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.
UM_CR 2022
No. Delegate files may be audited using one of the following methods as described in the factor explanation and noted below:
Either methodology is allowed, for consistency with other Delegation Oversight requirements for annual file audits.
UM_CR 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:
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:
Note: The underlined text is an update to the FAQ posted on January 15, 2022.
UM_CR 2022
No. Delegate files may be audited using one of the following methods as described in the factor explanation and noted below:
Either methodology is allowed, for consistency with other Delegation Oversight requirements for annual file audits.
UM_CR 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.
UM_CR 2022
NCQA considers it to be delegation if the organization uses another organization, including a mail service organization, to perform any function not listed in the “Vendor” section of Appendix 3.
NCQA considers it to be a vendor relationship if the organization uses another organization (e.g., a mail service organization) to perform functions evaluated by the elements or element components listed in the "Vendor" section of Appendix 3.
UM_CR 2021
A Corrective Action Plan (CAP) is required when an organization does not meet the minimum threshold for one or more must-pass elements. The CAP must be submitted to NCQA within 30 days after receipt of the final Accreditation status and must meet NCQA approval. The organization undergoes a CAP Survey that focuses on the failed must-pass elements (not at the factor level), i.e., all element factors, will be reviewed in addition to the factor(s) that failed the must-pass requirement.
NCQA schedules the CAP Survey for submission 6 months following the organization’s last full survey; the file review is 4 weeks later. The organization’s Accreditation status is noted “Under Corrective Action” status modifier noted on the report card during the corrective action period.
The fees for the CAP Survey can be found in the Pricing Exhibit on My NCQA. The look-back period is from the date of implementation of the corrective action up to the CAP Survey submission date and may be between 3 and 6 months before the CAP Survey submission.
After successful completion of the CAP Survey, the status modifier is removed from the organization’s status on the report card. The expiration date of the Accreditation status remains the same as the date specified in the decision that precipitated the CAP Survey. If a CAP Survey is unsuccessful, the Review Oversight Committee (ROC) may:
UM_CR 2019
For all product lines, dental and vision requests covered under the organization's medical benefit are within the scope of medical necessity review and must be included for UM file review for denials (UM 4-7) and appeals (UM 9), as outlined in the file review instructions.
Dental and vision requests not covered under medical benefits are not within the scope of denial and appeal file review.
UM_CR 2020
NCQA added the word “all” to CR 7 in the 2020 HPA standards and guidelines because it expects organizations to have policies for assessing all providers with which they contract. However, under the 2020 standards and in previous years, NCQA only scores policies for providers listed in CR 7, Elements B and C.
Because the definition may not be sufficient to clearly identify which organizations NCQA considers “providers,” here is a list of provider types in addition to those listed in Elements B and C:
UM_CR 2020
If an organization contracts with external entities to store its own credentialing data or contracts with CR delegates that store data, NCQA also reviews contracts from up to four randomly selected external entities, or reviews all external entities if the organization has fewer than four. If factor 4 is not addressed in a contract, the organization may also present the external entity’s policies and procedures for review. NCQA reviews documentation from the organization and from each external entity against the factor. To be scored “yes,” the organization's and each external entity’s documentation must meet the factor.
Note: The underlined text is an update to the FAQ posted on June 15, 2020. Refer also to the FAQ on the same date regarding cloud storage entities.
UM_CR 2020
If an organization contracts with external entities to store its own UM data or contracts with UM delegates that store data, NCQA also reviews contracts from up to four randomly selected external entities, or reviews all external entities if the organization has fewer than four. If factor 6 is not addressed in a contract, the organization may also present the external entity’s policies and procedures for review. NCQA reviews documentation from the organization and from each external entity against the factor. To be scored “yes,” the organization's and each external entity’s documentation must meet the factor.
Note: The underlined text is an update to the FAQ posted on June 15, 2020. Refer also to the FAQ on the same date regarding cloud storage entities.
UM_CR 2020
NCQA includes external entities that store, create, modify or use UM data for any function covered by the UM standards on behalf of the organization in the scope of Elements A and B, factor 6, with the exception of organizations whose only UM service provided for the organization is to provide cloud-based data storage functions and not services that create, modify or use UM data.
UM_CR 2020
