NCQA Flashcards
According to NCQA, which of the following sources can be used for verification of State Licensure?
A) AMA B) FSMB C) State licensing board
Answer: C
Which of the following is recognized by NCQA as an incomplete verification?
A) Internet verification from a website not controlled by the primary source that attests to the accuracy and timeliness of the information.
B) Verbal verification documenting the date of the verification, staff members signature, initials, and the credentials verified.
C) Dated and signed written verification from the primary source.
Answer: A
Does NCQA require board certification?
NCQA does not require board certification.
According to NCQA practitioners must be notified of credentialing decision within how many days?
60 Days
NCQA requires verification of malpractice history for how many years?
The last five year period
NCQA time frame for reappointment
every 36 months (3 years)
According to NCQA an organization must have credentialing policies in place to obtain approval to enter into…
A delegated agreement
According to NCQA practitioners must be notified of credentialing decision within how many days?
60 days
Which accrediting body requires five year verification of malpractice history?
NCQA
True or False - only the highest of training must be verified according to NCQA
True
Attestation must include inquiry regarding illegal drug use?
NCQA
Attestation must include inquiry regarding inability to perform essential functions?
NCQA
Attestation must include inquiry regarding history or loss of limitation of licensure or privileges or disciplinary actions?
NCQA
Attestation must include inquiry regarding felony convictions?
NCQA
Applicant must attest to limitation on ability to perform functions of the position with or without accommodation if any?
NCQA
NCQA requires the MCO to obtain a minimum of ??? years of work history?
Five years (5)
According to NCQA what policy must an organization have in place to obtain approval to enter into a delegated agreement?
Credentialing Policies
According to NCQA, how may days is the time limit on primary source verification of current licensure?
180 Days
According to NCQA practitioners must be notified of credentialing decision within how many days?
60 Days
Which accrediting body requires five year verification of malpractice history?
NCQA
NCQA requires verifications must be less than how many days old?
180
What is the verification time limit on malpractice history according to the NCQA?
180 days
What accreditation body states the NPDB is an acceptable source for sanctions or limitations on licensure, Medicaid/Medicare sanctions and malpractice history?
NCQA
According to NCQA verification of Medicare/Medicaid sanctions can be queried by any of what sources?
AMA, FSMB, HIPDB, OIG, Sanctions Report, NPDB, State Agency
According to NCQA, how often must an organization conduct an audit of the credentialing process delegated to another organization?
Annually
Is an internet verification from a website not contracted by the primary source that attest to the accuracy and timeliness of the information considered a complete verification by NCQA?
No
According to NCQA what providers are NOT required to be credentialed when working in an independent relationship?
Locum Tenens, Hospital based practitioners (ie: anesthesia, pathology, radiology, etc.)
Who requires only the highest level of training to be verified?
NCQA
According to NCQA any gap in personal history greater than ???? must be clarified in writing?
One year
According to NCQA what requires ongoing monitoring between credentialing cycles?
license sanctions
What is NCQA’s requirement for history of felonies on applications and reappointment?
The application requires a statement from the applicant.
According to NCQA standards; if deficiencies are noted during a site visit an action plan must be developed. The office site must implement the plan within ????? of the initial visit?
6 months
What is the time limit on PSV of current licensure according to NCQA?
180 days
What is the NCQA timeframe for appointment?
every 36 months to the month
Who must conduct site visits for complaints & evaluate every 6 months?
NCQA
What is the verification time limit for medicare sanctions for NCQA?
180 days
Does NCQA use credentialing committee to make recommendations?
Yes
NCQA current licensure verification time limit of CVO?
120 days
NCQA malpractice verification time limits for CVO?
120 days
NCQA time limits on professional liability malpractice for CVO?
Must be current, valid and verified within 305 calendar days prior to submission to each client/claim
Verification time limit for licensure per NCQA CVO standards?
120 days
Per NCQA standards on initial applications review of information on sanctions, restrictions, on licensure and limitations on scope of practice must cover what period of time?
the most recent five years
In the MCO, a review board or governing body may review a credentialing decision after the credentialing committee approval. What date does the NCQA use when assessing performance against timeliness requirements for PSV?
Decision date of the credentials committee
At reappointment NCQA requires 4 factors within prescribed time limits?
