FAQ Directory

Yes. The cell should be highlighted to indicate that it is calculated by IDSS.

This applies to the following Programs and Years:

Yes. Disregard the “N” in Table 1. Organizations may reduce the sample size for the CIS measure using the prior year’s rate or the current year’s administrative rate.

**This FAQ applies to QRS MY 2022.

This applies to the following Programs and Years:

CR 1, Element C, factor 5 requires organizations to have a process for monitoring that policies and procedures are followed for all other factors (factors 1–4) in this element at least annually. Policies and procedures must describe the monitoring process for factor 5.

For CR 1, Element D, the organization submits evidence that it identified, analyzed and acted only on modifications to credentialing/recredentialing information (CR 2 – CR 5) that did not meet the organization’s policies and procedures.

This applies to the following Programs and Years:

No. If the organization provides evidence of advanced system controls capabilities, it must submit policies and procedures for UM 11, Elements A and C and for CR 1, Element C. Policies and procedures must address all factors regarding advanced system control capabilities.

Organizations are only eligible to receive a score of Met for UM 11, Elements B and D, and for CR 1, Element D if they provide evidence of advanced system control capabilities that both automatically record dates and prevent changes that do not meet the organization’s policies and procedures.

This applies to the following Programs and Years:

For UM 12, Elements A and C:

• Factors 1–5 apply to receipt and notification dates, covered in UM 5 and UM 8–UM 9.
• Factor 6 applies to all UM system data for managing denials and appeals (not only the dates specified in factors 1–5), covered in UM 4–UM 7 and UM 8–UM 9.
• Factor 7 requires a monitoring process that covers compliance with all policies and procedures described in factors 1–6.

This applies to the following Programs and Years:

For CR 1, Element C:

• Factor 1 applies to verification source information from credentialing and recredentialing cycles, covered in CR 3, Elements A–C.
• Factor 2 applies to modified credentialing verification information from initial credentialing and recredentialing cycles, covered in CR 3, elements A–C.
• Factors 3–4 apply to all information associated with credentialing/recredentialing of practitioners, covered in CR 2–CR 5.
• Factor 5 requires a monitoring process that covers compliance with all policies and procedures described in factors 1–4.

This applies to the following Programs and Years:

No. Although the organization may set a monitoring goal, NCQA does not require it for UM 11, Elements B and D, factor 2 and CR 1, Element D, factor 2. The intent is that the organization reviews all instances of modifications that did not meet its policies and procedures.

This applies to the following Programs and Years:

UM 12, Elements A and C, factor 7 require organizations to have a process for monitoring that policies and procedures are followed for all other factors (factors 1–6) in this element at least annually. Policies and procedures must describe the monitoring process for factor 7.

For UM 12, Elements B and D, the organization submits evidence that it identified, analyzed and acted only on modifications to receipt and notification dates (UM 5) that did not meet the organization’s policies and procedures.

This applies to the following Programs and Years:

Both the organization and delegate must monitor the delegate’s system security controls as part of the delegation oversight requirements and may choose audit as the monitoring method. If auditing is the chosen method, the delegate provides an audit report of modifications that did not comply with its policies and procedures or with the delegation agreement.

The organization is not required to conduct an audit if it determines that the delegate adequately monitored and reported noncompliant modifications, but must provide documentation (a report, meeting minutes or other evidence) that it reviewed and agreed with the delegate’s findings. If the organization determines that the delegate did not adequately monitor noncompliant modifications, it must conduct its own audit of the delegate’s system controls.

The organization must submit its documentation and the delegate’s documentation as part of the survey.
 

This applies to the following Programs and Years:

No. If the organization provides evidence of advanced system controls capabilities, it must submit policies and procedures for UM 12, Elements A and C and for CR 1, Element C. Policies and procedures must address all factors regarding advanced system control capabilities.

Organizations are only eligible to receive a score of Met for UM 12, Elements B and D, and for CR 1, Element D if they provide evidence of advanced system control capabilities that both automatically record dates and prevent changes that do not meet the organization’s policies and procedures.

This applies to the following Programs and Years:

No. Although the organization may set a monitoring goal, NCQA does not require it for UM 12, Elements B and D, factor 2 and CR 1, Element D, factor 2. The intent is that the organization reviews all instances of modifications that did not meet its policies and procedures.

This applies to the following Programs and Years:

UM 11, Elements A and C, factor 7 require organizations to have a process for monitoring that policies and procedures are followed for all other factors (factors 1–6) in this element at least annually. Policies and procedures must describe the monitoring process for factor 7.

For UM 11, Elements B and D, the organization submits evidence that it identified, analyzed and acted only on modifications to receipt and notification dates (UM 5) that did not meet the organization’s policies and procedures.

This applies to the following Programs and Years: