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Shared Credentialing Audit Training Tool – 2019

NW Shared CredentialingAudit Training Tool

2019 Standards

This tool has been broken into the sections of the Credentialing and Recredentialing Shared Audit Tool. Each section describes in detail how to complete the 2019 Shared Credentialing Audit Tool. For comprehensive interpretation of the standards, refer to the 2019 NCQA Standards, URAC Health Plan Standards version 7.1, Medicare Managed Care Manual (CMS), and Washington State Medicaid (DSHS) Requirements.

2019_SA_Training Tool_01-01-2019 1


Audit Summary Report

Health Plan Audit DemographicsName of Plan

Auditor: Name of Plan

Performing Audit:

Auditor E-mail: Auditor Phone #: NCQA Accreditation

Expiration Date

Provider Organization (PO) Audit DemographicsPO Name: Audit Address:

PO’s Sub-delegate: City/State/Zip: PO’s Contact:

Contact Phone #: Contact E-mail: Audit Date:

NCQA Certification

Type:

Credentialing Certification (CR)

Other: ______________

Certified Entity PO MSO

Expiration Date:

File Selection Methodology:

5%/50, minimum 10/10 Comments:

8/30 (If par with a URAC Health Plan add 2 files when 8/8)# Cred in last 12 months

# Recred in last 12 months

Time frame of file selection (mm/yy –

mm/yy):

Audit via Onsite or Desktop

Secondary or additional PO names:

Auditor GuidelinesNAME OF PLAN AUDITOR Name of person performing audit

NAME OF PLAN PERFORMING AUDIT Health Plan performing audit

AUDITOR E-MAIL E-mail of Health Plan auditor who conducted the audit

AUDITOR PHONE # Phone number of Health Plan auditor who conducted the audit

NCQA ACCREDITATION EXPIRATION DATE

NCQA accreditation expiration date



PO NAME Name of PO being audited, not Sub-delegate

PO’S AUDIT ADDRESS The location where the audit took place/POs address

PO’S DELEGATE Input one of the following Sub-delegate Name Same as PO, or N/A

PO’S CONTACT PO’s credentialing contact

CONTACT PHONE PO’s credentialing contact’s phone number

CONTACT E-MAIL ADDRESS PO’s credentialing contact’s e-mail address

MEDICAL DIRECTOR PO’s Medical Director’s Name

MEDICAL DIRECTOR E-MAIL ADDRESS PO’s Medical Director’s e-mail address

AUDIT DATE Date audit performed

NCQA CERTIFICATION TYPE Specify Certification or Accreditation type and specify if the PO or if the Sub-delegate is certified

EXPIRATION DATE

PO Certification Expiration Date

FILE SELECTION METHODOLOGY

5%/50, minimum 10/10 or 8/30 (If par with a URAC Health Plan add 2 files when 8/8)

COMMENT SECTION Input the detail of the file review (e.g., if the PO does not have 30 files to pull, etc.) If the PO sub-delegates, denote the name of the sub-delegate(s) in the Comment Section.

If a Sub-delegate is owned by a PO or vice versa, this is not delegation and must be documented in the comments.

TIME FRAME OF FILE SELECTION 1 year (mm/yy – mm/yy)

SECONDARY OR ADDITIONAL PO NAMES

Add additional PO names/sites for clarity (if POs share the same Credentialing Committee).

If there are separate Committee’s, post separate results. When entering into the document more than one secondary name,list one PO per line with a return in between each name. Example: ABC XYZ Group

If the groups share the same committee, but have different organizational providers or different delegation agreements, a separate audit must be posted.

ICE Audit Process for Organizations Certified or Accredited by NCQA



Audits will be conducted utilizing either the 5% or 50, no less than 10/10 file methodology or the 8/30 (If par with a URAC Health Plan add 2 files if 8/8) methodology. Auditors will request a spreadsheet of all providers and will select files reviewed during the annual audit cycle. Under the 8/30 rule, eight initials (10 if URAC) and eight recreds (10 if URAC) will be reviewed with nothing further reviewed if all providers were compliant.

For POs with Medicare; auditors will need to review timeliness for DEAs, work history and Organizational Providers (OPs). Auditors will request a spreadsheet of all Organizational providers and will select files reviewed during the annual audit cycle.

This audit can be conducted on-site or as a desk-top audit. Score Standards 7 and 8 as applicable, NA if no OP Contracts or Delegation. Auditors must review CR 1 and CR 6 for all Certified or Accredited PO’s

The following elements are not part of the NCQA Certification/Accreditation review or are not eligible for automatic credit and must be reviewed as part of the delegation oversight process.

PO submits copies of the following policies and procedures and other non-file elements. (CR 1.A.1-10 11) Practitioner Credentialing Guidelines

- Review Policy and Procedures for Factors 1-10 (CR 1.B. 1-3) Practitioner Rights

- Review Policy and Procedures for Factors 1-3 (CR 1.C) Performance Monitoring for Recredentialing (CMS)

The policy must indicate that the PO’s recredentialing policy and procedure, requires review of information from quality improvement activities and member complaints in the recredentialing decision making process for all practitioners.

(CR 1.D) Contracts - Opt-Out Provisions (Medicare Opt-Out Policy)(CMS/TRICARE)- The policy must indicate that the PO does not employ or contract with practitioners who have opted

out of participation in the Medicare program. (CR 1.E) Medicare Exclusion/Sanction Policy (CMS/TRICARE)

- The policy must indicate that the PO does not employ or contract with practitioners who have been excluded or sanctioned from participating in Medicare and includes the verification source used to conduct Medicare sanction verifications.

(CR 5.B) Monitoring Medicare Opt-Out Reports (CMS)- Review the first sheet of the report which includes the staff signature and date for each report

during the auditing period (1yr)

(CR 6.A.1-4) Actions Against Practitioners- Review Policy and procedures for Factors 1-4.

(CR 6.B) Fair Hearing Panel Composition (CMS)- The policy must indicate that the majority of the hearing panel members are peers of the affected

practitioner.

(CR 7.A-E) Assessment of Organizational Providers - Auditor must review all elements for CR 8. Auto credit cannot be given as it is no longer reviewed

under the scope of certification).

(CR 7.B) Medical Providers for Medicare (CMS)- The PO’s policy and procedures must address the 10 additional Medicare Providers and Suppliers



(CR 7D) Assessment of Medical Providers (CMS) - Review OP Tracking Log/Spreadsheet or Files reviewed/approved during the audit period.

(CR 9.A (CR 8A.1- 6) Delegation Agreement

- Review agreement(s) between PO and Sub-delegate for all applicable factors

(CR 8.A) Written Delegation Agreement (CMS) - The PO’s delegation agreement must include a statement requiring the delegate to adhere to

Medicare Advantage/CMS requirements.

(CR 8D.1- 4) Review of Delegate’s Credentialing Activities, as applicable- Review evidence that the POs review included an annual review of the sub-delegates policy

and procedures- Review evidence that the POs review included an annual file review of the sub-delegate- Review evidence that the POs review of an evaluation of the sub-delegates performance

against NCQA standards for delegated activities.- Review evidence that the POs received and evaluated regular reports at least semi-

annually. (CR 8.E) Opportunities

- Review evidence that the PO followed up on any corrective actions.

PO submits the following file information:File Review Review the following information for the 10 initial and 10 recredential files selected by the Health Plan. Additional files will be requested if there is a deficiency or additional elements are required for the review.

Initial Credentialing – Review the checklist and the following documentation for each initial file: 1. (CR C3.A.2) A valid DEA certificate – Verification conducted within 180 calendar days of Credentialing

Committee decision (CMS) Scored in the bottom box2. (CR C3.A.5) Work History - Verification conducted within 180 calendar days of Credentialing Committee

decision.3. (CR C3.B.3) Medicare/Medicaid sanctions (CMS/TRICARE)

- Review OIG verification. Date of query and staff initials must be evident on checklist or report must be in file. Score in middle box

4. (CR C3.C.1-6) Application and Attestation (CMS) - Verification of questions completed and attestation signed within 180 calendar days of Credentialing Committee decisions

5. (CR C3.D) Hospital admitting privileges (CMS), if applicable, otherwise send documentation of coverage (primary source is not required)

6. (CR C3.E) Medicare Opt-Out review (CMS/TRICARE)- Review evidence via checklist or other documentation that indicates review of information from the most

recent Report or one of the CMS.gov Opt-Out sites.

Recredentialing – Send the checklist and the following documentation for each recredentialing file:1. (CR R3.A.2) A valid DEA Certificate – Verification of DEA conducted within 180 calendar days of

Credentialing Committee decisions (CMS) Scored in the bottom box2. (CR R3.B.3) Medicare/Medicaid sanctions (CMS/TRICARE)2019_SA_Training Tool_01-01-2019 5


- Review OIG verification. Date of query and staff initials must be evident on checklist or report must be in file. (CMS) Scored in the bottom box

3. (CR R3.C.1-6) Application and Attestation (CMS) - Verification of questions completed and attestation signed within 180 calendar days of Credentialing Committee decisions (CMS) Scored in the bottom box

4. (CR R3.D) Hospital admitting privileges (CMS), if applicable, otherwise send documentation of coverage (primary source is not required)

5. (CR R3.E ) Medicare Opt-Out review (CMS/TRICARE)- Review evidence via checklist or other documentation that indicates review of information from the

most recent Opt-Out Physician Report.

6. (CR R3.F) Review of Performance Information – Must include QI Activities and Grievance/ Complaints (CMS/URAC)- Review evidence of documentation – Check List, Reports, Form/sheet detailing the PO’s findings.

Auditors must review CR 1 for all Certified or Accredited Entities

CR 1: Credentialing Policies

Element A: Practitioner Credentialing Guidelines

The organization Specifies:

1. The types of practitioners it credentials and recredentials

2. The verification sources it uses The policy must describe the sources used to verify credentialing information of each of the

following criterion:- State License to Practice- DEA Registration- Education and Training - Board Certification- Work History- Malpractice Claims History- Current Malpractice Insurance Coverage- Hospital Admitting Privileges- State Sanctions and Restrictions on Licensure and Limitation on Scope of Practice.- Medicare/Medicaid Sanctions If one verification source is missing, then this factor is non-compliant. Pencils are not an acceptable writing instrument for credentialing documentation.

3. The criteria for credentialing and recredentialing Policies must define the criteria required to reach a credentialing decision and must be designed

to assess the practitioner’s ability to deliver care. Examples of criteria:

- A current and valid, unencumbered license to practice medicine in his/her state of practice



- Appropriate malpractice claims history- Must not have engaged in any unprofessional conduct or unacceptable business practices- Absence of sanctions or restrictions on licensure- Current and valid DEA to practice in CA- Absence of use of illegal drugs- Absence of criminal history

4. The process for making credentialing and recredentialing decisions Policies must define the process used and the criteria required to reach credentialing decisions

that are designed to assess the practitioner’s ability to deliver care. At a minimum, the Credentialing Committee must receive and review the credentials of

practitioners who do not meet the PO’s established criteria Policy must identify what is considered acceptable to be determined as a clean file, if the PO

utilized a clean file process.

5. The process for managing credentialing files that meet the organization's established criteria The PO’s policies and procedures must describe the process used to determine and approve

clean files. They must identify the Medical Director or equally qualified practitioner as the individual with the authority to determine that a file is “clean” and to sign off on it as complete, clean and approved. If the PO identifies an equally qualified practitioner to review the clean files, the practitioner must be responsible for oversight of the credentialing process.

- If the Medical Director or equally qualified practitioner signs off on clean files, the sign-off date is the Committee date.

- If the PO decides not to use the Medical Director or equally qualified practitioner, the PO can continue to send “clean files” to the Credentials Committee.

6. The process for requiring that credentialing and recredentialing are conducted in a nondiscriminatory manner Policies must explicitly state that credentialing and recredentialing decisions are not based solely

on an applicant’s race, ethnic/national identity, gender, age, sexual orientation or patient in which the practitioner specializes and describe the steps for monitoring and preventing discriminatory practices during the credentialing/recredentialing processes.

The PO’s procedures for monitoring and preventing discriminatory credentialing decisions may include, but are not limited to: periodic audits of practitioner complaints to determine if there are complaints alleging discrimination; maintaining a heterogeneous Credentialing Committee membership and requiring those responsible for credentialing decisions to sign an affirmative statement to make decisions in a non-discriminatory manner.

Monitoring involves tracking and identifying discrimination in credentialing and recredentialing processes. Policy must indicate that monitoring must be conducted at least annually.

Examples for monitoring for discriminatory practices:- Having a process for performing periodic audits of credentialing files (in-process, denied

and approved files)- Having a process for performing annual audits of practitioner complaints about possible

discrimination. (Can be reviewed and discussed during quarterly or semi-annual review of complaints)

Preventing involves taking proactive steps to protect against discrimination occurring in the 2019_SA_Training Tool_01-01-2019 7


credentialing and recredentialing processes.

Examples for preventing discriminatory practices:- Maintaining a heterogeneous credentialing committee and requiring those responsible

for credentialing decisions to sign a statement affirming that they do not discriminate.- Timeframe for prevention: None. Only review policy, committee members can attest

annually or at each meeting. The above information is intended to provide examples of how to ensure the nondiscriminatory

credentialing process. The auditor will be looking for a description in the credentialing policies and procedures of how the PO ensures credentialing and recredentialing are conducted in a nondiscriminatory manner. An auditor is not required to look for evidence of implementation of this process.

7 The process for notifying practitioners if information obtained during the organization's credentialing process varies substantially from the information they provided to the organization Policies must describe the process for notifying practitioners. A statement that practitioners are

notified of discrepancies does not meet the requirement.

8 The process for requiring that practitioners are notified of the credentialing and recredentialing decision within 60 calendar days of the Committee's decision The PO is not required to notify practitioners regarding recredentialing approvals, but must have

a process for notifying practitioners of initial credentialing decisions (approvals/denials) and recredentialing denials.

9. The Medical Director or other designated physician's direct responsibility and participation in the credentialing program

10. The process for securing the confidentiality of all information obtained in the credentialing process, except as otherwise provided by law The PO’s credentialing policies and procedures must clearly state the information obtained in

the credentialing process is confidential. The organization must also describe the mechanisms in effect to ensure confidentiality of

information collected.11. This number is reserved to maintain consistency with NCQA standards. Do not measure.

Note: Policies & procedures pending approval from the Credentialing Committee at the time of the audit will be scored non-compliant for those elements that are not current at the time of the audit. Note in comments.



Element B: Practitioner RightsThe organization notifies practitioners about their right to: The PO policies and procedures must state how the following 3 factors are met and how the

practitioners are notified: (e.g. application, contract, Website, letter):

1. Review information submitted to support their credentialing application Policies should allow for review of information obtained from outside sources (e.g. state licensing

agency, malpractice carrier) with the exception of references or other peer review protected information.

2. Correct erroneous information (submitted by another source) Policy must clearly state:

- The time frame for changes- The format for submitting corrections- Where corrections must be submitted-

3. Receive the status of their credentialing or recredentialing application, upon request Must describe the process for responding to such request including information that the PO may

share with the practitioners.

Element C: Performance Monitoring for Recredentialing – CMS/URAC

The organization’s recredentialing policies and procedures require information from quality improvement activities and member complaints in the recredentialing decision making process. (Source: Medicare Managed Care Manual, Chapter 6 § 60.3; URAC)

Not applicable if the PO does not hold Medicare and/or URAC Contracts

Element D: Contracts – Opt-Out Provisions – CMS/TRICARE

The Medicare Advantage organization has policies and procedures to ensure that it only contracts with physicians who have not opted out. (Source: Medicare Managed Care Manual: Chapter 6 § 60.2)

The policy must indicate that the PO does not employ or contract with practitioners who have opted out of participation in the Medicare program and includes the verification source used to conduct the Medicare Opt-Out verification.

Not applicable if the PO does not hold a Medicare Contract Opt-out practitioners may provide care to commercial members only

Element E: Medicare – Exclusion/Sanctions – CMS/TRICARE

The Medicare Advantage organization must have policies and procedures that prohibit employment or contracting with practitioners (or entities that employ or contract with such practitioners) that are excluded/sanctioned from participation (practitioners or entities found on OIG Report) (Source: Medicare Managed Care Manual, Chapter 6 § 60.2)

Not applicable if the PO does not hold a Medicare Contract



Element F: Notification of Credentialing Committee’s Decision – WA Medicaid

The WA Medicaid organization must have policies and procedures that outline process for notifying providers within fifteen (15) calendar days of the credentialing committee’s decision. (Source: Medicaid Contract Effective 1-1-2017)

CR 2: Credentialing Committee

Best Practices (not scored)Ad hoc Credentialing Committee meeting minutes must be documented at the time of the ad hoc meeting, and must be presented at the next formal meeting.

Minutes should be signed by the Committee Chair and dated within one month or by the date of the next meeting. If minutes are not signed and/or dated, auditor to educate and include in comment section (Do not score down).

Meetings should include a quorum of practitioners for each meeting, as established in the PO’s policy. If a quorum was not met, educate. (Do not score down)

Element A: Credentialing CommitteeThe organization’s Credentialing Committee:1. Uses participating practitioners to provide advice and expertise for credentialing decisions.

The PO must have policy and procedures as well as evidence to be compliant. Review the PO’s documented process and the committee minutes for evidence.Policies: The policy states that Credentialing committee is comprised of a range of participating

practitioners. If a PO’s Credentialing Committee is comprised of PCPs only, the PO must have the following in

order to be compliant:– Policies state that specialists are consulted, when necessary and appropriate.

Evidence: Representation includes a range of participating practitioners in the PO’s network. There is evidence through their Committee minutes that a specialist was consulted, when

applicable.- There is a listing that indicates what specialists are used, if appropriate.

2. Reviews credentials for practitioners who do not meet established thresholds. The PO must have policy and procedures as well as evidence to be compliant. Review the PO’s documented process and the committee minutes for evidence.

Policies: The credentialing committee must receive and review the credentials of practitioners who do not

meet the PO’s established criteria. The credentialing committee must give thoughtful consideration of the credentialing information.

Evidence: There is evidence that the Credentialing Committee reviewed credentials for practitioners who do

not meet established thresholds



The committee’s discussion must be documented within its meeting minutes. Credentialing Committee meetings and decision making may take place in the form of a real-time

virtual meetings (e.g. through video conferencing or WebEx conferences with audio). All meetings, including ad hoc, may not be conducted only through email.

3. Ensures that files that meet established criteria, are reviewed and approved by a medical director or designated physician The PO must have policy and procedures as well as evidence to be compliant. Review the PO’s documented process and the committee minutes or files for evidence. Score compliant if PO presents all files, including clean files to the CR committee.

Policies: The policy states that the Credentialing Committee ensures the files that meet established criteria

are reviewed and approved by a Medical Director or designated physician.

Evidence: The PO may choose to continue to submit all practitioner files to the Credentialing Committee for

review, or it may implement a process for the Medical Director to review clean files, as described in the credentialing policies and procedures.

If the Medical Director or designated physician reviews the clean files, there must be evidence of the designated Medical Director’s or designated physician’s review and approval in the practitioners file or on a list of all practitioners who meet the established criteria.

Auditor to review the PO's policy and reports. Reports may include Credentialing Committee meeting minutes or files or a list of approved practitioners signed or initialed by the medical director, for evidence that the requirement is met.

CR 3: Initial Credentialing Verification

General Updates: POs Combining Credentialing Committees within the annual audit period:

- If a PO merges their credentialing committee with another at any time during the annual audit period, a separate file pull and audit must be conducted for the PO. The PO will be audited for the combined committee and will have one audit at the next annual audit.

