Credentialing Standards   /   July 2018

What You Need to Know about NCQA Credentialing Requirements 4 – 8

What You Need to Know about NCQA Credentialing Requirements 4 – 8

In this series, we break down what you need to know about NCQA’s credentialing requirements. Below we cover NCQA credentialing requirements 4 – 8, which ensure that credentialing committees are reviewing all the necessary information about a provider’s credentials and work history so that the committee can make a well-informed decision.

In prior posts, we covered organizational requirements (CR 1), credentialing committees (CR 2), the establishment of credentialing verification requirements (CR 3) and ongoing monitoring (CR 9).

CR 4 Provider Application and Attestation: A complete provider application must include a current and signed attestation from the provider about why they cannot perform certain tasks, a history of loss of medical license, felony convictions and any limitations of privileges or disciplinary actions, as well as current malpractice coverage. The attestation must have been completed within the last 305 days for a CVO and 365 days for a health plan for it to be considered current.

CredSimple Pro Tip: Make sure your provider application is streamlined and easy for providers to complete. No one likes filling out applications that ask for the same information again and again.

CredSimple’s online application asks the provider to give their name, address and work history only once. If a provider’s information is available in CAQH, their data can be automatically imported without further data entry. Even with the attestation questions, CredSimple’s application takes an average of 20 minutes to complete, compared to the 2+ hours it takes to complete paper applications.

Better yet, because our application is online, it requires no data entry on your part — and triggers the primary verifications function immediately, making it possible to complete an application in 5 days or fewer.

CR 5 Initial Sanction Information: This requires that the credentialing committee receive and review information about each provider from third parties — i.e., the primary sources for sanctions including OIG, FSMB, state licensing boards and NPDB.

CredSimple Pro Tip: Ensure that all the data the review committee needs to make an informed decision is easy to access and understand. CredSimple’s cloud-based platform captures all pertinent primary source verification information, credentialing application data, and any additional attachments such as malpractice facesheets and immunization records. Because all the info is stored in one central location online, the committee review process is streamlined and can be conducted from anywhere.

CR 6 Practitioner Office Site Quality: This requirement is designed to ensure that a provider’s physical office meets the quality requirements of the plan. The plan needs to identify and then implement a monitoring program that sets standards and thresholds for the following:

  • Adequate accessibility — Are the building and office accessible to patients, including disabled patients?
  • Adequate appearance — Is the office clean? Does it have the appropriate lighting and safety features?
  • Adequate space — Does the office have the appropriate number of waiting rooms and exam rooms?
  • Adequate record keeping — Does the office keep patient files secure, confidential and thoroughly maintained?

When the office does not meet the plan’s predefined requirements in these areas, it is the plan’s responsibility to evaluate the office regularly until it does.

CredSimple Pro Tip: Clarity is key. Make sure your standards for office quality are clear and easily accessible by all the providers in your network.

CR 7 & 8 Recredentialing Verification and Recredentialing Cycle Length: These criteria ensure that the organization has the appropriate recredentialing process in place. Every 36 months, a provider needs to be recredentialed, which includes receiving current information from third parties about any disciplinary actions occurring since the last credentialing event.

CredSimple Pro Tip: While NCQA requires recrendentialing every 36 months, to stay compliant, ongoing monitoring is required in the interim. CredSimple’s automated monitoring ensures that credentials and data never become invalid. Our management system provides automatic alerts to sanctions, such as instances of malpractice and expiring licenses. Anytime the system detects an issue, it will appear as an alert on the client dashboard. With CredSimple, you will never be in the dark about your providers’ statuses again.

Now that you’ve tackled the credentialing committee requirements, read about credentialing requirement 9: ongoing monitoring, which is the next step to ensure compliance.

If you have any questions about the NCQA recredentialing requirements or would like to learn more about how CredSimple can help improve both your credentialing turnaround time and the accuracy of your provider data, feel free to contact us. We’re happy to help.

Further NCQA Credential Requirements blog posts:

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