FAQ Directory: Utilization Management, Credentialing and Provider Network

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2.15.2022 Annual Monitoring of UM System Controls Monitoring for Delegates Have the allowed methods to audit delegate files in UM 13, Element C, factor 5 changed?

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.

UM_CR 2022