POs Purchased by another PO: If a PO purchases another PO and obtains the credential files, they can continue with the current recredentialing process.

Random File Pull:

File Pull: Obtain a full spreadsheet of all credentialed practitioners (including terminated practitioners) who have been part of the PO’s network any time during the look-back period to make the file selection. Select file pull of either10 initial and 10 recredential files for the specified audit time period, using the NCQA 5% or 50, no less than 10/10 or if using the NCQA 8/30 file methodology and the PO is contracted with a group that follows URAC, 2 additional initial and recredentialing files must be selected when files meet 8/8 compliance for a minimum of 10/10. The only exception is if the practitioner was terminated for non-compliance with recredentialing standards (Non-responder). At a minimum, rosters must include the following: Name, Degree, Role (PCP/SPEC), Specialty, Status (Cred/Recred) and Current Cred Date. Board Cert status optional.



– File selection must include files from a period of 12 months. The file pull for credentialing and recredentialing files should include a range of practitioners with various types of degrees and specialties, including nurse practitioners and behavioral health practitioners.

– Do not include hospital based practitioners (Anesthesiology, Radiology, Telemedicine, Pathology, etc.)

– If the PO does not have any recredentialing files for the audit period, the auditor needs to look at the entire history to establish if recredentialing is being done to ensure compliance.

– Do not include provisionally credentialed files.

– (TRICARE ONLY) Certified Nurse Midwives (CNMs) may be included in the file pull.

Provisional Credentialing: Auditor will not review any files that have been provisionally credentialed. PO must complete a full credentialing review within 60 calendar days after being provisionally credentialed. If file is not approved after 60 calendar days and it is not taken to committee, this will be scored non-compliant for all elements. If provisional file is less than 60 calendar days, review next file.

Practitioner Termination: If a PO terminates a practitioner and later wishes to reinstate, the PO must initially credential the practitioner if there is a break in service for more than 30 days.

Using the Internet for PSV: When auditing the primary source verification on documents that are printed/processed from an internet site (e.g. NPDB), the data source date (as of date, release date) must be queried within the timeframe. The date of the query must be verified prior to the Credentialing Committee decision. If there is no data source date, the verifier must document the review date on the verification or the checklist.

PSV Documentation Methodology: Per the ICE Policy Committee, auditors cannot accept a checklist for primary source verification of the elements with the exception of a NCQA certified CVO. Timeliness of elements must be verified for NCQA certified CVOs.

- Automated credentialing system. The organization may use an electronic signature or unique electronic identifier of staff to document verifications (to replace the dating and initialing of each verification) if it can demonstrate that the electronic signature or unique identifier can only be entered by the signatory. The system must identify the individual verifying the information and the date of verification.

- The organization may use a single signature and date if the signature and date apply to all verifications. The primary source documents must still be provided.

NCQA Certified CVO Audit Disclosures: When a Health Plan audits a PO who utilizes a NCQA certified CVO and it is noted that an inappropriate PSV methodology was utilized, the Health Plan gives the PO a warning regarding the discrepancy and will score the audit on timeliness only. For example, when completing the shared audit tool, the PO will receive a “100%”; however, the auditor will mark in the “Comment” section a statement regarding the inappropriate verification. Each Health Plan may take action if they deem necessary.

File Review Results Grid: The results will auto populate from the Initial and Recred file tabs. For any non-compliant element or if denominator is less than 30, explain why in the section below the table.

Initial Credentialing: Initial credentialing is only for those practitioners who are initiating a contract with the PO. A recredentialing file that was placed into the initial credentialing file pull due to being out of recredentialing timeframe limit should not be included in the initial credentialing files. It must be included in the universe of recredentialing files. If this is the case, review the next file using the 8/30 NCQA file methodology.



Recredentialing Verification

General Updates: Late Recredentialing: Per NCQA, a practitioner cannot be initially credentialed if their

recredentialing is past due. The exception is: if a practitioner is on active military assignment, maternity/medical leave or sabbatical.

Recredentialing: PO must formally recredentialing its practitioners within 36 months through information verified from primary sources:

- A practitioner cannot be initially credentialed if their recredentialing cycle is past due. If an initial file is actually a recredentialing file, return the file into the first 8 of the recredentialing file pull and review an additional 22 recredentialing files or until file pull is exhausted. The file will be deficient for the recredentialing cycle length.

- Exception: If a practitioner is on active military assignment, maternity/medical leave or sabbatical, recredentialing must be completed within 60 calendar days of when practice is resumed.



Element A: Credentialing VerificationThe organization verifies that the following are within the prescribed time limits:

1. A current and valid license to practice.

Verification Time Limit: 180 calendar days

For web queries, use the data source date – e.g., release date or as of date

2. A valid DEA or CDS certificate, if applicable NCQA - Verification Time Limit: None. The certificate must be effective at the time of credentialing decisionCMS - Verification Time Limit: 180 calendar days. The following requirements are applicable for both NCQA and CMS. The PO may credential a practitioner whose DEA certificate is pending or pending a DEA with a

Washington, Oregon, or Alaska address, as applicable, if the PO has a documented process for allowing a practitioner with a valid DEA certificate to write all prescriptions requiring a DEA number for the prescribing practitioner until the practitioner has a valid DEA certificate.

If a practitioner does not have a DEA or CDS certificate, the PO must have a documented process to require an explanation why the practitioner does not prescribe medications and to provide arrangements for the practitioner's patients who need prescriptions requiring DEA certification. Both requirements must be met to meet compliance otherwise score down.

If unable to get a copy of the DEA, PO can confirm with DEA Registration Validation Website

- https://www.deadiversion.usdoj.gov/webforms/validateLogin.jsp

The document must be date stamped and initialed or the checklist must be initialed and dated.

Auditor must note in comments time limit or evidence deficiency.

Auditor must note in comments if 180 calendar days is met or not for CMS contracted groups.

3. Education and training, as specified in the explanationNCQA - Verification Time Limit – Education/training: Prior to the credentialing decision.CMS - Verification Time Limit: 180 calendar days. If a PO uses an AMA report, the report must state that the education/training has been “verified”.

“Being verified” or “being re-verified” is non-compliant. If a practitioner submits transcripts to the PO in the institution’s sealed envelope with an

unbroken institution seal, this is acceptable as PSV from graduation of medical or professional school education and training if the PO provides evidence that it inspected the contents of the envelope and confirmed that the transcript shows that the practitioner completed (graduated from) the appropriate training program.

If a practitioner is not board certified in the sub-specialty in which he/she is applying, there must be evidence of verification of residency and training in the sub-specialty (e.g., Fellowship in Cardiology, Rheumatology, Pediatric Endocrinology etc.), as relevant to the credentialed specialty.

If practitioner is Board Certified, Education and Training is scored 1. If Residency is verified and practitioner is not Board Certified, then Education/Training is scored and Board Certification is scored NA.

Education and Training is not combined with Board Certification, therefore apply NCQA 8/30 file methodology as applicable for this factor.

4. Board certification status, if applicableVerification Time Limit – Board certification: 180 calendar days


https://www.deadiversion.usdoj.gov/webforms/validateLogin.jsp


If a practitioner is board certified and the organization communicates this to it members, it must verify the certification, even if the board is not acceptable for verification of education and training because it does not primary-source verify. This also applies to Nurse Practitioners.

Expiration date of the board certification must be documented in the credentialing file. If ABMS or the certifying board does not provide the expiration date for a practitioner's board

certification, the PO must verify that the board certification is current. If practitioner has a lifetime certification status, verification of lifetime status must be documented

in the credentialing file. If board certification has expired it may be used as verification of education and training. (Per

NCQA) Education and Training is not combined with Board Certification, therefore apply NCQA 8/30 file

methodology as applicable for this factor. This can be an issue if you have less than 8 applicable files when you are following the 10/10 file methodology.

5. Work history [Not applicable for Recredentialing]Verification Time Limit: 180 calendar days NCQA changed the time limit verification to 365 days however, due to other California regulators

(e.g., CMS, DMHC, etc.) the ICE Policy Committee has decided to continue to require the 180 calendar day time frame.

Must document review of work history on the application, CV or checklist that includes the signature or initials of staff who reviewed work history and the date of review.

Work history must include the beginning and ending month and year for each work experience. The month and year do not need to be provided if a practitioner has had continuous employment

at the same site for five years or more. The year to year documentation at that site meets the intent.

If the practitioner completed education during the last 5 years and went straight into practice, check for gaps since initial licensing date and initial.

If the practitioner has practiced fewer than 5 years from the date of credentialing, the work history starts at the time of initial licensure. Experience as a non-physician health professional (e.g., PA, APN, LCSW) within the 5 years must be included. (Score compliant if initial health care work experience coincides with the time of the current application to the PO.)

The PO must review for any gaps in work history. If a work history gap of 6 months to 1 year is identified, the PO must obtain an explanation from the practitioner. Verification may be obtained verbally or in writing for gaps of 6 months to one year.

Any gap in work history that exceeds 1 year must be clarified in writing from the practitioner. The explanation of the gap needs to be sufficient to ascertain that the gap did not occur as a result of adverse and/or reportable situations, occurrences, or activities.

6. A history of professional liability claims that resulted in settlement or judgment paid on behalf of the practitioner. Verification Time Limit: 180 calendar days Claims history (5 years) via the National Practitioner Databank (NPDB) or the malpractice carrier.

- NPDB query or malpractice carrier claims history documentation with date of query and staff initials must be evident on checklist or report must be in file.

For POs using the Continuous Query (formerly Proactive Disclosure Service (PDS)- Evidence of current Continuous Query enrollment must be provided.- Continuous Query report must be reviewed within 180 calendar days of the initial

credentialing decision. - Evidence of review must be documented in the file or on checklist.



Element B: Sanction Information

The organization verifies the following sanction information for credentialing

Verification time limit: 180 calendar days.1. State sanctions, restrictions on licensure or limitations on scope of practice

The PO may obtain verification from the NPDB from all practitioners types listed below or

The The PO verifies the most recent five-year period available through any of the following sources:The

Physicians: - Appropriate state agencies.- Federation of State Medical Boards (FSMB).

Chiropractors: - State Board of Chiropractic Examiners.- Federation of Chiropractic Licensing Boards' Chiropractic Information Network-

Board Action Databank (CIN-BAD).

Oral surgeons: - State Board of Dental Examiners or State Medical Board.

Podiatrists: - State Board of Podiatric Examiners.- Federation of Podiatric Medical Boards.

Other nonphysician health care professionals: - State licensure or certification board. - Appropriate state agency.

For POs using the Continuous Query (formerly Proactive Disclosure Service (PDS))

– Evidence of current enrollment must be provided.

– Report must be reviewed within 180 calendar days of the initial credentialing decision.

– Evidence of review must be documented in the file or on checklist.

2. Medicare and Medicaid sanctionsThe organization may obtain verification from any of the following sources:

Verification sources for Medicare/Medicaid sanctions

NPDB List of Excluded Individuals and Entities (maintained by OIG and available over the

Internet) State Medicaid agency or intermediary. Medicare intermediary Medicare Exclusion Database Federal Employees Health Benefits Plan (FEHB) Program department record, published

by the Office of Personnel Management, Office of the Inspector General. AMA Physician Master File. FSMB. .

For POs using the Continuous Query (formerly Proactive Disclosure Service (PDS))



– Evidence of current enrollment must be provided.

– Report must be reviewed within 180 calendar days of the initial credentialing decision.

– Evidence of review must be documented in the file or on checklist.

For CMS Only (B.3) OIG must be the verification source Date of query and staff initials must be evident on a checklist or the OIG page must be in

the file. Score under the CMS scoring section as Met = 90-100%, Not Met = 0-89%.



Element C: Credentialing ApplicationApplications for credentialing include the following.

1. Reasons for inability to perform the essential functions of the position, with or without accommodation

2. Lack of present illegal drug usePO’s application may use alternative language or general language that may not be exclusive to present use or only illegal substances.

3. History of loss of license and felony convictions At initial credentialing, the practitioner must attest to any loss of license since their initial licensure. At recredentialing, practitioners may attest to any loss of license since the last credentialing cycle.

4. History of loss or limitation of privileges or disciplinary actions At initial credentialing, the practitioner must attest to any felony convictions since their initial

licensure. At recredentialing, practitioners may attest to any felony convictions since the last

credentialing cycle.

5. Current malpractice insurance coverage Malpractice coverage can be obtained by the application.

- The application form must include specific questions regarding the dates and amount of the practitioner’s current malpractice insurance.

- The practitioner must attest to the amount and dates of coverage. If the practitioner has applied for coverage, but the coverage is pending, the practitioner

may indicate the amount as zero or indicate coverage pending on the application, however, the practitioner must have coverage prior to approval.

A copy of the insurance face sheet or Certificate of Insurance (COI) may also be obtained in lieu of collecting information on the application.

There must be evidence that the practitioner has current and adequate malpractice coverage prior to the Credentialing Committee approval date. Coverage can be effective for future date or start date as long as they are not allowed to see members until the coverage is in effect.

6. Current and signed attestation confirming the correctness and completeness of the application Attestation must be signed and dated within the timeframe and must include all elements to be

compliant. If practitioner needs to re-sign the attestation it must be a full signature, just dating and initialing is

not acceptable. The 180 calendar day time frame is based on the date the practitioner signed the application.

- If the signature or attestation exceeds 180 calendar days the practitioner must attest only that the information on the application remains correct and complete, by re-signing and re-dating the attestation. Practitioner does not need to complete another application.

If practitioner completes all the questions, no further evidence is required. If the attestation is not signed and/or dated, within the appropriate time frame, all application

elements are non-compliant (except current malpractice coverage if copy of face sheet is obtained).- If one of the above questions is not answered, only that element will be scored non-compliant.- If one of the questions is answered incorrectly, auditor will not need to go any further to clarify



the answer. This element is only to answer the above 1-6 questions and that practitioner attest to the questions. Auditor may recommend suggestions to follow-up on questions answered that may appear to be answered incorrectly.

- When reviewing the CAQH application, review attestation questions in addition to the form that contains the generated date and the last update (attestation date) If the generated date on the form is older than 180 days, but there is a current attestation date, you may accept the application. Note to Auditor: the Work History or Malpractice Insurance may require an update or verification by another means.

Verification Time Limit: 180 calendar days NCQA changed the time limit verification to 365 days; however, due to other regulators (e.g.,

CMS) the ICE Policy Committee has decided to continue to require the 180 calendar day time frame.

NCQA does not require a date stamp on the initial application.

Element D: Hospital Admitting Privileges – CMS

Practitioner must have clinical privileges in good standing. Practitioner must indicate their current hospital affiliation or admitting privileges at a participating hospital. (Source: Medicare Managed Care Manual, Chapter 6 § 60.3)This element is applicable for all products.Primary source verification is not required. Verification Time Limit: 180 calendar days Data source: applications, curriculum vitae, hospital listing or letter from hospital If a practitioner has admitting privileges, the following must be noted to be compliant:

– Current status is obtained from the attestation questions, hospital letter or practitioner directory (e.g. unrestricted, restricted).

– Type of admitting privileges (e.g., active, courtesy, temporary) can be found in the application, hospital letter or directory

Practitioner (in the appropriate specialties) must have a formal inpatient coverage arrangement. If the practitioner does not have clinical privileges, the PO must have a written statement delineating

the inpatient coverage arrangement. This file will be scored compliant and not scored NA.- If the coverage letter is not dated, recommend it be dated. Do not score as deficient.

Allied health practitioners (Chiropractors, Optometrists, etc.) will not have hospital privileges and documentation in the file is not required for these types of practitioners.

Specialties such as Dermatology, Podiatry or Ophthalmology may not have hospital privileges, documentation must be noted in the file as to the reason for not having privileges. (e.g. A note stating that they do not admit as they only see patients in an outpatient setting is sufficient)

Element E: Monitoring Physicians Who Have Opted Out – CMS/TRICARE The Medicare Advantage Organization monitors its credentialing files to ensure that it only contracts with practitioners who have not opted out. (Source: Medicare Managed Care Manual, Chapter 6 § 60.2) The PO is responsible for reviewing the information Medicare Opt-Out List via hard copies or

electronic or one of the CMS.gov Opt-Out sites Certain healthcare provider categories cannot opt-out of Medicare. These include chiropractors,

physical therapists and occupational therapists in independent practice. Score as NA. If a PO employs their practitioners, the initial credentialing review of employed practitioners must

include a review of the Medicare Opt-Out Report. Note: Confirmation has been received from CMS that review of Opt-Out reports is required at

credentialing and recredentialing. All files for POs that employ their practitioners must have



evidence of review in all files credentialed. The following are acceptable ways to verify review of the Opt-Out report:

1. Checklist/Verification: Must have the following elements to be compliant.- Staff initial/signature- Run date for WA reports (if the run date is not included on the checklist, but can be found on

the WA report, give full compliance and note in comments section that checklist needs to include the run date)

- Review date for WA reports. (If checklist/document does not indicate WA report was reviewed, auditor to check reports to see if report was reviewed in order to give full compliance)

- Indicate whether or not the practitioner is listed on the report. (Auditors: If the status for the WA report is not indicated review the Opt-Out report for compliance)

OR

2. Pages of the WA listing report showing where the providers name would have been listed in alpha order. (Make sure report date/run date and staff initials are present)

If a PO uses a CVO for credentialing, evidence of this element must be provided for review during the audit, as this element is not reviewed by NCQA for certification.

Element F: Review of Performance Information – CMS/URACThe organization includes information from quality improvement activities and member complaints in the recredentialing decision-making process. Source: Medicare Managed Care Manual, Chapter 6 § 60.3; URAC)

1.. Quality activities (e.g., adverse events, medical record review and data from quality improvement activities. Performance information may also include additional information such as: utilization management data, enrollee satisfaction surveys, other activities of the organization)

2. Grievance/complaints Verification Time Limit: Last recred cycle to present. Not all quality activities need to be present to be compliant. Other activities may consist of medical record site review, medical record review, access studies. Factors 1 & 2 must be present for Element F to be compliant.



CR 4: Recredentialing Cycle Length

Element A: Recredentialing Cycle LengthThe length of the recredentialing cycle is within the required 36-month time frame.

A PO that determined that there was a system wide problem with its initial credentialing process, and as a result implemented corrective action through early recredentialing may present evidence of such actions to the health plan during the audit. - The Health Plan auditor will comment in recredentialing cycle length that PO has gone through

early recredentialing to correct deficiencies found in the initial credentialing process.

If a file was recredentialed early to correct a deficiency, score file non-compliant for cycle length and make comments.

A recredentialing file that was placed into the initial credentialing file pull due to being out of timeframe should not be included in the initial credentialing files. It must be included in the universe of recredentialing files. If this is the case, request a new file using either the 5% or 50 no less than 10/10 file methodology or the 8/30 (If par with a URAC Health Plan add 2 files when 8/8) methodology.

A recredentialing file that is past due cannot be terminated and then reinstated before or within 30 days and processed as an initial credentialing file. The past due file should be recredentialed as soon as possible instead of being terminated.

If a practitioner is given administrative termination for reasons beyond the PO’s control (e.g., the practitioner failed to provide complete credentialing information), and is then reinstated within 30 calendar days, the PO may recredential the practitioner as long as it provides documentation that the practitioner was terminated for reasons beyond its control and was recredentialed and reinstated within 30 calendar days of termination. The PO must initially credential the practitioner if reinstatement is more than 30 calendar days after termination.

A PO must verify that a practitioner who returns from military assignment, maternity/medical leave or a sabbatical has a valid license to practice before he or she resumes seeing patients. Within 60 calendar days of when the practitioner resumes practice, the PO must complete the recredentialing cycle. If there is a termination of 30 days, the PO can initially credential the practitioner before rejoining the PO.

