1. Delegated Credentialing: Do You Know Where to Start?
2017 WAMSS Conference, April 26, 2017
Carrianne Dockter, CPCS, CPMSM
Manager, Delegation Oversight, Molina Healthcare, INC

2. Your Presenter Carrianne Dockter CPCS and CPMSM Certified
17 years Credentialing experience, 13 years in Managed Care
13 years Delegation Oversight
Manager, Delegation Oversight of Molina Healthcare’s Corporate team

3. Delegation: What Is It?
NCQA: Occurs when the organization gives another entity the authority to carry out a function that it would otherwise perform
Medicare Advantage: A business relationship between the organization and a first-tier, downstream and/or related entities to perform certain functions that otherwise would be the responsibility of the organization to perform

4. Delegation: Who Benefits?
Health Plans:
Less Credentialing duplication
Increased Provider satisfaction
Provider Groups:
Quicker Health Plan Enrollment
Faster Reimbursement

5. Delegation: Are You Ready?
Regulatory Requirements:
Managed Care business needs
NCQA vs TJC
Medicare Advantage Requirements
Medicaid Requirements

6. Delegation: Are You Ready?
Panel Size Requirements:
100 or fewer
100 or more

7. Delegation: Are You Ready?
Policy Requirements:
Policies vs Bylaws
Draft vs Approved

8. Delegation: Are You Ready?
File Processing:
Medicare/Medicaid Sanctions
Board Certification
DEA Certificates
Privileges and Peer References

9. Delegation: Are You Ready?
Documentation:
Verifications vs Checklists

10. Delegation: Are You Ready?
Approval Timeframes:
180 days
365 days
120 days

11. Delegation: Are You Ready?
Approving Committees:
Board, MEC, and Credentialing Committee
First Committee/Last Committee

12. Delegation: Are You Ready?
Appeals:
Multi Level
Single Level

13. Delegation: Are You Ready?
Ongoing Monitoring:
License Sanctions
OIG/SAM
State Medicaid exclusion lists
Continuous Query

14. Delegation: Are You Ready?
Site Visits:
Existing requirements, New NCQA Standard: MED 4
TJC and DNV Certifications

15. Delegation: Are You Ready?
Sub Delegation:
Delegation Agreements
Audits and Oversight
NCQA Certifications

16. Questions?