Frequently Asked Questions (FAQs) About NCQA's Accreditation, Certification and HEDIS^®.

Product:

CR		Documentation expectation for organizations using Proactive Disclosure Service
		Question: May a checklist be used to document review of credentialing information?
		Resolution: Yes. Organizations may use an appropriately signed (or initialed) and dated checklist to document verification and review of the PDS reports.
CR		Documentation expectation for organizations using Proactive Disclosure Service (PDS)
		Question: Must organizations present evidence of practitioner enrollment in the PDS?
		Resolution: Yes. Organizations must provide evidence from the PDS of practitioner enrollment in the PDS.
CR		Documentation expectation for organizations using Proactive Disclosure Service (PDS)
		Question: Must organizations document review of PDS alerts within NCQA-specified time frames?
		Resolution: Yes. Organizations must clearly document review of alerts received within 180 calendar days of the Credentialing Committee’s decision for CR 3, 5 and 7, and within 30 calendar days of ongoing monitoring in CR 9.
CR		Documentation expectation for organizations using Proactive Disclosure Service (PDS)
		Question: What if no PDS alerts are received after enrollment in the PDS?
		Resolution: NCQA requires only notation or documentation that no alert reports were received within 180 calendar days before the Credentialing Committee’s decision. Organizations should present the dated reports provided at enrollment to the Credentialing Committee, or to the medical director, in the case of clean files.
CR		Documentation expectation for organizations using Proactive Disclosure Service (PDS)
		Question: What if no PDS alerts are received for ongoing monitoring?
		Resolution: Organizations must document or note that no alerts were received during the look-back period.
CR1		Nondiscriminatory credentialing and recredentialing
		Question: Does maintaining a heterogenous credentialing committee and requiring those responsible for credentialing decisions to sign a statement affirming that they do not discriminate, meet the requirements for CR 1, Element A, factor 7, as indicated in the examples section?
		Resolution: The scenario presented only addresses the "prevention" aspect of the requirements, but it does not address the "monitoring" aspect of the requirements. The organization's policies and procedures must explicitly describe the steps that organizations take to monitor and prevent discriminatory practices.
CR2		Medical director oversight for credentialing a physical therapy network
		Question: Must a physician provide oversight of a credentialing program for a physical therapy organization that only credentials physical therapists?
		Resolution: No. An organization may allow a senior level physical therapist with appropriate education, training and professional experience in physical therapy to oversee this type of program. The physical therapist must be licensed to practice independently.
CR3		Lack of expiration date for board certification
		Question: What is NCQA’s documentation requirement if a medical board does not provide an expiration date?
		Resolution: If the medical board does not provide the expiration date for a practitioner's board certification, the organization must verify and document that the board certification is current within 180 calendar days of the credentialing decision date.
CR3		Expiration date for board certification not provided by ABMS member board American Board of Pediatrics
		Question: How should organizations handle NCQA's expiration date and timeliness requirements if the Medical Board does not provide an expiration date for a practitioner's board certification?
		Resolution: If the medical board does not provide the expiration date for a practitioner's board certification, the organization must verify that the board certification is current. Verification must be documented 180 calendar days prior to the recredentialing decision date.
MISC		Use of the term "days" within the standards and guidelines
		Question: Do all references to “days” in the standards and guidelines mean “calendar days”?
		Resolution: Yes. Unless otherwise specified, all references to “days” in the standards and guidelines mean calendar days.
MISC		Notification of information available on the Web site
		Question: Which methods are acceptable for notifying members or practitioners in writing that information is available on the Web site?
		Resolution: Organizations may use mail, fax or e-mail to notify members or practitioners that information is available on the Web site.
MISC		Automatic credit for file review
		Question: Does the 70 percent criterion for automatic credit apply to file-review elements when using an NCQA Accredited or NCQA Certified delegate?
		Resolution: No. The 70 percent criterion for automatic credit does not apply to CR or UM file review elements in which the delegate is NCQA Accredited or NCQA Certified in CR or UM. All CR or UM files from NCQA Accredited or Certified delegates are eligible for automatic credit regardless of the percentage of the organization’s membership covered by the delegate’s services.

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