FAQ Directory: Utilization Management, Credentialing and Provider Network

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2.15.2022 Annual Monitoring of CR System Controls Monitoring for Delegates Have the allowed methods to audit delegate files in CR 8, Element C, factor 5 changed?

No. Delegate files may be audited using one of the following methods as described in the factor explanation and noted below:

  • 5 percent or 50 of its files, whichever is less, to ensure that information is verified appropriately.
    • At a minimum, the sample includes at least 10 credentialing files and 10 recredentialing files. If fewer than 10 practitioners were credentialed or recredentialed since the last annual audit, the organization audits the universe of files rather than a sample.
  • The NCQA “8/30 methodology” available at https://www.ncqa.org/programs/health-plans/policy-accreditation-and-certification/

Either methodology is allowed, for consistency with other Delegation Oversight requirements for annual file audits.

UM_CR 2022