1. Credentialing: 2017 Updates and Frequently Asked Questions
Veronica C. Locke
4/27/2017

2. Overview of credentialing standards, including updates
Distinct differences between CR standards and certification programs (CR and CVO certification)
Discussion

3. NCQA’s Credentialing Standards
Section 1:
NCQA’s Credentialing Standards

4. Total versus Partial Credentialing
Which NCQA programs have credentialing?
Total comprehensive credentialing programs
Accreditation
Health Plan (HP) Accreditation
Managed Behavioral Health Organizations (MBHO) Accreditation
Certification
Credentialing (CR) Certification
Credentialing Verification Organizations (CVO) Certification
Partial Credentialing Programs
Accreditation/Certification
Disease Management (DM) Accreditation/Certification
Case Management (CM) Accreditation
CM-Long Term Services and Support (LTSS) Distinction

5. Breakdown of Credentialing Programs
Similarities and differences… HP
MBHO
UM-CR
CVO DM CM
Credentials Verification Y  Y
Ongoing Monitoring
Credentialing Policies
Somewhat
CR Delegation, including Agreement/Collaboration with Clients
Internal Quality Improvement Process
Credentialing Committee
Recredentialing Cycle Length
Practitioner Office Site Quality
Notification to Authorities and Practitioner Appeal Rights
Protecting Credentialing Information
Assessment of Organizational Providers
Somewhat 

6. Credentialing Standards
Fundamentals

7. Just as a reminder… Terminology Practitioner = person
Provider = facility

8. So, why is credentialing really important?

9. Common Denominator:
The organization has a rigorous evaluation process that allows it to make knowledgeable decisions about potential practitioners in the network

10. Practitioner Credentialing Guidelines
Written policies and procedures include:
Types of practitioners credentialed/ recredentialed
Verification sources used
CR criteria
Making CR decisions
CR file management process that meets the organization’s criteria
CR delegation
Ensure that the CR process does not discriminate
Notify practitioners of variances in information
Ensure that practitioners are notified of the CR decision within 60 calendar days
Medical director or designated physician’s role
Ensure confidentiality of information
Directories and other materials are consistent with collected CR data

11. Scope of Credentialing
Evaluating policies and real files
The scope of file review is more prescriptive and specified in the Standards and Guidelines.
Practice independently
Independent relationship
Service within the medical benefit
NCQA evaluates both policies and credentialing files

12. Independent Relationships
NCQA’s credentialing “Golden Phrase”
Directing a member to a specific practitioner (not provider) or practitioner group
Not directing a member to a provider or facility (i.e., hospital)

13. “within the scope of credentialing”
Do you have real-life examples of practitioners who are
“within the scope of credentialing”

14. Who is “within the scope of credentialing”?
Practitioner Type
Scope of credentialing?
Primary care physicians
Pathologists
Independently practicing NPs
Podiatrists
Radiologists
Anesthesiologists
Mammography center physicians
PhD Psychologists
ER physicians
Yes No
Yes
Yes
Depends
Depends No
Yes No

15. Practitioner Rights
Written policies and procedures include:
Practitioner’s right to review information submitted to support the CR application
Practitioner’s right to correct erroneous information
Practitioner’s right to be informed of status of application, upon request

16. Credentialing Committee
The credentialing committee:
Includes participating practitioners
Reviews practitioners who do not meet established thresholds
Does not need to review clean files
Final review committee by NCQA’s standards

17. Credentialing Committee
Things to remember:
NCQA does not specify committee size or number of participating specialties
Regional or national committees are acceptable
Must have representation from practitioners within scope of credentialing
Credentialing policies must specify who reviews “clean” files

18. Credentialing Decisions
Two methods:
One-step process:
All files go to credentialing committee
Two-step process:
Clean files go to medical director (or other qualified physician) for review and approval
Files that do not meet established criteria go through the credentialing committee for review

19. Credentialing Decisions
Determining the credentialing date for practitioners is based on committee decision date.
For clean files: Medical director approval date
For files that go to committee: Date of committee meeting when decision was made
NCQA does not prescribe the decision that the organization makes, only that it:
Collects and verifies information, and
Makes a decision within a specified period
Determining credentialing date for practitioners is based on committee decision date
NCQA does not prescribe the decision that the organization makes

