FAQ Directory: Utilization Management, Credentialing and Provider Network

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.

UM_CR 2023

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

UM_CR 2023

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.

UM_CR 2023

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

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

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

No. NCQA does not accept future dates of program completion as valid verification of completion of education and training.

UM_CR 2022

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

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

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

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

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