1) DEA or CVS (Credential Verification System/Service)
2) Board Certification
3) Liability Claims, Settled or judgements
4) Licensure
NCQA requires these factors prior to provisional credentialing?
current license, past five years of claims, settlements or NPDB report, application with signed attestation
What is the verification time limit for licensure per NCQA CVO Standards?
120 Days
According to NCQA standards, on intial application review of information on sanctions, restrictions on licensure and limitations on scope of practice must cover what period of time?
Most recent five year period
In regards to the credentialing process, NCQA standards require the organization to have written policies and procedures to delineate a practitioner’s rights. These include:
1) The right to review information submitted to support the credentialing application.
2) Right to correct erroneous information
3) Right to receive notification of these rights
4) Right to receive status application upon request.
When credentialing, NCQA requires the organization to verify four factors that can prescribe time limits. What are they?
1) DEA 2) Board certification 3) History of professional liabilities resulting in settlement 4) Licensure
NCQA requires verification of which three factors prior to provisionally credentialing a provider?
PSV current license, past five years malpractice or NPDB, current signed application with attestation
Name two sources of verification of education of a chiropractor according to NCQA?
1) Chiropractic College 2) State licensing agency
According to NCQA what verification is required before provisional credentialing is permitted?
1) current licensure 2) 5 year malpractice history
NCQA requires applicants to confirm good health & competence to perform essential functions - how is this achieved?
signed attestation
What is the verification time limit for verification of Medicare/Medicaid sanctions according to NCQA?
180 days
According to NCQA, how long is the signature on the attestation good for, for the CVO’s?
305 days
According to NCQA, how long is the signature on the attestation good for?
365 days
Name 3 sources of verification of education of a dentist according to NCQA?
1) Dental School 2) Specialty Board 3) State licensing board
NCQA requires MCO’s to recredential practitioner’s every
3 years
What six criteria are observed in an initial site visit by NCQA?
1) Physical accessibility 2) Physical appearance 3) Adequacy of waiting and exam rooms 4) Appointment availability 5) Adequacy of treatment 6) Record keeping processes
According to NCQA who has ultimate authority in credentialing decisions?
credentials committee or medical director if it is clean file
According to NCQA application, PSV must be dated within ???? days of the credentialing decision?
180 days
According to NCQA what credential must be verified at the time of recredentialing?
current malpractice, state licensure
According to NCQA, how long is the board certification good for?
180 days
Name 3 sources of verification of education of a podiatrist according to NCQA?
1) School 2) Specialty board 3) state licensing agency
According to NCQA a set of standardized measures used to compare health plan is ???
HEDIS
NCQA grants a CVO certification of a period of?
2 years
Per NCQA standards what is the time limit for provisional credentialing?
60 days
According to NCQA standards, a copy is acceptable certification of the document
medical school diploma
According to NCQA, the timeframe within which the DEA verification is permitted is:
no timeframe, must be current at the time of credentials committee review
Does NCQA require locum tenens to be credentialed when working in an independent relationship within the inpatient setting?
no
NCQA requirements for professional practice questions include
1) the correctness and completeness of the application 2) current malpractice coverage 3) lack of present illegal drug use
NCQA requirements for delegated credentialing are permitted under a written delegation document that includes:
1) be mutually agreed upon 2) describe the delegated activities 3) describe the responsibilities of the organization and the delegated entity
According to NCQA standards, which credential MUST be obtained at the time of credentialing?
current malpractice insurance certificate
According to NCQA requirements, the verification time limit for work history is:
365 calendar days for health plan, 305 calendar days for CVO, MA Deeming surveys 180 calendar days
Per NCQA the following must be verified at time of recredentialing
1) license 2) DEA 3) board certification 4) Medicare/Medicaid sanctions 5) malpractice
NCQA defines credentialing as a process by which
an organization reviews and evaluates qualifications of licensed independent practitioners to provide services to its members.
NCQA describes credentialing as:
The process by which the managed care organization authorizes contracts with or employs clinicians who are licensed to practice independently to provide service to its members.
Who does NOT get credentialed @ NCQA?
