FAQ Directory: Utilization Management, Credentialing and Provider Network

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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

9.15.2022 Use of NSC to verify education and training Can the National Student Clearinghouse be used to verify education and training?

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

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 Retaining practitioner records How long should practitioner records be retained?

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

9.15.2022 Backdating effective dates Can an organization backdate an effective date for a practitioner to the practitioner’s start date in the network?

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

9.15.2022 File Review Scope for NCQA-Accredited Health Plans seeking UM-CR-PN Accreditation How many files are reviewed in a UM-CR-PN Survey for Accredited Health Plans?

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

5.24.2022 Updated: Boilerplate Language in Delegation Agreements for System Controls May organizations’ delegation agreements contain boilerplate language for system controls delegates?

Yes, if the language specifies that the delegate must meet NCQA requirements (UM 12, Elements A and C, factor 6; UM 13, Element C, factor 5; CR 1, Element C, factor 4; CR 8, Element C, factor 5), template language may be used in the delegation agreement. Language specific to each delegate is not required.

Note: The underlined text is a correction. The previous FAQ referred to the wrong element. 

UM_CR 2022

5.15.2022 System Controls Goal for Analysis Is a goal required for system controls monitoring analysis for UM 12, Elements B and D, factor 2 and CR 1, Element D, factor 2?

No. Although the organization may set a monitoring goal, NCQA does not require it for UM 12, Elements B and D, factor 2 and CR 1, Element D, factor 2. The intent is that the organization reviews all instances of modifications that did not meet its policies and procedures.

UM_CR 2022

5.15.2022 Clarify scope for new UM System Controls Oversight requirement (UM 12, Elements B and D) How are the new oversight requirements, UM 12 Elements B and D, different from the monitoring requirements in factor 7 in UM 12, Element A and C?

UM 12, Elements A and C, factor 7 require organizations to have a process for monitoring that policies and procedures are followed for all other factors (factors 1–6) in this element at least annually. Policies and procedures must describe the monitoring process for factor 7.

For UM 12, Elements B and D, the organization submits evidence that it identified, analyzed and acted only on modifications to receipt and notification dates (UM 5) that did not meet the organization’s policies and procedures.

UM_CR 2022

5.15.2022 Clarify scope for new Credentialing System Controls Oversight requirement (CR 1, Element D) How is the new oversight requirement, CR 1, Element D, different from the monitoring requirement in factor 5 in CR 1, Element C?

CR 1, Element C, factor 5 requires organizations to have a process for monitoring that policies and procedures are followed for all other factors (factors 1–4) in this element at least annually. Policies and procedures must describe the monitoring process for factor 5.

For CR 1, Element D, the organization submits evidence that it identified, analyzed and acted only on modifications to credentialing/recredentialing information (CR 2 – CR 5) that did not meet the organization’s policies and procedures.

UM_CR 2022

5.15.2022 System Control Requirements Review by Product Line If auditing is used to monitor an organization’s system controls or a delegate’s system controls, is sampling by product line required?

No. Sampling is not required by product line if the product lines are managed the same (a single system is used to manage all product lines).

UM_CR 2022