Only the files that have been recredentialed within the time period and have gone to committee will be included in the file review. If the auditor discovers that a file was selected that has not gone through the recredentialing cycle or committee and it is non-compliant for recredentialing auditor will include in comments but not in the file review. Auditor also must note in comments the total # of providers that appear on the spreadsheet of credentialed practitioners that have not been recredentialed within the last 36 months.



SV: Practitioner Office Site Quality (Source: Medicare Managed Care Manual, Chapter 6 & 60.3 NCQA Medicaid MED 4: Health Plans) Element A: Performance Standards and Thresholds[N/A – Unless par for Medicare and/or Medicaid AND delegated for Site Visits.]

The organization sets site performance standards and thresholds for:

1. Physical accessibility The PO must have standards and thresholds that address ease of entry into the building or

practice site and accessibility of space within the building or practice site. Accessibility standards must include standards for ease of access for physically disabled

patients.

Office-site criteria - Example- Handicapped accessible- Adequate seating

2. Physical appearance PO standards and thresholds must at a minimum include cleanliness, lighting and safety plus

any others that the PO deems appropriate.

Office-site criteria - Examples Physical appearance

- Clean- Well-lit waiting room- Posted office hours

3. Adequacy of waiting and examining-room space The PO must have standards and thresholds for the appropriate size and seating for waiting

rooms. Standards should consider number of patient visits per hour and the number of practitioners.

4. Adequacy of medical/treatment record keeping The PO must have standards and thresholds for medical/treatment record orderliness, security,

confidentiality and documentation.

Medical record keeping criteria - Examples- Secure/confidential filing system- Legible file markers- Records can be easily located

If the criteria for Physical Accessibility and Appearance and Adequacy of Waiting room, Examining rooms and Medical/treatment record keeping is outlined on the site audit tool, this is compliant.



Element B: Site Visits and Ongoing Monitoring

The organization implements appropriate interventions by:

1. Continually monitoring member complaints for all practitioner sites The PO must have a process for detecting deficiencies. The process must include continual

monitoring of member complaints and other data. (e.g., complaint monitoring, practice-specific member surveys, reports from provider relation staff visits and staff audits)

This information may be found in the Quality Committee minutes, QI/QA Department or logs.

Policy may include established reasonable thresholds, taking into consideration the severity of the issue, for the number of complaints it must receive before conducting an office site visit.

Evidence must indicate the following (if applicable): PO must provide evidence for tracking member complaints against thresholds. Evidence can be

logs or spreadsheets.

2. Conducting site visits of offices within 60 calendar days of determining that the complaint threshold was met

Policy applies to all practitioners within its network and must state the following:

PO will conduct site visits for complaints related to:

Physical Accessibility (e.g., handicapped accessibility)

Physical Appearance (e.g., cleanliness and orderliness, well-lit waiting room, posted office hours)

Adequacy of Waiting and Examining Room space (e.g., adequate waiting room space, adequate number of examining rooms per practitioner)

NCQA does not require site visits for complaints about availability of appointments or adequacy of treatment record keeping however, they must be included on the site tool and P&Ps.

Site visit will be performed within 60 calendar days of the complaint threshold being met.

Evidence must indicate the following (if applicable): A site visit resulting from a complaint must include an evaluation of all office site criteria.

However, it is not required to conduct a site visit for complaints about adequacy of treatment record keeping or availability of appointments.

The site visit must be performed within 60 calendar days of the complaint threshold being met. Reviewer must see evidence of site visit being performed if complaint threshold is met.

3. Instituting actions to improve offices that do not meet site standards and thresholds in Element A

Policy must include if a site does not meet the PO’s performance thresholds, the site must develop and implement an action plan for improvement.

If a site does not meet the PO’s performance threshold, there must be evidence that the PO has developed and implemented an action plan for improvement.

Evidence of the CAP and notation regarding distribution to and education of the applicable practitioner must be documented on the spreadsheet or report. Documentation can be kept in the credentialing file or binder.



4. Evaluating the effectiveness of the actions at least every six months, until deficient offices meet site standards and the thresholds in Element A

Policy must include the process for evaluating the effectiveness of the action plan at least every six months, until the offices meet the threshold.

If a deficiency is found during the site visit, a follow-up visit must occur within 6 months. Evidence of the site visit must be documented in the spreadsheet or report. Documentation can

be kept in the credentialing file or binder.

5. Documenting follow-up visits for offices that had subsequent deficiencies.

Policy must state that the PO conducts a follow-up visit of a previously deficient office if the practice site meets the reasonable complaint threshold subsequent to correcting the deficiencies. PO conducts a follow up visit of a previously deficient office if the site meets the complaint threshold subsequent to correcting the deficiencies.

Follow up visit must be conducted within 60 calendar days of the reasonable complaint threshold being met.

If one of the PO’s practitioners meets the criteria, there must be evidence of the office site visit in the spreadsheet or report. Documentation can be kept in the credentialing file or binder.

If there is another complaint within the same office regarding the same issue, the PO is required to perform another site audit; it must follow-up as required.

If there is another complaint about the same office, but for different office-site criteria, the PO must perform another site visit.

Notes: Auditor must document in the appropriate section of the documentation page the following for all audits including NCQA certified POs:

Identify the threshold for site visits per the PO’s policy and procedure. Document the number of complaints identified. Whether or not policy states that when appropriate, complaints will be forwarded to the

applicable Health Plan upon receipt. This is for those Health Plans that do not delegate monitoring of complaints (do not score down).

Note: Both Policies and Evidence must be reviewed for compliance



CR 5: Ongoing Monitoring

Element A: Ongoing Monitoring and InterventionsThe organization implements ongoing monitoring and takes appropriate interventions by:

1. Collecting and reviewing Medicare and Medicaid sanctions The PO must have policies and procedure as well as evidence to be compliant. Note missing elements in comments. Policies Policies must describe how the PO verifies the practitioner’s Medicare and Medicaid status.Evidence The PO is responsible for reviewing the information within 30 calendar days. . If PO utilizes a spreadsheet, auditor may choose to spot check evidence. If a spreadsheet is not

utilized, auditor to review evidence from each quarter. Score non-compliant and comment if PO is not following a consistent process for ongoing

monitoring. If reports are not reviewed at all or not reviewed on a monthly basis, note in comments which

reporting cycle is missing and score non-compliant. The PO that subscribes to a sanctions alert service must have evidence of its subscription to the

sanctions alert service during the look back period. For POs using the Continuous Query

The Continuous Query generates individual alerts from NCQA-recognized sources reporting an action. PO must provide evidence of the practitioner’s continuous enrollment in the Continuous Query and must have a process for reviewing sanction alerts within 30 calendar days of their release.

PO must show evidence of the annual enrollment listing of providers enrolled and review of alerts within 30 calendar days of its release.

Per NCQA, if no reports were received for ongoing monitoring, PO will only need to document or note that no reports were received during the monthly look-back period.

This documentation can be kept electronically or via an electronic or paper log/checklist.A spreadsheet/tracking log may be used as documentation for compliance. Name of board/entity, date of query, date of report, and signature/initials of staff must be included. Auditors may spot check as needed, however it is not mandatory.

All evidence may be kept electronically. If an NCQA CVO performs ongoing monitoring, score compliant and note in evidence section

that PO is using an NCQA CVO and receiving sanction alerts. Review delegation agreement, as applicable.

Note examples in documentation tab of evidence source, i.e., Minutes, spreadsheet, monitoring process.

Note: Tools to evaluate and/or document ongoing monitoring are available to auditors and POs.



2. Collecting and reviewing sanctions or limitations on licensure The PO must have policies and procedures as well as evidence to be compliant. Note missing elements in comments. Policies The PO must have policies and procedures for ongoing monitoring of sanctions and limitations

on licensure. Policies must state which verification sources are used. Policies must state how the PO queries information if reporting entities do not publish sanction

information, on a set schedule, at least every 6 months, if applicable. Mark this element as compliant even if the language is not in the policies and recommend that they add it.

Policies must state how the PO queries information if the reporting entities do not release sanction information reports, if applicable. PO is required to conduct individual queries for any affected practitioner 12-18 months after the last credentialing cycle. Mark this element as compliant even if the language is not in the policies and recommend that they add it.

Evidence The PO is responsible for reviewing the information within 30 calendar days for those boards that

release on a set schedule. Any board that releases on a routine schedule (monthly/quarterly); this is considered a set schedule. Auditor should refer to the ICE Ongoing Monitoring Document for reporting schedule.

Compare practitioner types being monitored with practitioner types listed on PO roster. If any discrepancies found, score non-compliant.

If PO utilizes a spreadsheet, auditor may choose to spot check evidence. If a spreadsheet is not utilized, auditor to review evidence from each quarter.

Score non-compliant and comment if PO is not following a consistent process for ongoing monitoring.

If reports are not reviewed at all or not reviewed on a monthly basis, note in comments which reporting cycle is missing and score non-compliant.

If the PO subscribes to a sanctions alert service, there must be evidence of its subscription to the sanctions alert service during the look back period and review information within 30 days of its release. For POs using the Continuous Query

The Continuous Query generates individual alerts from NCQA-recognized sources reporting an action. PO must provide evidence of the practitioner’s continuous enrollment in the Continuous Query and must have a process for reviewing sanction alerts within 30 calendar days of their release.

PO must show evidence of the annual enrollment listing of providers enrolled and review of alerts within 30 calendar days of its release, if any is received.

Per NCQA, if no reports were received for ongoing monitoring, PO will only need to document or note that no reports were received during the monthly look-back period.

This documentation can be kept electronically or via an electronic or paper log/checklist. In areas where reporting entities do not publish sanction information on a set schedule, the PO

must query for this information at least every 6 months. To demonstrate performance against this element indicator, the PO must document that the reporting entity does not routinely publish sanction information.

If the reporting entity does not release sanction information reports, the PO is required to conduct individual queries for any affected practitioner 12-18 months after the last credentialing cycle.

