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
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
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
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:
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:
Note: The underlined text is an update to the FAQ posted on January 15, 2022.
HP 2022
No. Delegate files may be audited using one of the following methods as described in the factor explanation and noted below:
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:
Either methodology is allowed, for consistency with other Delegation Oversight requirements for annual file audits.
HP 2022
New delegation agreements implemented on or after January 1, 2022, must include a description of the delegate’s UM/CR system security controls.
For delegation agreements in place prior to January 1, 2022, NCQA has extended the time frame for including a description of UM/CR system controls in the delegation agreement. All delegation agreements under the 2024 HPA standards (effective July 1, 2024) must include a description of UM/CR system controls. Prior to July 1, 2024, organizations may alternatively provide a delegation agreement and other mutually agreed upon documentation OR the delegate's system controls policies and procedures in lieu of a delegation agreement with a description of UM/CR System controls.
HP 2022
NCQA considers it to be delegation if the organization uses another organization, including a mail service organization, to perform any function not listed in the “Vendor” section of Appendix 2.
NCQA considers it to be a vendor relationship if the organization uses another organization (e.g., a mail service organization) to perform functions evaluated by the elements or element components listed in the "Vendor" section of Appendix 2.
HP 2021