised the explanation to include “Factor 2: Face-to-face encounter” subhead and text. The encounter must be between the member and representative from any of the following:
      • The ICT.
      • The organization’s case management and coordination staff.
      • A health care provider contracted with the health plan.
  • SNP 3, Element A:
    • Revised factor 5 to read: “Including the ICT, as outlined in SNP 2, Element C, to oversee the MOC’s evaluation and monitoring process.”
    • Revised the scope of review to clarify that the organization includes the ICT in the monitoring and evaluation process.
    • Replaced the “Factor 5: Appropriate personnel” subhead with “Factor 5: The ICT” and revised the explanation to read:
      • The organizational chart documents the organization’s reporting structure and staff responsible for administering the MOC program, including the ICT, as specified in SNP 2, Element C, factor 1. According to the defined MOC, the organization must use an ICT to manage member care. The ICT includes:
        • Practitioners with demonstrated expertise and training,
        • Training in a defined role appropriate to their licensure in treating individuals similar to the targeted population of the organization, as applicable.

HP 2022

10.15.2022 Mail Service Organization Delegates Are any delegation oversight factors considered not applicable for organizations that use a mail service organization delegate to meet distribution requirements (per a July 15, 2021 FAQ)?

Yes. Using UM 13: Delegation of UM as an example, the following describes factors that would be considered NA:
UM 13, Element A: Delegation Agreement

  • Factor 3 (semiannual reporting): This factor is NA for mail service organization delegates that only perform annual distribution (e.g., UM 11, Element B (annual updates for pharmaceutical restrictions/preferences).
    • Note: Factor 4 (performance monitoring): Annual distribution must be specified as part of the organization’s process for monitoring delegate performance, if applicable.
    • Factor 3 is not scored NA for distribution that occurs more frequently than annually (e.g., denial and appeal notices).
  • Factor 5 (process for providing member experience and clinical performance data to delegates when requested): This factor is NA for mail service organization delegates.

UM 13, Element C: Review of the UM Program

  • Factor 1 (annual review of delegate’s UM program): This factor is NA for mail service organization delegates.
  • Factor 4 (semiannual evaluation of reports): This factor is NA for mail service organization delegates that only perform annual distribution.
    • Factor 4 is not scored NA for distribution that occurs more frequently than annually (e.g., denial and appeal notices).

Note: Factor 2 (annual audits): This factor is not scored NA, but the organization may submit the delegate’s timeliness report of mail distribution in lieu of an audit. This must be specified in the delegation agreement.

HP 2023

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 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 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

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