Credentialing How Tos   /   July 2018

What You Need Know: NCQA Requirements, Part 3: Credentialing Requirements

What You Need Know: NCQA Requirements, Part 3: Credentialing Requirements

In this series, we break down what you need to know about credentialing, re-credentialing and delegated credentialing. Here we cover the establishment of credentialing requirements (CR 3). In prior posts, we covered organizational requirements (CR 1) and credentialing committees (CR 2).

But before we dive into the nitty-gritty, remember that the simplest way to get full credit for credentialing and re-credentialing in your next NCQA survey is to delegate to an NCQA-certified CVO such as CredSimple.

Part 3: Credentialing Requirements (CR 3)

First, it is important to submit a credentialing application that meets the minimum standards. An application for credentialing must, at minimum, include the following:

  • Factor 1: Reasons for the inability to perform the essential functions of the position the provider is being onboarded to do
  • Factor 2: Lack of present illegal drug use
  • Factor 3: History of loss of license and felony convictions
  • Factor 4: History of loss or limitation of privileges or disciplinary actions
  • Factor 5: Current malpractice insurance coverage (the NCQA requirement is that insurance is current at time of attestation)
  • Factor 6: Current and signed attestation confirming the correctness and completeness of the application


Second, you’ll need to show the surveyors that your organization has a robust program to verify provider’s credentials to demonstrate that you have ensured that “practitioners have the legal authority and relevant training and experience to provide quality care.”

You’re required to verify the following elements:

 

Verification needed

What this means                                                                                                                                                                       

License

 

 

A provider is required to have a valid, current license to practice at the time of the credentialing decision. The medical board for the state in which the practitioner practices is the acceptable primary source to validate this element.

 

DEA permit or CDS certificate

 

Verification of a current, active DEA or CDS certificate is required to ensure that practitioners can write prescriptions. The organization is required to perform the verification for each state in which practitioner is writing prescriptions and practicing.

 

Education

 

 

 

The organization must verify the highest level of education and training. Going from the highest level to the most basic level, board certification, residency, and medical school attendance must be verified. For instance, if a practitioner is board certified, the organization can verify to this level to satisfy NCQA requirements, and no further verification needs to be performed directly with the residency or medical school.
Board certification status

 

 

 

 

Board certification is not a requirement for a practitioner to be credentialed. However, the organization is required to verify if the practitioner states that he/she is board certified. Acceptable sources include:
● American Board of Medical Specialties (ABMS)
● Equivalent official display agent (e.g., CredSimple, an official display agent of the ABMS)
● state licensing agency, provided the state performed the primary source verification originally with the specialty board

 

Work history

 

 

The work history of a provider needs to be verified with a CV or resume provided to the organization. A minimum of five years of work history should be obtained. Employment dates must include month and year. Any gap greater than six months must be explained verbally or in writing. If the gap exceeds one year, the practitioner must provide a written explanation.

 

Malpractice

 

 

Malpractice history up to five years must be obtained, including residency and fellowship. The National Provider Data Bank (NPDB) is the primary source to query to obtain malpractice history.

 

Sanctions

 

State sanctions, Medicare sanctions, Medicaid sanctions, or restrictions on licensure or limitations in scope of practice need to be checked against primary sources. The NPDB is a recommended primary source that is comprehensive and trusted.

 

Want to know more about primary source verifications? Check out our article, The ABCs of PSVs.

CredSimple Pro Tip

Application design is important. An application that is easy to read and fill out is essential for providers who are busy with patients and other paperwork. Increase goodwill with your providers by giving them an application that is intuitive and does not require them to answer the same questions (such as their name and address) more than once. They will thank you for providing them with a simplified application. Furthermore, there is an increasing demand for web-based applications. These are easier to fill out than paper or PDF applications, and they decrease total turnaround time. For more information about how CredSimple can help you with your credentialing process, contact us.

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