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
FAQ Directory: Utilization Management, Credentialing and Provider Network
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8.23.2018 How long does it take to earn Credentialing Accreditation?
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 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 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
8.15.2018 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?
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?
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?
9.15.2017 Utilization Management and Use of Voicemail When does voicemail meet UM notification requirements?
Voicemail meets UM requirements only when the organization notifies a practitioner about the opportunity to discuss a denial decision. The organization must document who left the message, along with the date and time it was left. Voicemail messages do not meet any other notification requirement.
UM_CR 2018
8.15.2017 Overturned appeals Who can overturn a medical necessity or benefit denial on appeal?
5.15.2017 Updated: Pharmacists as Same-or-Similar Specialists May pharmacists be considered “same-or-similar” specialists?
No. Beginning with files processed on and after February 1, 2017, pharmacists are not considered same-or-similar specialists because they do not treat patients in most instances.
Note: An FAQ communicating that pharmacists are not considered same-or-similar specialists was posted on October 15, 2016, and this policy was applied beginning February 1, 2017 (90 days from notification).
UM_CR 2017
4.15.2017 UM 9B: Timeliness of the Appeal Process for Medicaid Under the new Medicaid Managed Care Final Rule, effective July 1, 2017, Medicaid organizations are required to have only one level of appeal. However, this may not be effective immediately for organizations with contracts prior to this date. How will NCQA evaluate Medicaid organizations coming through under the 2017 standards and guidelines?
Organizations with one level of appeal will be evaluated against the timeliness requirements specified in the current 2017 standard. Medicaid organizations that maintain a two-level appeal process will be evaluated under the 2016 standard requirements; these time frames apply:
- For preservice first-level appeals: 30 calendar days.
- For postservice first-level appeals: 60 calendar days.
UM_CR 2017