A spreadsheet/tracking log may be reviewed as documentation for compliance. Must include following: Name of board, date of query, date of report, and signature/initials of staff. Auditors may spot check as needed, however it is not mandatory.



If an NCQA CVO performs ongoing monitoring, score compliant and note in evidence section that PO is using an NCQA CVO and receiving sanction alerts. Review delegation agreement, as applicable.

Note examples in documentation tab of evidence source, i.e., Minutes, spreadsheet, monitoring process

3. Collecting and reviewing complaints The PO must have policies and procedures as well as evidence to be compliant. Note missing elements in comments. Policy and evidence may be found in the Quality department.Policies Policies must state PO evaluates practitioner’s specific complaints upon receipt Policies must state PO evaluates practitioner’s history of complaints at least every 6 months. Policies state that Quality or collecting and reviewing complaints are not delegated and

complaints are forwarded to the Health Plans as applicable, is compliant for this factor.Evidence The PO must investigate practitioner specific complaints from members upon their receipt. The PO must evaluate practitioner’s history of issues, if applicable, at least every 6 months.

4. Collecting and reviewing information from identified adverse events Adverse event is an injury that occurs while a member is receiving healthcare services from a

practitioner. The PO must have policies and procedures as well as evidence to be compliant. Note missing elements in comments. Policy and evidence may be found in the Quality department.Policies Policies must state monitoring for adverse events occurs at least every 6 months. Policies state that Quality / collecting and reviewing adverse events are not delegated and events

are forwarded to the Health Plans as applicable, is compliant for this factor.Evidence The PO must monitor practitioner adverse events at least every 6 months. The PO may limit monitoring of adverse events to primary care physicians and high-volume

behavioral healthcare providers.



5. Implementing appropriate interventions when it identifies instances of poor quality related to factor 1-4 Policies The PO must have policies and procedures as well as evidence to be compliant. Note missing elements in comments. Policy and evidence may be found in the Quality department.Evidence The PO must have a process to determine if there is evidence of poor quality that could affect the

health and safety of its members and implement the appropriate policy based on action/intervention.

Interventions can be identified in one of the following: Committee minutes, practitioner files, or PO file binders.

Note in comments if there are no sanctions, complaints or adverse events.

Element B: Monitoring Medicare Opt-Out Report - CMSThe organization maintains a documented process for monitoring whether network physicians have opted out of participating in the Medicare program. (Source: Medicare Managed Care Manual, Chapter 6 § 60.3)

Medicare Opt-Out applies to: MD, DO, DDS, DMD, DPM, OD and PA, NP, CNS, CRNA, CNM, Psychologist, CSW, RD or Nutrition Professional.

Certain healthcare provider categories cannot opt-out of Medicare. These include chiropractors, physical therapists and occupational therapists in independent practice. Score as NA.

The PO must have policy and procedures as well as evidence to be compliant. Note missing elements in comments.

The PO is responsible for reviewing the information quarterly or. The Complete Listing of Medicare Opt-Out Providers is distributed on a quarterly basis.

The report must be dated and initialed.

If any reports are not reviewed within the appropriate timeframe, score as non-compliant.

A check list may be used to document the date of electronic file download. The check list must contain the date of the download and signature of the PO personnel who verified it.

Score N/A and note in comments if a PO does not have a Medicare contract, but has a process for monitoring physicians who have opt out of participating in the Medicare program.

PO must review quarterly Opt-Out reports even if they employ their practitioners.

If PO uses a CVO for ongoing monitoring verify that the monitoring reports includes Opt-Out reports. Auditor needs to ensure that reports are from CMS Contractor.



Auditors must review CR 6 for all Certified or Accredited Entities

CR 6: Notification to Authorities and Practitioner Appeal RightsElement A: Actions Against Practitioners(Source: Medicare Managed Care Manual, Chapter 6 § 60.4, )The organization has policies and procedures for:

1. The range of actions available to the organization Policies must specify: the PO reviews participation of practitioners whose conduct could adversely affect members’

health or welfare. the range of actions that may be taken to improve the practitioner performance before

termination (e.g. Profiling, Corrective Actions, Monitoring, Medical Record Audit, etc.). The PO reports its actions to the appropriate authorities.

- Appropriate Licensing Board, NPDB,

2. Making the appeal process known

- The PO’s policies and procedures must give practitioners the right to appeal and must include the following steps within the appeal process: (Provide written notification when a professional review action has been brought against a practitioner, including reasons for the action

- Allow practitioners to request a hearing/appeal and the timing for submitting the request.

-

Element B: Appeals Process for Termination/Suspension - CMSThe Medicare Advantage organization’s policies and procedures regarding suspension or termination of a participating physician require the organization to:

Ensure that the majority of the hearing panel members are peers of the affected physician. (Source: Medicare Managed Care Manual, Chapter 6 § 60.4)

A peer is an appropriately trained and licensed physician in a practice similar to that of the affected physician. Panel members do not have to possess identical specialty training.

Policies and procedures do not always have to state the word “majority”, but at least 51% of the members must be peers.



CR 7: Assessment of Organizational Providers (OPs)

General Updates: Contracting Status: All Health Plans will ask the PO the following questions:

- Do you directly contract with ANY Organizational Providers? - Are you responsible for claims payment for those Organizational Providers?

Exception: - If the PO does not contract with Organizational Providers, then all of CR 7 is not applicable.

Policies and procedures are not required if the PO does not contract directly with OPs. Do not score this section and check the N/A box of the SA Tool.

Audit process to assess the current annual audit cycle instead of the entire OP spreadsheet.

Audits will be conducted utilizing either the 5% or 50 no less than 10/10 file methodology or the 8/30 (If par with a URAC Health Plan add 2 files when 8/8) methodology. The auditor will request a spreadsheet with all organizational providers and will select files reviewed during the annual audit cycle. Under the 8/30 rule, eight initials (10 if URAC) and eight recreds (10 if URAC) will be reviewed with nothing further reviewed if all providers were compliant.

Element A: Review and Approval of Providers

The organization’s policy for assessing a health care delivery provider specifies that before it contracts with a provider, and for at least every three years thereafter, it: (Source: Medicare Managed Care Manual, Chapter 6 § 70)

1. Confirms that the provider is in good standing with state and federal regulatory bodies Policies must specify the sources used.

2. Confirms that the provider has been reviewed and approved by an accrediting body Policies must state which accrediting bodies it accepts for each type of provider. A PO that contracts only with accredited facilities must have a written policy stating that it does

not contract with unaccredited facilities. In this case the PO meets this factor.

3. Conducts an onsite quality assessment, if the provider is not accredited Policies must state that if the provider is not accredited an onsite quality assessment must be

conducted. The PO must develop a selection process and assessment criteria for each type of non-accredited provider with which it contracts which includes a process for ensuring that the provider credentials its practitioners.

A CMS or state review may be used in lieu of a site visit and may not be greater than 3 years old at the time of verification/approval.

A PO that contracts only with accredited facilities must have a written policy stating that it does not contract with unaccredited facilities. In this case the PO meets this factor.

If The state or CMS has not conducted a site review of the provider, and the provider is in a rural area, as defined by the U.S. Census Bureauthe organization must provide evidence that the provider meets the criteria



Element B: Medical Providers The organization includes at least the following medical providers in its assessment:

1. Hospitals

2. Home health agencies

3. Skilled nursing facilities

4. Free-standing surgical centers Policies and procedures must include all facility types in which they contract. If PO is not contracted

with a facility type, it does not have to be stated in the policy. Policy may state all types as applicable. Complete the grid of the SA tool as follows:

Yes = PO is contracted with OP and it states so in the policy No = PO is contracted, but OP is not stated in the policy NA = PO is not contracted for the OP

Element B: Medical Providers and Suppliers required by CMS In addition to the provider types listed above, Medicare Advantage organizations must also provide documented processes for assessing the following types of providers in which they contract: (Source: Medicare Managed Care Manual, Chapter 6 § 60.3)

HospicesClinical laboratories Comprehensive outpatient rehabilitation facilities (CORF)Outpatient physical therapy providers (only applies to institutional facilities who take Medicare Part A. Does not apply to independently licensed PTs)Outpatient speech pathology providersEnd-stage renal disease services providersOutpatient diabetes self-management training providersPortable X-ray suppliersRural health clinics (RHC)Federally qualified health centers (FQHC)

Applies to Medicare/CMS Only Policy and procedures must state which organizational provider types are contracted. A

statement in the policies and procedures would meet the requirement. POs that contract with these types of OPs and do not provide a documented process will be

scored 0%. If the policies and procedures address all types of providers the PO will be considered compliant

and will not need to specify which types they do not contract with. Complete the grid of the SA tool as follows:




Element C: Behavioral Health ProvidersThe organization includes behavioral healthcare facilities providing mental health or substance abuse services in the following settings:

1. Inpatient

2. Residential

3. Ambulatory If the PO has “carved out” behavioral healthcare services, this is not applicable. Policies must address each facility (inpatient, residential, ambulatory) that they are contracted with. PO will not be compliant if their policies and procedures state “all behavioral facilities, as applicable.” Complete the grid of the SA tool as follows:


Element D: Assessing Medical ProvidersThe organization assesses contracted medical health care providers against the requirements and within the timeframe in Element A. (Source: Medicare Managed Care Manual, Chapter 6 § 70)

If the PO uses a comprehensive spreadsheet or log showing credentialing of Medical organizational providers, use the spreadsheet results to calculate compliance, and completion of the File Review Results Grid is not required. Review the entire spreadsheet but only score for current audit time frame. Only score providers reviewed/approved since the previous audit (e.g., if previous audit was

conducted 7/1/18 and the OP was reviewed/approved 3/1/17 this would be outside the time frame).

Audits will be conducted utilizing either the 5% or 50, no less than 10/10 file methodology or the 8/30 (If par with a URAC Health Plan add 2 files when 8/8) methodology. Auditors will request a spreadsheet of all organizational providers and will select files reviewed during the annual audit cycle. Under the 8/30 rule, eight initials (10 if URAC) and eight recreds (10 if URAC) will be reviewed with nothing further reviewed if all providers were compliant.

Each element should be reviewed within 36 months of the prior verification. Credentialing Committee review is not required and not assessed for the 36 month timeframe.

If there was no activity in the applicable time frame, note in comments, and score as NA.

Applies to Medicare/CMS Only: CMS Institutional provider and suppliers must be certified by CMS. Note in comments if provider is not certified

Note: POs must ensure that Medicare-covered benefits are provided only by providers that have signed

participation agreements with CMS. Comment on number and types of OPs reviewed.



Element E: Assessing Behavioral Health ProvidersThe organization assesses contracted behavioral healthcare providers.

If the PO uses a comprehensive spreadsheet or log showing credentialing of Behavioral Health organizational providers, use the spreadsheet results to calculate compliance, and completion of the File Review Results Grid is not required. Review the entire spreadsheet but only score for current audit time frame. Only score providers reviewed/approved since the previous audit (e.g., if previous audit was conducted 7/1/17 and the OP was reviewed/approved 3/1/16 this would be outside the time frame).

Audits will be conducted utilizing either the 5% or 50 no less than 10/10 file methodology or the 8/30 (If par with a URAC Health Plan add 2 files when 8/8) methodology. Auditors will request a spreadsheet of all organizational providers and will select files reviewed during the annual audit cycle. Under the 8/30 rule, eight initials (10 if URAC) and eight recreds (10 if URAC) will be reviewed with nothing further reviewed if all providers were compliant.

Each element should be reviewed within 36 months of the prior verification. Credentialing Committee review is not required and not assessed for the 36 month timeframe

If there was no activity in the applicable frame, note in comments and score as NA.

Comment on number and types of OPs reviewed



Organizational Provider: Elements D & E

Verification is conducted on all medical providers and behavioral health providers prior to completion of the credentialing process and on-going every three (3) years

The PO verifies the following:Confirms that the provider is in good standing with state and federal regulatory bodies

State (Department of Health Care Services) – A copy of the license and expiration date Physician-owned clinics are not required to be licensed DHCS, but they must be accredited by an

agency approved by the Medical Board. If the physician-owned clinic is appropriately accredited, there would not be a violation of the Knox-Keene Act of Title 28.

If a state license is not issued by the Department of Health Care Services, the facility should have a business license or certificate of occupancy.

Federal Regulatory Bodies -Review of OIG or Medicare/Medicaid sanctions must be documented on the spreadsheet or in

The file. -The monthly review of the OIG report as part of the “Ongoing Monitoring: qualifies as complaint For this section as long as the facilities are included on the OIG Report. The facilities are Located at the top of the report -If Medicare and Medicaid sanctions are not reviewed, this will be scored non-complaint for Federal Regulatory bodies, as applicable

Confirms that the provider has been reviewed and approved by an accrediting body

When conducting a credentialing audit on behalf of ICE, the following Accrediting Entities have been approved for use by the ICE Policy Committee. All other entities are not approved for use when conducting a shared audit.

Hospitals The Joint Commission (TJC) Healthcare Facilities Accreditation Program (HFAP), accrediting program approved by the

American Osteopathic Association (AOA) Det Norske Veritas National Integrated Accreditation for Healthcare Organization (DNVNIAHO) Center for Improvement of Healthcare Quality (CIHQ)

Home Health Agencies The Joint Commission (TJC) Community Health Accreditation Program (CHAP) Accreditation Commission for Health Care Inc. (ACHC)

Skilled Nursing Facilities The Joint Commission (TJC) Commission on Accreditation or Rehabilitation Facilities (CARF) Continuing Care Accreditation Commission (CCAC)

Free-Standing Surgical Centers The Joint Commission (TJC) American Association for Accreditation of Ambulatory Surgical Facilities (AAAASF)



Accreditation Association for Ambulatory Health Care (AAAHC) Healthcare Facilities Accreditation Program (HFAP), accrediting program approved by the

American Osteopathic Association (AOA)

Behavioral Health Providers (Intensive Outpatient Programs and Residential Treatment Programs) The Joint Commission (TJC) Commission on Accreditation or Rehabilitation Facilities (CARF) Healthcare Facilities Accreditation Program (HFAP), accrediting program approved by the

American Osteopathic Association (AOA) Council on Accreditation for Children and Family Services (COA)

Hospice The Joint Commission (TJC) Community Health Accreditation Program (CHAP)

Clinical Laboratories The Joint Commission (TJC) Clinical Laboratory Association Improvement Amendments (CLIA) Certificate or CLIA Waiver Commission on Office Laboratory Accreditation (COLA) College of American Pathology (CAP) Other CMS approved accreditation organizations can be found under download “List of

Accreditation Organizations at https://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/Accreditation_Organizations_and_Exempt_States.html

Comprehensive Outpatient Rehabilitation Facilities The Joint Commission (TJC) Commission on Accreditation or Rehabilitation Facilities (CARF)

Outpatient Physical Therapy Providers American Association for Accreditation of Ambulatory Surgical Facilities (AAAASF)

Outpatient Speech Pathology Providers American Association for Accreditation of Ambulatory Surgical Facilities (AAAASF)

Providers of End-stage Renal Disease Services The Joint Commission (TJC)

Outpatient diabetics self-management training providers American Association of Diabetes Educators (AADE) Indian Health Service (IHS)

Portable X-ray Supplier Federal Drug Administration (FDA) Certification

Rural Health Clinics The Joint Commission (TJC)



American Association for Accreditation of Ambulatory Surgical Facilities (AAAASF)

Federally Qualified Health Centers The Joint Commission (TJC)

Note: A Medicare certification number is not acceptable for use in lieu of a site visit if a facility is not accredited.

Conducts an on-site quality assessment, if the provider is not accredited If an organizational provider is not accredited, the PO develops and implements standards of

participation, including conducting a site visit. Unlike the requirement for accredited providers, NCQA requires site visit for non accredited facilities to include a process for insuring that the provider credential its practitioners.

CMS or state review or certification does not serve as accreditation of an institution; however, in the case of non accredited institutions, the PO may substitute a CMS or state review in lieu of the required site visit. However, a letter from CMS which shows that the facility was reviewed and indicates that the facility passed inspection is applicable in lieu of the survey report if the PO reviewed and approved CMS criteria as meeting its standards. Site visit cannot be greater than 3 years old.

NCQA does not require the organization to conduct site visits of non-accredited providers in the following circumstances:

The state or CMS has not conducted a site review of the provider, andThe provider is in a rural area, as defined by the U.S. Census Bureau- For providers in rural areas, non accredited sites do not need to have state or CMS

site audits. According to the U.S. Census Bureau definition, rural areas comprise of open country and settlements with fewer than 2,500 residents.

The organization must identify excluded providers and provide the evidence that the above conditions are met.

If the organization is not approved by an accrediting body, then an onsite quality assessment must be conducted at least every three years. This includes CMS or State Audits, which cannot be older than 36 months at the time of the verification.

Note: A Medicare certification number is not acceptable for use in lieu of a site visit if a facility is not accredited.

Confirms at least every three years that the provider continues to be in good standing with state and federal regulatory bodies and, if applicable is reviewed and approved by an accrediting body

In order to confirm that POs are conducting organizational provider recredentialing timely, one must ensure the appropriate documents are date stamped or have some indication of a verification date. Although there is no time limit for gathering the credentialing verifications for organizational providers (e.g., 180-day rule), date stamps/verification dates are needed in order to ensure that is s being re-verified every three (3) years as required.



CR 8: Delegation of CR

General Updates: MSO:

- All contracted MSOs will be considered a delegated entity when auditing for the ICE Shared Credentialing Program. Each Health Plan will audit the MSO as delegated and will use the information appropriately per their Health Plan performance thresholds.

- If a MSO and a PO are or under the same ownership, this is not considered delegation.

- If a PO changes MSOs during the annual audit period, score only the current agreement and note changes in the comment section to include termination date of prior MSO.

- If a PO terminates a delegation arrangement during the annual audit period, note the termination date in the comments and score N/A.

- If a PO with Medicare or Medicaid contracts delegates to an NCQA Certified entity, the PO must audit for Medicare and Medicaid requirements. Acceptance of certification only will not meet compliance for the additional regulatory requirements.

Delegated Entity Clarification:

If PO gives another organization the authority to perform certain functions on its behalf, this is considered delegation e.g., Primary Source Verification of License, collection of the application, verification of Board Certification. Ongoing monitoring or data collection and alert services are NOT seen as delegation. If PO uses another organization for collecting data for ongoing monitoring or sanctions monitoring for CR 3 B or CR 5, and the PO then handles the review of information and intervention, it is not considered delegation CR 8 E: Opportunities for Improvement:

Delegation oversight process for POs with more than 4 delegates: - Auditors must list all delegates with their delegation agreement effective date on the Audit Tool.- If delegates have more than 4 delegates:

- Auditors will select and review a sample of up to 4 delegates for oversight of CR 8 Elements A, C-E.

- The following year, auditor will select the rest of the delegates that were not audited from the previous year.

- Each audit year select different delegates for the review.- For POs with fewer than four delegates all delegates need to be assessed.

Always complete the grid on the tool when a PO delegates any part of the credentialing process. Must list all delegates with their NCQA Certification Expiration date and the Delegation Agreement Effective Date on the ICE NW Tool tab under CR 8.

If the PO did not use the delegate during the look-back period, but has not termed their Delegation Agreement, note this on the tool and score NA.

Effective date may be at the front of the delegation agreement If date is not in the front, take latest signatory date from both parties as effective date.



Element A: Written Delegation Agreement

The written delegation agreement . (Source: Medicare Managed Care Manual, Chapter 11 § 110.2)1. Is mutually agreed upon

- Dated and signed agreement between both parties must be evident.2. Describes the delegated activities and the responsibilities of the organization and the

delegated entity. Delegation agreement specifies the credentialing activities: Performed by the delegate in detailed language Not delegated, but retained by the organization If the delegate subdelegates, the delegation agreement must state that the delegate or the organization is responsible for subdelegate oversight.The PO may include a general statement that addresses the retained functions (e.g., the PO retains all other CR functions not specified in this agreement as the delegate’s responsibility).

