Credentialing Standards   /   May 2018

NCQA Credentialing Standards Part 1: Organizational Requirements

NCQA Credentialing Standards Part 1: Organizational Requirements

One of our goals for our blog is to demystify credentialing so we are creating a series especially for leaders and business process owners who want to gain a deeper understanding of the NCQA standards and credentialing guidelines but don’t have time to wade through 100 pages of regulations. In this series, we’ll break down what you need to know about credentialing, recredentialing and delegated credentialing. In this first installment, we cover organizational requirements, which include your organization’s policies and procedures (CR1). 

Before we dive into the nitty-gritty, it’s worth noting 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 1: Organizational Requirements for NCQA Standards

Policies and Procedures (CR1)

NCQA standards require that all healthcare organizations have a “a well-defined credentialing and recredentialing process for evaluating and selecting licensed independent practitioners to provide care to its members” (CR1). In your credentialing process, you will want to define the following sections:

 ID NCQA DefinitionWhat It Means
1The types of practitioners the organization credentials and recredentials.All licensed independent practitioners (LIPs) are required to be credentialed. This includes physicians who are MDs or DOs and advanced-practice nurses (APNs) who practice independently.

Best Practice: Although NCQA audits the credentialing files of LIPs (including MDs, DOs, and APNs), it is highly recommended to credential all practitioners to the same standards. This ensures maximal quality and safety to patients and protects the organization from additional risk.

2The verification sources the organization uses.NCQA standards require that the authorized primary source (e.g., state medical board, DEA, ABMS) be queried to verify the credentials of a provider during the credentialing process. Here’s a handy guide to primary sources.

 

3The criteria for credentialing and recredentialing.NCQA requires that providers be recredentialed at least once every three years.

Best Practice: Provider organizations should recredential every 24 months. Payers should recredential at least every 36 months.

4The process for making credentialing and recredentialing decisions.Document standards for providers and, importantly, the basis for decision-making so that if a provider is denied from participating in the network, it’s clear why and that it’s not a question of discrimination.

Best Practice: Work with the compliance team to establish baseline criteria. Include specific criteria for licensure, history of disciplinary actions, and malpractice.

5The process for managing credentialing files that meet the organization’s established criteria.Are you required to send all files to the credentialing committee?

Best Practice: For efficiency, set up criteria for what constitutes a “clean file” and designate the medical director or qualified practitioner to approve clean files.

6The process for delegating credentialing or recredentialing.NCQA requires that an organization have proper delegation agreements in place that explicitly dictate the scope of work in the delegated relationship.

Best Practice: To maximize efficiency, consider delegating application processing of primary source verifications (PSVs) to an NCQA-certified CVO.

7The process for ensuring that credentialing and recredentialing are conducted in a non-discriminatory manner.This may seem like common sense these days, but it’s important to document the company’s non-discriminatory policies for network selection.

Best Practice: In addition to the common categories used in non-discrimination policies, such as sex, age, and race, it’s important to state that the plan does not discriminate against providers who have a client base of Medicaid or Medicare patients. All files completed by the CVO are reviewed by the credentialing committee, and providers have the right to be informed of the committee’s decision and, ultimately, to appeal if necessary.

8The process for notifying practitioners if information obtained during the organization’s credentialing process varies substantially from the information they provided to the organization.

 

Document a process to notify providers if the provided information in application forms differs from the primary source. This goal allows practitioners to discover errors and ensures organizations receive truthful attestations from providers.

Best Practice: For efficiency, triage these issues within 30 days of the application submission.

9The process for ensuring that practitioners are notified of the credentialing and recredentialing decision within 60 calendar days of the credentialing committee’s decision.

 

Document a process for notifying the practitioner of the final decision, and have an appeal process for cases in which the organization denies a provider.

Best Practice: Communication has a material impact on provider relations. Notify providers as quickly as possible of both approvals and denials.

10The medical director or other designated physician’s direct responsibility and participation in the credentialing program.

 

NCQA standards require that the organization assign a physician or peer provider to lead the credentialing program.  In addition, the medical director is to call upon a committee of peers with varied professional expertise, enabling the fair and competent evaluation of providers applying for enrollment.
11The process for ensuring the confidentiality of all information obtained in  the credentialing process, except as otherwise provided by law.

 

All provider information is confidential and must be managed securely by a CVO. Only authorized agents such as a CVO may query primary sources on behalf of a health plan and their providers.
12The process for ensuring that listings in practitioner directories and other materials for members are consistent with credentialing data, including education, training, board certification, and specialty.

 

A health plan is required to list the most up-to-date information about the doctors in its network. Provider data must be accurate in order to best serve the members of a health plan.

 

CredSimple Pro Tips for NCQA Standards:

  • Apply a KISS (Keep It Simple, Stupid) mindset to your policies and procedures documents to avoid over-engineering your documentation.
  • Don’t simply copy the language from NCQA guidelines verbatim. You and your team need to think about the standards and how they apply to your unique organization. Copied-and-pasted content in your documents will raise red flags for NCQA surveyors.
  • Use a version-control process to track dates and times so that it is easy for the surveyor to see that your documentation has been in place for the entire lookback period. (A lookback period is six months for an initial survey and 24 months for renewal surveys.)

CredSimple is an NCQA-certified credentialing verification organization (CVO). We scored 100% in all categories surveyed. This post was created by Dr. Garry Choy, Chief Compliance Officer; Mike Simmons, CEO; 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 2016 Health Plan Standards.)

Continue to part 2 in the series: NCQA Organizational Requirements, Credentialing Committee

NCQA Credentialing Standards 2017

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