FAQ Directory: Health Plan Accreditation

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.

HP 2022

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.

HP 2022

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.

HP 2022

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.

HP 2022

No. Sampling is not required by product line if the product lines are managed the same (a single system is used to manage all product lines).

HP 2022

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.

HP 2022

For Maryland practitioners credentialed between December 2021 and February 2022, NCQA will not penalize organizations on inability to verify licensure due to the MDH network security incident. NCQA accepts the MDH’s grace period on licensure expirations and accepts temporary licenses issued by the MDH and will consider them current and valid. Organizations should adhere to guidance provided by MDH and document the guidance in the affected practitioners’ credentialing files.

HP 2022

Yes. NCQA has decided to allow sampling for organizations that use auditing as the method for monitoring in UM 12, Elements A – D and CR 1, Elements C and D. Organizations must use the “5% or 50 files” audit method: Organizations randomly select 5% or 50 files, whichever is less, from each applicable file type, to review against the requirements: 

• Credentialing and recredentialing. (5% or 50 files total)  
  • At a minimum, the sample includes at least 10 credentialing files and 10 recredentialing files. If fewer than 10 practitioners were credentialed or recredentialed since the last annual audit, the organization audits the universe of files rather than a sample. 
• UM denials (5% or 50 files). 
• UM appeals (5% or 50 files). 

For each applicable file type noted above, the organization must determine the sample size of 5% or 50 files (whichever is less) based on all files in the file universe. The file universe includes all files with or without modifications. The sample that will be audited must include only files with modifications (i.e., modifications that meet and do not meet the organization’s policies and procedures). NCQA does not specify how the organization selects the sample once the sample size is determined using the entire file universe. It may select the sample of modified files from the universe or, if the organization can identify files with modifications, it may randomly select the sample that will be audited from only the modified files.

The organization’s analysis report must include the number or percentage of files that do not meet the organization’s policies and procedures.
Example for UM denials:

• An organization’s UM denial file universe contains 800 files with and without modifications. Therefore, the minimum required sample for review is 40 files (5% of 800) which is less than 50 files. The organization must randomly select the 40 files for review from the total universe of 800 files or from only files with modifications (if the organization’s system has the capability to identify files with modifications). All 40 files must have a modification and are reviewed against the organization’s policies and procedures to identify noncompliant modifications.

Note: The underlined text is an update to the FAQ posted on January 15, 2022.

HP 2022

No. Delegate files may be audited using one of the following methods as described in the factor explanation and noted below:

• 5 percent or 50 of its files, whichever is less, to ensure that information is verified appropriately.
• The NCQA “8/30 methodology” available at https://www.ncqa.org/programs/health-plans/policy-accreditation-and-certification/

Either methodology is allowed, for consistency with other Delegation Oversight requirements for annual file audits.

HP 2022

No. Delegate files may be audited using one of the following methods as described in the factor explanation and noted below:

• 5 percent or 50 of its files, whichever is less, to ensure that information is verified appropriately.
  • At a minimum, the sample includes at least 10 credentialing files and 10 recredentialing files. If fewer than 10 practitioners were credentialed or recredentialed since the last annual audit, the organization audits the universe of files rather than a sample.
• The NCQA “8/30 methodology” available at https://www.ncqa.org/programs/health-plans/policy-accreditation-and-certification/

Either methodology is allowed, for consistency with other Delegation Oversight requirements for annual file audits.

HP 2022

New delegation agreements implemented on or after January 1, 2022, must include a description of the delegate’s UM/CR system security controls.
 
For delegation agreements in place prior to January 1, 2022, NCQA has extended the time frame for including a description of UM/CR system controls in the delegation agreement. All delegation agreements under the 2024 HPA standards (effective July 1, 2024) must include a description of UM/CR system controls. Prior to July 1, 2024, organizations may alternatively provide a delegation agreement and other mutually agreed upon documentation OR the delegate's system controls policies and procedures in lieu of a delegation agreement with a description of UM/CR System controls.

HP 2022

The APM measure may be used if it is relevant to the population. Because it applies to children and adolescents, it was removed from the factor 6 examples to align with the exception (factor 6 is NA if the organization’s membership does not include adult members).

HP 2022