20. Credentialing Verification/ Recredentialing Cycle Length
What is evaluated?
Determining the credentialing date for practitioners is based on committee decision date.
For clean files: Medical director approval date
For files that go to committee: Date of committee meeting when decision was made
NCQA does not prescribe the decision that the organization makes, only that it:
Collects and verifies information, and
Makes a decision within a specified period
Verification sources
Timeliness of verification
Decision process
Timing of recredentialing,
if applicable

21. Primary source verification
What is appropriate?
PSV:
Process for verifying credentialing information comes directly from the entity that originally issues the practitioners’ credentials.
Example: State licensing board that issues practitioners’ licenses.
NCQA also allows verification from accepted sources that are specified in the credentialing standards.
Directly from issuing entity
NCQA-approved source
Specified source in organization’s credentialing policies

22. What needs to be verified?
Credentials requiring verification
Licensure
DEA/CDS certificates
Education/training
Board certification, if applicable
Work history
Malpractice history

23. Obtaining information
How to get the information
Oral
Written
Internet
Websites
Cumulative reports
Automated systems
Agents of approved sources
Issues credentials on behalf of primary source with written acknowledgement/confirmation that entity is able to distribute

24. Information Verification Source
Current, valid license (for all states where practitioner is providing care for the organization)
State licensing agency
DEA/CDS (for all states where practitioner is providing care for the organization)
Copy of certificate
Visual inspection of certificate
DEA/CDS Agency confirmation
NTIS database entry
AMA Masterfile
State pharmaceutical licensing agency
Work history
Application
Curriculum vita
Malpractice claims history
NPDB query or initial report from NCQA-recognized disclosure service
Five years claims history from malpractice carrier

25. Information
Verification Source
Education/training (MD/DO) as board certification as highest level
ABMS entry
AMA Masterfile
AOA Profile Report or Physician Masterfile
Confirmation from specialty board
Confirmation from state licensing agency (proof of PSV needed)
Education/training (MD/DO) as residency as highest level
Confirmation from residency program
Education/training (MD/DO) as education as highest level
Confirmation from medical school
ECFMG (intl graduates after 1986)
Education/training (non-MD/DO) as education as highest level
Confirmation from professional school
Confirmation from specialty board or registry (proof of PSV needed)

26. Obtaining information (cont.)
Time frames
The organization verifies the license on 7/1/2014.
The file is presented to the committee on 1/2/2015.
NCQA counts backward from 1/2/ (the Credentialing Committee decision date) to determine if the limit is met.
Licensure: Up to 180 calendar days
Malpractice history: Up to 180 calendar days
Work history: 365 calendar days
Education/training: No limit
Board certification: Up to 180 calendar days
DEA: No limit

27. Do you have real-life examples of meeting timeliness requirements?

28. Example of timeliness Licensure: 180 calendar days
Organization verifies a practitioner’s license in the state of which she provides medical care: 7/1/2015
Practitioner’s file is presented to the organization’s Credentialing Committee: 1/2/2016
NCQA counts backward from 1/2/2016 (the CC date) to determine if timeliness requirement was met
Did the organization meet NCQA’s timeliness requirements?
The timeliness requirement is NOT MET because the information is 185 calendar days old

29. Sanction information Appropriate sources
The organization verifies the license on 7/1/2014.
The file is presented to the committee on 1/2/2015.
NCQA counts backward from 1/2/ (the Credentialing Committee decision date) to determine if the limit is met.
State sanctions, restrictions on license or limitations
Medicare/Medicaid sanctions
Acceptable sources:
State agencies, NPDB, FSMB (licensure)
FEHBP, OIG, FSMB, NPDB, Medicare/Medicaid sanctions report (Medicare/Medicaid)

30. Credentialing Application
Required attestation questions
NCQA does not prescribe the answer on the application, just that the organization has the practitioner attest to the questions
Reasons for inability to perform
Lack of present illegal drug use
History of loss of privileges or any disciplinary actions
History of loss of licensure and felony convictions
Current malpractice coverage
Attestation that everything is correct and complete

