Credentialing How Tos   /   July 2018

What You Need to Know about NCQA CR 2: Credentialing Committee

What You Need to Know about NCQA CR 2: Credentialing Committee

In this series, we break down what you need to know about credentialing, recredentialing and delegated credentialing. In today’s post, we cover the establishment of a credentialing committee (CR 2). In a prior post, we covered organizational requirements (CR 1), and in future posts we’ll cover credentialing requirements (CR 3 through CR 8) and delegation of credentialing (CR 9).

But before we dive into the nitty-gritty of today’s installment of what you need to know about the NCQA credentialing committee requirement (CR 2) remember that the simplest way to get 100% credit for credentialing and recredentialing in your next NCQA survey is to delegate to an NCQA-certified CVO such as CredSimple.

Part 2: Organizational Requirements, Credentialing Committee (CR 2)

NCQA requires that health plans have a “well-defined credentialing and recredentialing process for evaluating and selecting licensed independent practitioners to provide care to its members.” In your credentialing process, you will want to pay close attention to the following sections:

IDNCQA DefinitionWhat It Means
A1The organization must have a credentialing committee that uses participating practitioners to provide advice and expertise for credentialing decisions.

 

All health plans need a credentialing committee to govern the process of approving or denying enrollment of a physician. The goal of this process is to have the incoming physician peer-reviewed by physicians of similar specialty background. Reviews must take place in real time, in person or using teleconferencing technology; they cannot be conducted by email.
A2 The credentialing committee must review credentials for practitioners who do not meet established thresholds. The committee must be fair and give thoughtful consideration to credentialing data presented on all eligible providers. Credentialing decisions and the reasoning behind those decisions must be carefully documented during the review meeting.

 

A3The organization      ensures that files that meet established criteria are reviewed and approved by a medical director or designated physician.A medical director or qualified physician can review and approve clean files. Evidence of review must be documented by a unique electronic identifier or a handwritten signature on paper.
Best Practice: NCQA allows and encourages clean files to be handled in this way to help the organization achieve timely turnaround times

 


CredSimple Pro Tips:

Timeliness can be an issue because credentialing committees must meet in real time. Therefore, your credentialing department should make it as easy as possible for the credentialing committee to review the necessary files.

  • Don’t burden the credentialing review committee with clean files when a medical director or qualified physician can review and approve these cases. Set up your credentialing committee for success by translating credentialing committee by-laws into actionable malpractice thresholds and organizing providers into tiers for automatic approval or mandatory review.
  • Provide complete verification information to committee members to reduce the back and forth between administrative professionals and the committee. Make sure the information is up to date and comprehensive in order for it to be useful for a committee while it is in session.
  • Systematically record committee decisions to create an auditable record, taking the necessary action to add or remove a provider from a provider roster.

CredSimple is an NCQA-certified credentialing verification organization (CVO). We scored 100% in all categories surveyed. This post is created by Chief Compliance Officer Dr. Garry Choy, CEO Mike Simmons and several other contributing members. Our goal is to make it easier for you and your company to pass your next NCQA survey with flying colors.

(Note: This post is based on NCQA 2018 Health Plan Standards.)

 

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