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FAQ Directory: Managed Behavioral Healthcare Organization Accreditation

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3.17.2025 Delegation Oversight Information Integrity Annual Audit Are organizations required to conduct an annual delegation oversight audit to meet 2025 UM and CR information integrity audit requirements?

No. For standards year 2025 only, NCQA will allow all organizations, regardless of their audit schedule, to submit a detailed implementation plan in lieu of conducting the delegation oversight information integrity audit.    

The implementation plan for each applicable delegate must include:

  • The delegate’s name.
  • The entity conducting the audit (organization or delegate).
    • If the delegate conducts the audit, the implementation plan must include the organization’s plan for review and evaluation of audit findings.
  • The title of staff who conduct the audit.
  • The audit methodology.
  • The audit due date.

Organizations must submit either an information integrity audit report or an audit implementation plan (for selected delegates) at the time of survey submission for the following products:

  • HP: UM 13, Element C, factors 5-7; CR 9, Element C, factors 5-7.
  • CRPN: CR 3, Element C, factors 5-7.
  • UMCRPN: UM 13, Element C, factors 5-7.
  • MBHO: UM 12, Element C, factors 5-7; CR 9, Element C, factors 5-7. 

Organization-level information integrity audits must be conducted, and an implementation plan is not acceptable for the following requirements: 

  • HP: UM 12, Element D; UM 12, Element F, CR 8, Element C.  
  • CRPN: CR 2, Element C.
  • UMCRPN: UM 12, Element D; UM 12, Element F.
  • MBHO: UM 11, Element D; UM 11, Element F; CR 8, Element C.

Note: A related question was posted on 1/15/2025: “Do organizations need to conduct a delegation audit(s) on the 2025 Information Integrity standards within 12 months prior to survey submission date?” This FAQ replaces that post.

MBHO 2025