FAQ Directory: Utilization Management, Credentialing and Provider Network

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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.
 

UM_CR 2023

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.

UM_CR 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. 

UM_CR 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.

UM_CR 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.

UM_CR 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.

UM_CR 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.

UM_CR 2022

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.  

UM_CR 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.

UM_CR 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. 

UM_CR 2022

5.15.2022 Delegation Oversight System Controls Monitoring - Audits Are both the organization and delegate required to conduct system controls audits for factor 5 in UM 13, Element C and CR 8, Element C?

Both the organization and delegate must monitor the delegate’s system security controls as part of the delegation oversight requirements and may choose audit as the monitoring method. If auditing is the chosen method, the delegate provides an audit report of modifications that did not comply with its policies and procedures or with the delegation agreement.

The organization is not required to conduct an audit if it determines that the delegate adequately monitored and reported noncompliant modifications, but must provide documentation (a report, meeting minutes or other evidence) that it reviewed and agreed with the delegate’s findings. If the organization determines that the delegate did not adequately monitor noncompliant modifications, it must conduct its own audit of the delegate’s system controls.

The organization must submit its documentation and the delegate’s documentation as part of the survey.
 

UM_CR 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).

UM_CR 2022