3. Requires at least semiannual reporting of the delegated entity to the organization. Information reported by the delegate on what activities are delegated Reporting can be lists of credentialed/recredentialed practitioners, committee meeting minutes How and to whom information is reported. Score NA for NCQA certified CVOs.

4. Describes the process by which the organization evaluates the delegated entity’s performance.

5. Specifies that the organization retains the right to approve, suspend and terminate individual practitioners, providers and sites, even if the organization delegates the decision making.

If the delegation agreement does not specify the right to approve language, but it is documented through another communication between the organization and the PO, score compliant.

If delegate does not have decision making authority (i.e. CVO for primary source verification) score NA.

6. Describes the remedies available to the organization if the delegated entity does not fulfill its obligations, including revocation of the delegation agreement.



Element A: Delegate Adherence to Medicare Advantage Requirements- CMS

All delegation agreements include a statement that delegates must adhere to Medicare Advantage requirements. (Source: Medicare Managed Care Manual, Chapter 11 § 110.2):

1. The organization may delegate authority for performing the functions within the NCQA/CMS standards to another entity; however, it must maintain responsibility for ensuring that the function is being performed according to organization expectations and to NCQA standards. The following assessment for compliance of delegated NCQA/CMS standards is based on NCQA/CMS’s delegation policy.

There is evidence that both parties to the agreement have signed and dated the agreement. The PO’s delegation agreement must include a statement requiring the delegate to adhere to

CMS regulations. If agreements have language that the delegate will adhere to state and federal regulations, the

agreement is considered compliant. This language is not required for CVO agreements – Score NA and note in comments

Element B: Pre-Delegation EvaluationFor new delegation agreements initiated in the look-back period, the organization evaluated delegate capacity to meet NCQA requirements before delegation began. (Source: Medicare Managed Care Manual, Chapter 11 § 110.2) A PO may use an accredited Health Plan audit as the pre-delegation evaluation. If a PO uses a

Health Plan audit, the auditor must review evidence that the Health Plan audit was reviewed and approved, i.e. Committee minutes, email approval or other methods indicating acceptance of review. If a PO changes MSOs, the PO must evaluate the new MSO prior to contracting.

The PO must have a systematic method for conducting this evaluation, especially if more than one delegation agreement is in effect. The following list are examples:- Site visit- Written review of the delegate’s understanding of the standards and the delegated tasks- Staffing capabilities - Performance records (e.g., Audit)- Exchange of documents and review- Pre-delegation/Committee meetings- Telephone consultation- Virtual review

Auditors need to review for any amendments or newly delegated activities within the last 12 months. If there were any amendments, the PO must have documentation, dated before delegation began showing that it evaluated the entity before implementing delegation. Note in comments newly added activities.

If the pre-delegation evaluation was performed more than 12 months prior to implementing delegation, the PO must conduct another pre-delegation evaluation.

If contract effective date is more than 12 months, score NA. For NCQA CR Certified PO or NCQA Certified CVOs or if the contract effective date is less than 12

months, score 100%.



Element C: Review of Delegate Credentialing ActivitiesFor delegation arrangements in effect for 12 months or longer the organization. (Source: Medicare Managed Care Manual, Chapter 11 § 110.2):

1. Annually reviews its delegate’s credentialing policies and procedures. Review evidence that the PO annually reviewed their delegate’s credentialing policies and

procedures.

For delegates that are NCQA Certified or accredited: Review evidence of annual review of policy and procedures for delegated functions, as

applicable If delegating to a PO for all credentialing functions, review of CR 1 and CR 6 is required.

Policies for CR 2 and CR 5receive oversight relief.

2. Annually audits credentialing and recredentialing files against NCQA standards for each year that delegation has been in effect. A PO may use an accredited Health Plan audit/ICE Shared Audit as the annual file audit

evaluation. If a PO uses a Health Plan audit/ICE Shared Audit, the auditor must review evidence that the Health Plan audit was reviewed and approved, i.e. Committee minutes, email approval or other methods indicating acceptance of review.

If a PO does not use a Health Plan’s audit, the PO must audit per the ICE shared audit tool or

per NCQA standards. For delegates NCQA Certified in CR, Accredited as a Health Plan, NCQA Certified CVOs or if

the contract effective date is greater than 12 months, score 100%. Score NA if there was no initial credentialing or recredentialing activity.

3. Annually evaluates delegate performance against NCQA standards for delegated activities.

This audit includes all pieces of the credentialing process (e.g., policies and procedures, site visits, as applicable, file audit, etc.)

For delegates NCQA Certified in CR, Accredited as a Health Plan, NCQA Certified CVOs or if the contract effective date is greater than 12 months, score 100%.

4. Semi-annually evaluates regular reports, as specified in element A.

Assess the Quality or Credentialing Committee Minutes It is acceptable to only receive lists of credentialed and recredentialed practitioners from

NCQA-accredited or NCQA-certified delegates. Delegates that are not NCQA-accredited or NCQA-certified need to demonstrate that it

collects credentialing data from the delegate, evaluates that data, and takes corrective action if needed and follow-up on deficiencies.

If no performance issues are identified, reporting could be limited to lists of credentialed and recredentialed practitioners.

For MSOs – see reporting numbers which can usually be found in the Quality Improvement Meeting Minutes.

For non-certified CVOs, invoices of providers reviewed may be used as reports For NCQA Certified CVO’s score 100%.



Element D: Opportunities for ImprovementFor delegation arrangements that have been in effect for more than 12 months, at least once in the past year, the organization identified and followed up on opportunities for improvement, if applicable. (Source: Medicare Managed Care Manual, Chapter 11 § 110.2) Findings from the PO’s pre-delegation evaluation, annual evaluation, file audits or ongoing reports

can be sources for identifying areas of improvement for which it takes actions. The PO can use a Health Plan audit to look for opportunities of improvement. If the PO sees that the

Health Plan found opportunities for improvement, the PO reviews the corrective action plan (CAP) from the delegated entity and reviews to see if the audit was reviewed and approved, i.e. Committee minutes, email approval or other methods indicating acceptance of review of the CAP.

If contract effective date is less than 12 months or if no opportunities for improvement, score NA. Score this element 100% if all delegates are NCQA Accredited or NCQA Certified



URAC RequirementsURAC requirements must be reviewed when the PO being audited is contracted with an ICE participating Health Plan that follows URAC.A. Malpractice coverage must be verified by either the face sheet, also known as a declaration sheet or

to collect an attestation from the insurance company.(N-CR5) 1) Provider files must have a copy of the provider’s malpractice face sheet or evidence of

verification from the carrier.2) Score 1 for compliant and 0 for non-compliant on the initial and recred tabs of the ICE

NW Audit Tool. B. The organization provides written notification to providers of the determination of the providers’

credentialing application within ten (10) business days of the determination. (N-CR 13) 1) Mechanisms for meeting the intent of the standard include: Provide notification in writing to

the provider; Provide a list of credentialed/recredentialed providers to the group practice; Recredentialing notification stated in either the provider manual or the provider’s contract (i.e., the provider is considered to be recredentialed unless otherwise notified).

2) When reviewing provider files populate the date the letter was sent to the provider in the appropriate field on the initial and recred tab of the ICE NW Audit Tool.

CMS/WA Medicaid RequirementsCMS/Medicaid requirements must be reviewed when the PO being audited is contracted for Medicare and/or Medicaid line of business with one of the ICE participating Health Plans. The following Medicare/Medicaid requirements must be evident in the provider files. The auditor will score 1 for compliant and 0 for non-compliant elements.

A. SAM/EPLS- evidence in the provider file that the SAM/EPLS query was conducted within 180 days of the decision date.

WA Medicaid Requirements

A. Medicaid Provider Termination and Exclusion List – Evidence in the provider file that the Medicaid Provider Termination and Exclusion List was reviewed within 180 days of the decision date. (Effective for files processed after 1/1/2017).

B. Death Master File- evidence in the provider file that the Death Master File was reviewed within 180 days of the decision date. (Effective for files processed after 1/1/15.)1) If Delegate has been unable to obtain access to the DMF, please indicate their actions in

the Comments.C. NPPES- evidence in the provider file that the NPPES was reviewed prior to the decision date.

(Effective for files processed after 1/1/15.)

OR State RequirementsOregon State requirements must be reviewed when auditing a PO that credentials practitioners who practice in the state of Oregon. A. Health Maintenance Organizations and Preferred Provider Organizations are required to approve or

reject a provider credentialing application within 90 days of receipt of a complete application containing all required credentialing information. (Oregon Revised Statutes 743.918(2).

1) ”Complete application” means a provider's application to an organization to become a credentialed provider that includes: (A) Information required by the organization; (B) Proof that the provider is licensed by a health professional regulatory board as defined in ORS 676.160; (C) Proof of current registration with the Drug Enforcement Administration of the United States Department of Justice, if applicable to the provider's practice; and



(D) Proof that the provider is covered by a professional liability insurance policy or certification meeting the health insurer's requirements.

“Credentialing period” means the period beginning on the date an organization receives a complete application and ending on the date the organization approves or rejects the complete application or 90 days after the health insurer receives the complete application, whichever is earlier. (Eff. 10/1/09)

When reviewing provider files enter the date the completed application was received in the appropriate column on the initial tabs of the ICE NW Audit Tool.

B. Each hospital and health care service contractor shall use the Oregon Practitioner Credentialing Application and the Oregon Practitioner Recredentialing Application adopted pursuant to ORS 442.805 and in accordance with OAR 409-045-0000.

1) When reviewing provider files ensure the uniform credentialing and Recredentialing application was used and score appropriately on the initial and recred tabs of the ICE NW Audit Tool.


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