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

New FAQs are posted on the 15th of every month.
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CR   Verification of Education and Training for expired Board Certification
    Question: Must an organization verify education and training for a practitioner whose board certification has expired?
    Resolution: An organization that is initially credentialing a practitioner whose board certification has expired must verify the highest level of completion of residency or graduation from medical school to meet the verification requirement. If the organization is recredentialing a practitioner with an expired board certification that was previously verified, verification of education and training is not required. The organization need only note the expiration date in the practitioner's credentialing file.
 
CR   Use of alert services to meet credentialing standards
    Question: Are alert services, such as the Proactive Disclosure Service of the National Practitioner Data Banks, acceptable sources for verification of sanctions?
    Resolution: Yes, if the alert service is sponsored by an acceptable source for NCQA sanction requirements (i.e., CR 5; CR 7D; CR 9A, factor 2) and meets NCQA standards for electronic verification.
 
CR1   Delegation of Credentialing Activities
    Question: If an organization does not currently delegate activities, do the credentialing policies and procedures need to specify that the organization does not delegate credentialing activities to receive credit for CR 1 Element A, factor 6?
    Resolution: Yes, an organization that does not delegate credentialing must state in its credentialing policies and procedures that it does not delegate credentialing activities.
 
CR1   Practitioners who need to be credentialed
    Question: Are practitioners in rental networks within the scope of credentialing?
    Resolution: It depends. Rental network practitioners are considered within the scope of credentialing in any of the following circumstances. 1. The organization uses the rental network as part of its primary network and has members who reside in the area 2. Rental network practitioners are specifically for out-of-area care and members may see only those practitioners 3. Rental network practitioners are specifically for out-of-area care and there is an incentive communicated to members to see rental network practitioners

Rental network practitioners are considered to be outside of the scope of credentialing if all of the following criteria are met. 1. The rental network is specifically for out-of-area care 2. Members may see any practitioner, not just rental network practitioners 3. There are no incentives for members to use rental network practitioners

 
CR3   Verification of Lifetime Board Certification
    Question: Must organizations verify a lifetime board certification at both initial credentialing and recredentialing?
    Resolution: Yes. If a practitioner states that he or she is board certified, an organization must verify lifetime board certification at initial credentialing and at recredentialing. Lifetime board certification can be revoked for various reasons, including failure to maintain professional standing and disciplinary action. If the board does not give an expiration date for lifetime certification, the organization must document "lifetime" in the file.
 
CR3   ABMS Compendium
    Question: Does NCQA accept the ABMS compendium as a primary source for verification of board certification of practitioners?
    Resolution: No. The ABMS compendium is no longer an acceptable primary source for verification of practitioner board certification. The ABMS has phased out the Official ABMS Directory Print Set and the ABMS Medical Specialist Plus CD-ROM as forms of primary source verification. The only acceptable ABMS sources are products or services specifically designated by the ABMS as Official ABMS Display Agents and those which come directly from the ABMS and its member boards (not agents or licensees), where a dated certificate of primary source authenticity has been provided.
 
CR3   Verification of DEA or CDS certificate
    Question: The Drug Enforcement Administration amended, effective January 2, 2007, its registration regulations to make it clear that when an individual practitioner practices in more than one state, he or she must obtain a separate DEA registration for each state. Does this change NCQA’s DEA verification requirements for Element B of CR 3 and CR 7?
    Resolution: NCQA requires organizations to verify DEA or CDS, as applicable. Effective for credentialing decisions made on or after July 1, 2007, the organization must provide evidence of verification of valid DEA or CDS certificate, as applicable, in every state in which the practitioner provide care to the organization’s members.
 
CR7   Verification of DEA or CDS certificate
    Question: The Drug Enforcement Administration amended, effective January 2, 2007, its registration regulations to make it clear that when an individual practitioner practices in more than one state, he or she must obtain a separate DEA registration for each state. Does this change NCQA’s DEA verification requirements for Element B of CR 3 and CR 7?
    Resolution: NCQA requires organizations to verify DEA or CDS, as applicable. Effective for credentialing decisions made on or after July 1, 2007, the organization must provide evidence of verification of valid DEA or CDS certificate, as applicable, in every state in which the practitioner provide care to the organization’s members.
 
CR7   ABMS Compendium
    Question: Does NCQA accept the ABMS compendium as a primary source for verification of board certification of practitioners?
    Resolution: No. The ABMS compendium is no longer an acceptable primary source for verification of practitioner board certification. The ABMS has phased out the Official ABMS Directory Print Set and the ABMS Medical Specialist Plus CD-ROM as forms of primary source verification. The only acceptable ABMS sources are products or services specifically designated by the ABMS as Official ABMS Display Agents and those which come directly from the ABMS and its member boards (not agents or licensees), where a dated certificate of primary source authenticity has been provided.
 
