FAQ Directory: Health Plan Accreditation

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2.15.2022 Updated: Sampling for UM/CR System Controls Monitoring May organizations that use auditing as a method for monitoring system controls use sampling for UM 12 and CR1, Elements C and D?

Yes. NCQA has decided to allow sampling for organizations that use auditing as the method for monitoring in UM 12, Elements A – D and CR 1, Elements C and D. Organizations must use the “5% or 50 files” audit method: Organizations randomly select 5% or 50 files, whichever is less, from each applicable file type, to review against the requirements: 

  • Credentialing and recredentialing. (5% or 50 files total)  
    • 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. 
  • UM denials (5% or 50 files). 
  • UM appeals (5% or 50 files). 

For each applicable file type noted above, the organization must determine the sample size of 5% or 50 files (whichever is less) based on all files in the file universe. The file universe includes all files with or without modifications. The sample that will be audited must include only files with modifications (i.e., modifications that meet and do not meet the organization’s policies and procedures). NCQA does not specify how the organization selects the sample once the sample size is determined using the entire file universe. It may select the sample of modified files from the universe or, if the organization can identify files with modifications, it may randomly select the sample that will be audited from only the modified files.

The organization’s analysis report must include the number or percentage of files that do not meet the organization’s policies and procedures.
Example for UM denials:

  • An organization’s UM denial file universe contains 800 files with and without modifications. Therefore, the minimum required sample for review is 40 files (5% of 800) which is less than 50 files. The organization must randomly select the 40 files for review from the total universe of 800 files or from only files with modifications (if the organization’s system has the capability to identify files with modifications). All 40 files must have a modification and are reviewed against the organization’s policies and procedures to identify noncompliant modifications.

Note: The underlined text is an update to the FAQ posted on January 15, 2022.

HP 2022