FAQ Directory: Utilization Management, Credentialing and Provider Network

No. Effective immediately for delegation oversight standards, organizations receive automatic credit for the delegation agreement semiannual reporting requirement in Element A, and for the delegation oversight semiannual report evaluation in Element C, when an NCQA-Accredited/Certified delegate performs an NCQA-required activity.  

For example, in Health Plan Accreditation, NET 6, Element A, factor 3 and NET 6, Element C, factor 3 receive automatic credit for an NCQA-Accredited/Certified delegate. 

This applies to all products. 

Note: This updated FAQ replaces the original version published on September 15, 2025. 

This applies to the following Programs and Years:

Yes. When an organization conducts its UM Information Integrity audit, the audit universe includes data from the most recent 12 months from the timing of the audit. So, although the audit occurs within the look-back period, data reviewed may  include decision notification files from outside the formal look-back window, depending on timing. 

This applies to the following Programs and Years:

If a reviewer is external to the organization, the title/role must reflect it (e.g., “External Reviewer,” “External Independent Reviewer”). 

This applies to the following Programs and Years:

Yes, if the software uses the organization’s clinical criteria, policies and procedures and benefit package information, and the organization maintains control over the software implementation. Organizations may not use the software to make any denial decisions; those must be made by an appropriate clinical professional. Appeal decisions require same-or-similar specialist review, as specified in the NCQA standards.

NCQA considers the use of external software to make approval decisions to be a vendor relationship for applicable requirements (e.g., UM 4, Element F). Refer to Appendix 3: Delegation and Automatic Credit Guidelines for additional information.

This applies to the following Programs and Years:

No. NCQA does not require names or signatures of the reviewers on UM denial and appeal notifications. Please refer to UM 4, Element C and UM 9, Element D for documentation requirements. 

This applies to the following Programs and Years:

NCQA makes disaster accommodations on a case-by-case basis during the accreditation survey process.

The organization must document the events from the disaster that prohibited your organization from meeting the standard/element. During the accreditation survey, the surveyor will document all findings which will be reviewed by our Review Oversight Committee (ROC) to determine if any accommodations or exceptions should be granted.

The organization should communicate with the assigned ASC if accommodations are requested.

This applies to the following Programs and Years:

No. Organizations are still required to monitor for system controls. The NA for the system controls policies and procedures requirement (e.g., UM 12, Element A, factor 7, in Health Plan Accreditation) does not affect an organization’s ability to meet the corresponding system controls monitoring requirement (e.g., UM 12, Element B in Health Plan Accreditation); it means the organization is not required to describe the monitoring process in its policies and procedures, but must monitor that its systems are protecting data from unauthorized modifications. Also, as noted in “Related information” in the monitoring requirements (e.g., UM 12, Element B in Health Plan Accreditation), NCQA only reviews specific components for monitoring (e.g., for UM, NCQA reviews that the organization monitored receipt and notification dates).

Note: The referenced memo is on the NCQA website at https://www.ncqa.org/wp-content/uploads/2025-Retroactive-Changes-Memo_Final.pdf. It applies to the 2024/2025 standards year only; no exceptions (NA scores or other changes) will be made for the 2023 or prior standards years. Surveys conducted on standards prior to 2024 standards will be reviewed and scored accordingly; any corrective actions issued prior to the 2024 standards still apply

This applies to the following Programs and Years:

No. NCQA UM standards do not allow the use of AI to make medical necessity denial decisions, or any appeal decisions. 

If an organization uses AI in the UM process, medical necessity review requires that denial decisions be made only by an appropriate clinical professional and appeal decisions require same-or-similar specialist review, as specified in the NCQA standards.  

This applies to the following Programs and Years:

If an organization delegates more than 50% of primary source verifications and one or more of its delegates loses Accreditation/Certification status, NCQA considers this a Reportable Event. The organization must notify NCQA (through My.NCQA.org) within 30 calendar days.

This applies to the following Programs and Years:

No. Notice of Medicare Non-Coverage (NOMNC) denial files are out of NCQA’s scope of review and should be excluded from the UM file universe.

This applies to the following Programs and Years:

Yes. Organizations may use SAM.gov to verify Medicare and Medicaid sanctions for CR 3, Element B, factor 2 and CR 5, Element A, factor 1.

This applies to the following Programs and Years:

Yes. Using UM 13: Delegation of UM as an example, the following describes factors that would be considered NA:
UM 13, Element A: Delegation Agreement

• Factor 3 (semiannual reporting): This factor is NA for mail service organization delegates that only perform annual distribution (e.g., UM 11, Element B (annual updates for pharmaceutical restrictions/preferences).
  • Note: Factor 4 (performance monitoring): Annual distribution must be specified as part of the organization’s process for monitoring delegate performance, if applicable.
  • Factor 3 is not scored NA for distribution that occurs more frequently than annually (e.g., denial and appeal notices).
• Factor 5 (process for providing member experience and clinical performance data to delegates when requested): This factor is NA for mail service organization delegates.

UM 13, Element C: Review of the UM Program:

• Factor 1 (annual review of delegate’s UM program): This factor is NA for mail service organization delegates.
• Factor 4 (semiannual evaluation of reports): This factor is NA for mail service organization delegates that only perform annual distribution.
  • Factor 4 is not scored NA for distribution that occurs more frequently than annually (e.g., denial and appeal notices).

Note: Factor 2 (annual audits): This factor is not scored NA, but the organization may submit the delegate’s timeliness report of mail distribution in lieu of an audit.  This must be specified in the delegation agreement.

Update: The strikethrough text is an update to the FAQ posted on October 15, 2022.

This applies to the following Programs and Years: