FAQ Directory: Utilization Management, Credentialing and Provider Network

Yes, the following CAQH question meets the intent of the requirement in CR 3, Element C, factor 2:

This applies to the following Programs and Years:

Yes. NCQA uses language in the Explanation that organizations may use more general or extensive language to query practitioners about impairment.

Note: This question was previously posted on August 15, 2023 and reevaluated by NCQA. This FAQ answer replaces the previously posted response.

This applies to the following Programs and Years:

No. An organization that only provides print services is not considered a delegate or a vendor, and is outside the scope of NCQA requirements.

This applies to the following Programs and Years:

Yes. Organizations may submit the mail service delegate's timeliness report of mail distribution of UM denials and appeals in lieu of an audit. This is not required to be specified in the delegation agreement.

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years:

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).

This applies to the following Programs and Years:

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

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years:

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.
 

This applies to the following Programs and Years: