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FAQ Directory: Utilization Management, Credentialing and Provider Network
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8.23.2018 How do I get started with Credentialing Accreditation?
8.23.2018 Where can I find information to help me get started with Credentialing Accreditation?
- Accreditation Process and Timeline: Key steps, timing and resources for a successful accreditation.
- Standards and Guidelines: The complete standards and guidelines, including the intent and scope of review.
- Interactive Survey Tool: Contains the complete standards and guidelines; you can also determine your organization’s survey readiness—the tool calculates your potential survey score.
This applies to the following Programs and Years:
UM-CR 2017, 2016|UM-CR-PN 2018, 20198.23.2018 What organizations are eligible for Credentialing Accreditation?
Credentialing Accreditation is for organizations that provide full scope credentialing services. Eligible organizations:
- Must not be licensed as an HMO, POS, PPO or EPO.
- Must not be eligible for NCQA Accreditation as a health plan or an MBHO.
- Must perform credentialing functions directly or through a contract.
- Must perform credentialing activities for at least 50% of a practitioner network.
Note: A “practitioner network” is the practitioner network of clients and organizations.
This applies to the following Programs and Years:
UM-CR 2017, 2016|UM-CR-PN 2018, 20198.23.2018 How long does it take to earn Credentialing Accreditation?
8.23.2018 Where can I find the Standards and Guidelines?
Find the Standards and Guidelines document in the NCQA eStore.
This applies to the following Programs and Years:
UM-CR 2017, 2016|UM-CR-PN 2018, 20198.23.2018 What are the Credentialing Accreditation requirements?
Credentialing Accreditation assesses an organization’s performance in the following areas:
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This applies to the following Programs and Years:
UM-CR 2017, 2016|UM-CR-PN 2018, 20198.23.2018 How does Credentialing Accreditation help my organization?
NCQA Credentialing Accreditation is designed to ensure that organizations pursuing accreditation can maintain a high-quality network for members and contracted clients. The standards provide a framework for adopting industry best practices to accurately and efficiently credential and recredential health care professionals—ensuring that medical organizations employ qualified professionals and align with state requirements.
This applies to the following Programs and Years:
UM-CR 2017, 2016|UM-CR-PN 2018, 20198.23.2018 What is Credentialing Accreditation?
NCQA Credentialing Accreditation is a comprehensive program that evaluates the operations of organizations providing full-scope credentialing services, which include verifying practitioner credentials, designated credentialing-committee review of practitioners and monitoring practitioner sanctions.
This applies to the following Programs and Years:
UM-CR 2017, 2016|UM-CR-PN 2018, 20198.23.2018 What is the price for 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.
This applies to the following Programs and Years:
UM-CR 2017, 2016|UM-CR-PN 2018, 2019
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.
This applies to the following Programs and Years:
HP 2018, 2019|MBHO 2018|UM-CR-PN 2018, 20197.15.2018 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.