CR10   Notification of Appropriate Authorities
    Question: Does the notification of appropriate authorities requirement for contract suspensions and terminations apply to actions taken against non-physicians or just those taken against physicians?
    Resolution: The notification requirement applies to both physicians and non-physicans. The Health Care Quality Improvement Act of 1986 amended in January of 1998, indicates that reporting requirements are not limited to physicians; they apply to non-physicians too.
 
DEL   Automtic Credit for Elements not Reviewed During a Delegate’s Survey
    Question: Can an organization receive automatic credit for an element if the NCQA-accredited or certified delegate has not been reviewed against that element?
    Resolution: No. In order for an organization to receive automatic credit for an element that was delegated to an NCQA-accredited or certified entity, the delegate must have been reviewed against that element during its last survey. NCQA reviews the delegate's last survey to determine what elements will receive automatic credit when the organization comes through a survey.
 
EoC6   Site Visit Assessment and Evaluation of Medical Record Practices
    Question: What does NCQA require for proof of site visit assessment and evaluation of medical/treatment record keeping practices?
    Resolution: NCQA requires evidence of the practitioner’s actual site visit assessment and evaluation of medical/treatment record keeping practices. Simply providing a numeric score within a credentialing file does not meet the requirement.
 
MISC   Points Display for Appendix 1
    Question: Are the points shown in Appendix 1 of the Standards and Guidelines exactly the same as those in the Interactive Survey System (ISS)?
    Resolution: No. The ISS does not round or truncate points, whereas delegation points in Appendix 1 are rounded to two decimal places for display. Because of this, the numbers in the Standards and Guidelines are slightly different in the SGs from those in the ISS.
 
MISC   Acceptable Writing Instruments for Documentation
    Question: Is a pencil an acceptable writing instrument for documentation?
    Resolution: Effective January 1, 2009, NCQA will not accept use of pencil as an acceptable writing instrument for accreditation or certification documentation purposes.
 
QI3   Use of the Provider/Practitioner Manual as Documentation
    Question: May an organization use its Provider/Practitioner Manual to meet QI 3, Elements A–D?
    Resolution: Yes. An organization may use its provider/practitioner manual to meet the requirements in QI 3, Elements A–D under the following conditions.
1. The provider/practitioner contract must specify that the manual is an extension of the provider/practitioner contract and provider/practitioners must abide by the conditions set forth in both the contract and in the manual.
2. The manual must include NCQA requirements.
 
QI10   Continued Access to Practitioners
    Question: For QI 10, Element C, factor 1, does the 90-day requirement for continued access start from the date of the notice to members or from the date of contract termination?
    Resolution: If the practitioner contract is discontinued, the 90-day requirement for continued access starts from the date of contract termination.
 
RR7   Exception for Medicare and Medicaid Plans
    Question: Should there be an exception for Medicare and Medicaid plans for RR 7, Element B, factor 5?
    Resolution: Yes, factor 5 is scored NA for Medicare and Medicaid.
 
UM4   Practitioner Review of Denials
    Question: Should all pharmacy denials (noted in the exceptions of UM 4, Element C) be excluded from an organization’s list of reasons for denial?
    Resolution: If a pharmaceutical is denied, for any reason, the organization must decide if the denial is based on medical necessity or benefits, using NCQA definitions. This determines whether the denial should be included in the file sample list. If the organization provides an alternative pharmaceutical to one that is requested, based on generic substitution or therapeutic alternatives, NCQA considers it an approval, which would not be included in the denial file review.
 
UM7   Notification of Appeal Rights
    Question: Does NCQA require that the notification of the appeal rights/process be given to the treating practitioner?
    Resolution: Yes. As described in the intent of UM 7, practitioners need to be notified of a denial along with the appeal rights/process.
 
UM7   Notice of Member Representation when Member's are not at Financial Risk
    Question: For denials in which the member is not at financial risk, must the denial notice to the treating practitioner include an explanation of the right to "member" representation to meet the intent of UM 7, Element D since the health plan is not required to send notification to the member in Element C?
    Resolution: The denial notice to the practitioner would need to contain the required information for UM 7 Element C factor 3 and the member representation component of UM 7 Element D factor 2 only when the practitioner is acting as the member's authorized representative. NCQA assumes that the practitioner is acting as the member's authorized representative for urgent preservice and urgent concurrent requests from practitioners; therefore, denial notices to the practitioner in such cases would need to include the referenced information. NCQA does not assume that the practitioner is acting as the member's authorized representative for nonurgent and postservice requests and does not require the practitioner denial notice to include the referenced information in such cases.
 
UM9   Final Internal Denials or Denials Overturned by the IRO
    Question: For Elements F and G, if an organization has more than five files, , what is NCQA’s expectation for file selection?
    Resolution: If there are more than five files, the organization should provide the five most recently completed files.

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