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FAQ Directory: Utilization Management, Credentialing and Provider Network

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8.23.2018 How long does it take to earn Credentialing Accreditation?

The typical evaluation time frame is 12 months from application submission to decision, depending on an organization’s readiness. Some organizations may already be working within NCQA guidelines.

UM_CR 2016

8.23.2018 How do I get started with Credentialing Accreditation?

If you are not currently accredited and want to learn more, contact NCQA. If you are currently accredited and want to talk to someone about your status or about renewing or adding accreditations, submit a question through My NCQA.

UM_CR 2016

8.23.2018 What are the Credentialing Accreditation requirements?

Credentialing Accreditation assesses an organization’s performance in the following areas:

  • Internal Quality Improvement Process
  • Agreement and Collaboration With Clients
  • Protecting Credentialing Information
  • Credentialing Policies
  • Credentialing Committee
  • Credentialing Verification
  • Recredentialing Cycle Length
  • Ongoing Monitoring
  • Notification to Authorities and Practitioner Appeal
    Rights
  • Assessment of Organizational Providers
  • Delegation of CR

UM_CR 2016

8.23.2018 Where can I find the Standards and Guidelines?

8.23.2018 What is the process for earning Credentialing Accreditation?

The first step to earning accreditation is a discussion with an NCQA program expert. Purchase and review the program resources, conduct a gap analysis and submit your online application.

Align your organization’s processes with the CR standards. NCQA conducts the survey and determines your accreditation status within 30 days of the final review.

See a step-by-step process.

UM_CR 2016

8.23.2018 Where can I find information to help me get started with Credentialing Accreditation?

8.23.2018 What other organizations have earned Credentialing Accreditation?

More than 90 organizations have earned NCQA Credentialing Accreditation. See the NCQA Report Card for a directory of accredited organizations.

UM_CR 2016

8.23.2018 What is the price for Credentialing Accreditation?

Pricing is based on multiple factors. Obtain full pricing information by submitting a request through My NCQA.

UM_CR 2016

8.15.2018 Updated: Use of Acronyms in UM Denial and Appeal Notices In UM 7, Elements B, E and H and UM 9, Element D, the explanation under Factor 1: states that the reason for denial should not include abbreviations or acronyms that are not defined. Similar language is in UM 8 A.
Does this mean that they must be spelled out (e.g., “We are denying your request for a deoxyribonucleic acid (DNA) test because…”) or explained (“We are denying your request for a DNA test, which is a test that looks at your genetic information in order to…”), or both?

The intent of the requirement is that the denial or appeal notice be written in language that can be easily understood by members. Because abbreviations/acronyms may include terms that are not easily understood, even when spelled out, they must be explained. NCQA is updating the explanation under each applicable factor of the referenced elements to read:

The denial [appeal] notification states the reason for the denial [upholding the denial] in terms specific to the member’s condition or request and in language that is easy to understand, so the member and practitioner understand why the organization denied the request [upheld the denial] and have enough information to file an appeal.
 
An appropriately written notification includes a complete explanation of the grounds for the denial, in language that a layperson would understand, and does not include abbreviations, acronyms or health care procedure codes that a layperson would not understand. The organization is not required to spell out abbreviations/acronyms if they are clearly explained in lay language. Denial [Appeal] notifications sent only to practitioners may include technical or clinical terms.
 

NCQA will post an update in December for the 2018 and 2019 HP and UM-CR-PN and 2018 MBHO publications to reflect this change.

UM_CR 2019

7.15.2018 Medical necessity review for personal care services Does NCQA require medical necessity review for personal care services, such as cooking, cleaning and transportation?

No. Medical necessity review is not required for personal care services and other activities of daily living in UM 4–UM 7. However, if these services are covered benefits, any denial decision may be appealed and is included in the scope of appeal file review for UM 9.

UM_CR 2018

11.15.2017 Updated: Timeliness of postservice appeal decisions for Medicare and Medicaid Does the recent change for Medicare and Medicaid postservice appeals from 60 calendar days to 30 calendar days align with Chapter 13 of the Medicare Managed Care Manual?

No. Medicare product lines continue to follow the 60-calendar-day time frame for postservice appeals.

Note: The requirement is correct for Medicare product lines; Medicaid product lines continue to follow the 30-calendar-day time frame for postservice appeals.

UM_CR 2018

9.15.2017 Denial Notices—Right to Representation The denial notification must include a statement that members may be represented by anyone they choose, including an attorney. If the notification states that members have the right to be represented by anyone, but does not specify “including an attorney,” is this acceptable?

Yes. If the notification indicates that members may be represented by anyone, this is acceptable because the reference to “anyone” implies “including an attorney.” If the notification lists specific types of individuals, it must also specify “an attorney.”

UM_CR 2018