31. Recredentialing Cycle Length
How long is enough?
Within 36-month time frame
Count to the month, not day

32. Recredentialing Cycle Length
Termination and reinstatement
Administrative terminations do not “stop the clock” on timeliness
Organization is unable to recredential a practitioner within 36 months of initial credentialing
Receipt of credentialing information within 30 calendar days (before 37th month)
Avoids initial credentialing (reverifying all credentials in CR 3)
Scores down on timeliness requirement
Receipt of credentialing after 30 calendar days (after 37th month)
Needs to initial credential practitioner

33. CR 4: Recredentialing Cycle Length
Extending the recredentialing cycle length
Active military assignment
Maternity (or medical) leave
Sabbatical
The organization documents the reason for the extension and recredentials practitioners within 60 calendar days of return.

34. Ongoing Monitoring/Interventions
The organization collects and reviews:
Sanction alert services acceptable
Medicare/Medicaid sanctions
Limitations/sanctions on licensure
Member complaints
Adverse events
Interventions for instances of poor quality
Demonstration of a systematic monitoring process for evaluating quality, safety issues between credentialing cycles

35. Actions against Practitioners
The organization has a process for:
Range of actions available
Reporting to authorities
Appeal process
Has the organization made the process known to practitioners?
Is this process communicated in writing for the practitioners, including specific reasons for the decision?

36. Organizational Provider Assessment
For HPs and MBHOs only
Organizations policies specify that before it contracts with a provider and every three years thereafter, it:
Confirms provider is in good standing with state and federal regulatory bodies, and
Confirms that the provider has been reviewed and approved by an accredited body, or
Conducts an onsite assessment if the provider in not accredited

37. Organizational Provider Assessment (cont.)
For HPs and MBHOs only
NCQA does not prescribe accrediting bodies to use
Organizations outline the accrediting bodies it uses
Examples of accrediting bodies:
The Joint Commission (TJC)
Commission on Accreditation of Rehabilitation Facilities (CARF)
Accreditation Association for Ambulatory Health Care (AAAHC)

38. Organizational Provider Assessment (cont.)
For HPs and MBHOs only
Medical
Behavioral health
Hospitals
Home health agencies
Skilled nursing facilities
Freestanding surgical centers
Inpatient
Residential
Ambulatory

39. In summary…
Ensure that CR policies are complete and an effective credentialing committee is in place.
Confirm that CR criteria and verification sources meet NCQA requirements.
Ensure timely verification and decision-making.
Implement a process for ongoing monitoring.
Institute a well-defined practitioner appeal process.

40. Authority ≠ Responsibility
Delegation
What is delegation?
An organization (client) gives authority to another organization (delegate) to perform an activity that the client would otherwise perform to meet NCQA’s requirements
Client organization retains responsibility (accountability)
Authority ≠ Responsibility

41. Delegation (cont.) Two Aspects Delegation
Giving another entity authority to perform activities
Delegation Oversight
Making sure entity performs to organization’s and NCQA’s standards

42. Delegation What is delegation? Delegation Oversight requirements
Written delegation agreement
Provisions for PHI
Pre-delegation evaluation
Annual review of policies and procedures, including file audit, as appropriate
Semiannual reporting
Opportunities for improvement

43. Delegate organization
Subdelegation
Example
I love this slide. Can we make font bigger. Also, maybe animate? you can make this a build with the arrows and boxes. happy to help if you want
I will add animation.
Client organization
Health plan delegates credentialing of behavioral healthcare practitioners
Delegate organization
MBHO delegates verifications
Subdelegate
CVO performs verifications

44. Differences and similarities of credentialing standards
Section 2:
Differences and similarities of credentialing standards

46. Similarities between CR and CVO
Four similarities
Quality improvement process
Privacy requirements
Written credentialing policies
Delegation cooperation
Quality improvement process
Privacy requirements
Written credentialing policies
Delegation cooperation (and evidence)

47. Differences between CR and CVO
Two distinct differences
Time frames
Credentialing Committee