Those who practice exclusively within the inpatient setting; those who practice exclusively within free standing facilities; pharmacists working for a pharmacy locum tenens (unless working for longer than 90 days); Rental network practitioners
NCQA Attestation addresses the following:
Reasons for any inability to perform the essential functions of the position, with or without accommodation lack of present illegal drug use history of loss of license and felony convictions. History of loss or limitation of privileges or disciplinary activity current malpractice coverage the correctness and completeness of application
NCQA Education verification time limit
None
NCQA verification time limit for work history
365 calendar days for health plan, 305 calendar days for CVO, 180 days for Medicare advantage deeming surveys
NCQA verification time limit for Board Certifications
180 days, 120 days for CVO
Does NCQA require verification of Board Certification?
if the practitioner claims to be board certified the organization must verify it.
Does NCQA require verification of Board certification at reappointment?
Yes, if the certification has expired or if additional certification has been added.
Verification time limit for licensure according to NCQA?
180 days , 120 days for CVO
Verification time limit of malpractice insurance coverage according to NCQA?
180 days, 120 days
Non discrimination according to NCQA
policies and procedures must explicitly state the steps that the organization takes during the credentialing/re-credentialing processes to monitor for and prevent discriminatory practices.
Medicare/Medicaid Sanctions/Exclusions requirement by NCQA
organizations are responsible for ongoing monitoring of Medicare/Medicaid sanctions between re-credentialing cycles.
NCQA requires a query of Medicare/Medicaid sanctions by a query form:
Federal Employees Health Benefits Plan; FSMB; NPDB/HIPDB; List of excluded inidividuals and entities (maintained by OIG); Medicare and Medicaid Sanctions and Reinstatement Report; State Medicaid agency or Medicare Intermediary
current competence is determined by NCQA how?
not addressed
Attestation time limit for NCQA
365; 305 for CVO
Attestation time limit for NCQA Medicare advantage deeming surveys
180; 120 for CVO
Complaints - NCQA 2015 Health Plan Accreditation and 2013 CVO with updates
must continually monitor member complaints for all practitioner sites. There must be a process to monitor and investigate member complaints related to the quality of all practitioner office sites and must conduct site visits for complaints related to physical accessibility, physical appearance, and adequacy of waiting and examining room space if the organization’s complaint thresh-hold is met. The organization implements appropriate actions and evaluates the effectiveness of those actions at least every six months, until deficient offices meet the thresh-holds. The organization must also conduct ongoing monitoring that includes the collection and review of complaints. The organization must have mechanisms in place to investigate practitioner specific complaints from members upon their receipt. Both the specific complaint and the practitioner’s history of issues must be evaluated. There must be evidence of an evaluation of the history of complaints for all practitioners at least every six months.
Compliance with Law - NCQA 2015 Health Plan Accreditation and 2013 CVO with updates
the administrative policies and procedures indicate that organizations providing managed care services must comply with applicable federal, state and local laws and regulations, including requirements for licensure. Thus, the organization’s leaders are responsible for any regulations relating to credentialing.
Continuing Medical Education - NCQA 2015 Health Plan Accreditation and 2013 CVO with updates
not specifically addressed.
CVO’s/Delegation: NCQA 2015 Health Plan Accreditation and 2013 CVO with updates
CVOs are allowed to be used and credentialing policies and procedures include the process used to delegate credentialing and re-credentialing, what can be delegated, how the decision to delegate is made. The organization maintains the right to approve/terminate practitioners, and has responsibility for oversight of the delegated agency. There must be a mutually agreed upon document describing each organization’s responsibilities, the delegated activities, the process for evaluation and outcome if obligations are not fulfilled. There must be, at least, semiannual reporting by the delegated entity to the organization. If the CVO achieves NCQA certification this oversight responsibility is waived. For Medicare deeming, the delegation agreement must include a statement requiring the delegate to adhere to Medicare regulations.
Criminal Background Checks: NCQA 2015 Health Plan Accreditation 2015 and 2013 CVP with updates
Not specifically addressed.
Current Competence: NCQA 2015 Health Plan Accreditation and 2013 CVO with updates
not specifically addressed. NCQA requires the organization to assess the practitioner’s ability to deliver care based on the credentialing information collected and verified prior to making a credentialing decision. The organization develops and implements policies and procedures for ongoing monitoring of practitioner sanctions, complaints and quality issues between re-credentialing cycles and takes appropriate action against practitioners when it identifies occurrences of poor quality.
