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FAQ Directory: Managed Behavioral Healthcare Organization Accreditation

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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.

MBHO 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.

MBHO 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. 

MBHO 2022

9.15.2022 Use of expired board certification to verify education and training Can an expired board certification be used to verify education and training?

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.

MBHO 2022

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

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-MBHO organizations, 30 files are reviewed per product line. 

MBHO 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.

MBHO 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. 

MBHO 2022

5.15.2022 MBHO: Clarify scope for new UM System Controls Oversight requirement (UM 11, Elements B and D) How are the new oversight requirements, UM 11 Elements B and D, different from the monitoring requirements in factor 7 in UM 11, Element A and C?

UM 11, 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 11, 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.

MBHO 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.

MBHO 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).

MBHO 2022

5.15.2022 MBHO: UM and CR Advanced System Controls—Policies and Procedures Are organizations that provide evidence of “advanced system controls” eligible to receive Met for UM 11, Elements A and C, and for CR 1, Element C?

No. If the organization provides evidence of advanced system controls capabilities, it must submit policies and procedures for UM 11, Elements A and C and for CR 1, Element C. Policies and procedures must address all factors regarding advanced system control capabilities.

Organizations are only eligible to receive a score of Met for UM 11, Elements B and D, and for CR 1, Element D if they provide evidence of advanced system control capabilities that both automatically record dates and prevent changes that do not meet the organization’s policies and procedures.

MBHO 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.

MBHO 2022