No. The requirement is that organizations query practitioners about present illegal drug use, not about ability to practice.
UM_CR 2024
NCQA requires practitioners to attest to their lack of present illegal drug use, but not to past drug use or history of drug use.
Organizations are not required to refer exclusively to the present; therefore, an organization may choose to ask about both present and past drug use.
UM_CR 2024
No. Only addressing the UM denial notification to the provider does not meet the intent of the requirement. The UM denial notification must also be addressed to the attending/treating practitioner.
If information on the attending/treating practitioner was not provided with the request, the organization attempts to identify the practitioner and documents its efforts to identify the practitioner. If the organization is not able to obtain the name of the attending/treating practitioner, the practitioner’s name is not required. In such a case, the organization must address the notification "To the Attention of the Attending/Treating Practitioner.”
For urgent concurrent decisions, the organization may inform the hospital Utilization Review department staff without attempting to identify the attending/treating practitioner, with the understanding that staff will inform the practitioner.
In all cases, if the practitioner is not known, the organization must address the notification “To the Attention of the Attending/Treating Practitioner”; the practitioner’s name is not required.
UM_CR 2023
Yes. Organizations may use an API to access data from a primary or approved source, and must provide documentation that the API collects information only from primary or approved sources.
Organizations that use an API must still meet the “Appropriate documentation” requirements in CR 1, Element A, including documentation that the organization's staff reviewed the information.
As noted in an FAQ from February 15, 2023, use of another entity’s software to collect credentialing information is not considered delegation unless the entity also reviews the information on the organization’s behalf.
UM_CR 2023
Yes, if the delegation agreement addresses the required information in the Explanation (e.g., CR 8, Element A, factor 3 for credentialing). The delegation agreement must specify:
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:
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
UM 13, Element C: Review of the UM Program
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. 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
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
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