Designated Equivalent Sources: NCQA 2015 Health Plan Accreditation and 2013 CVO with updates
NCQA does not use the language “designated equivalent sources”. See each credentialing element for a listing of NCQA approved sources. Verification of credentials through an agent that contracts with an approved source to provide credentialing information is allowed. Prior to using this method documentation must be obtained from the agent indicating that there is a contractual relationship between it and the approved source.
Disaster or Emergency Management Plan Privileges: NCQA 2015 Health Plan Accreditation and 2013 CVO with updates
Not specifically addressed
Drug Enforcement Agency Certificate (DEA) or State Controlled Dangerous Substances Certificate NCQA 2015 Health Plan Accreditation and 2013 CVO with updates
DEA or CDS certificate verified in each state where the practitioner provides care to its members through one of the following: A copy of the DEA or CDS certificate; documented visual inspection of the original certificate; confirmation with the DEA or CDS Agency; Confirmation with the National Technical Information Service (NTIS) database; AMA physician master file (DEA only); confirmation from the state pharmaceutical licensing agency where applicable. (AOA) official osteopathic physician profile report or AOA Physician Master File. If the practitioner does not prescribe medications requiring DEA or CDS certificate, there must be a documented process to require an explanation as to why the practitioner does not prescribe medications. There must be arrangements for the practitioner’s patients who need prescriptions for medications requiring DEA or CDS certification. The 180/120 day time limitation does not apply to this element providing the DEA/CDS is current at the time of action/transmittal.
Education: NCQA 2015 Health Plan Accreditation and 2013 CVO with updates
The organization need only verify the highest level of credentials attained. For example, if a physician is board certified, verification of board certification meets this element because specialty boards verify education and training. Residency is considered the highest level of training, not fellowship. Any of the following can be used to verify education and training:
- The primary source
- The state licensing agency or specialty board or registry
- sealed transcripts may be accepted if the organization shows evidence that it inspected the contents of the envelope and confirmed that the practitioner completed (graduated from) the appropriate training program.
Other acceptable sources for physicians (MDs are):
- AMA Physician Masterfile
- AOA Official Osteopathic Physician Profile or AOA Physician Master File
- Educational commission for foreign medical graduates for international medical graduates after 1986.
- FCVS for closed residency programs
*If the organization uses confirmation from a NCQA approved source, such as the state licensing agency or registry the organization must verify that the source performs PSV, and at least annually, the organization must obtain written confirmation from the approved source that it performs primary source verification NCQA does not require the organization to obtain written confirmation from the licensing board if there is a state statute that requires the licensing board to obtain verification of education and training directly from the institution. Verification time limit prior to the credentialing decision.
Felony Convictions: NCQA 2015 Health Plan Accreditation and 2013 CVO with updates
The application must include a statement regarding felony convictions.
Licensure/Licensure Sanctions: NCQA 2015 Health Plan Accreditation and 2013 CVO with updates
Time limit - 180 days MCO and 120 days for CVO. Confirm that the practitioner holds a valid current license, is in effect at the time of the credentialing committee’s decision. Verify license only in the states where the practitioner provides care for organization members. Verification directly with state licensing agency. If the organization uses the internet to verify licensure, the web site must be from the appropriate state licensing agency.
NPDB and continuous query can be used to verify sanctions.
The organization must verify the most recent 5 year period available for sanctions or limitations on licensure in each state where the practitioner provides care for its member using one of the following:
Physicians: Appropriate state agencies, FSMB, NPDB (continuous query)
Chiropractors: Federation of Chiropractic Licensing Boards Chiropractic Information network - Board Action Databank (CIN-BAD)
State board of chiropractic examiners
Oral Surgeons: NPDB (continuous query)
State board of dental examiners
Podiatrists: Federation of Podiatric Medical Boards, State board of Podiatric Examiners, NPDB (continuous query)
Non-Physician behavioral healthcare professionals: Appropriate state agency, state licensure or certification board, npdb (continuous query), organizations are responsible for the ongoing monitoring of sanctions or limitations on licensure between re-credentialing cycles. On initial credentialing practitioners attest to any loss of license since initial licensure was granted. On re-credentialing, practitioners attest to loss of licensure since the last re-credentialing cycle.
Verification of Medical Education according to NCQA
requires HP/CVO the highest of three levels of education and training.
the three levels of education and training as defined by NCQA
graduation from medical or professional school, residency, board certification
