No. The requirement is that organizations query practitioners about present illegal drug use, not about ability to practice.
UM_CR 2024
FAQ Directory: Utilization Management, Credentialing and Provider Network
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8.15.2023 Credentialing application question about present illegal drug use Would the following question on a credentialing application meet the intent of CR 3, Element C, factor 2?
“Are you currently using illegal drugs that could affect your ability to practice medicine?”
8.15.2023 Lack of present illegal drug use Does NCQA require practitioners to attest to their lack of present and past illegal drug use?
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
7.17.2023 UM 5, Elements A-C: Notifying the Practitioner If an organization receives a request from a provider rather than a practitioner (for example, a lab or DME company), may the organization address the UM denial notification to the provider without also notifying the attending or treating practitioner as well?
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
7.17.2023 Use of software to collect credentialing information (API) May an organization use an application program interface (API) that retrieves data directly from a primary or approved source, even though it is not a web crawler?
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
6.15.2023 Use of Delegate's Self-Service Portal for Delegation Reporting Is it acceptable for organizations to pull reports from a delegate’s system for the delegation agreement reporting requirement?
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:
- How often the organization accesses the reports (i.e., must be at least semiannually). The frequency must be specified. Stating “on demand” or “as needed” does not meet the requirement.
- What information is reported by the delegate in the delegate's system about the delegated activities.
- How the organization will access the delegate’s system, and to whom information is reported (i.e., to appropriate committees or individuals in the organization).
UM_CR 2023
5.15.2023 Definition of Annual Does NCQA’s definition of “annual” allow for a 2-month grace period?
5.15.2023 Applicable Standards for Mail Service Organizations Considered Delegates What standards are considered a delegation relationship if an organization uses a mail service organization to meet the distribution requirements?
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
2.15.2023 Use of software to collect credentialing information Is it considered delegation if an organization uses software to only collect credentialing information?
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
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 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
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