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Transcript of NCQA Standards Update and Effective Managed Care...
4/20/2017
1
R a c h e l l e L . S i l v a , B S , C P M S M , C P C S
A r k A M S S S p r i n g C o n f e r e n c e
A P R I L 2 1 , 2 0 1 7
NCQA Standards Update and Effective Managed Care Tools/Best
Practices
Objectives
Identify the NCQA standards to ensure compliance
Discuss effective tools that will assist in making the credentialing process more efficient
Incorporate best practices into the credentialing process to efficiently work with different managed care organizations
NCQA CR1
The organization has a well-defined credentialing and recredentialing process for evaluating and selecting
licensed independent practitioners to provide care to its members.
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CR 1-Element A Practitioner Credentialing Guidelines
Factor 1: Practitioners within the scope of
credentialing Practitioners who are licensed, certified or registered by the state
to practice independently (without direction or supervision)
Practitioners who have an independent relationship with the organization
Practitioners who provide care to members under the organization’s medical benefits
Related information:
Practitioners who do not need to be credentialed
CR 1-A Continued
Factor 2: Verification sources The primary source (or its Web site)
A contracted agent of the primary source (or its Web site)
An NCQA-accepted source listed for the credential (or its Web site)
Cr 1-A Factor 2 Related Information
Appropriate Documentation Copies of credentialing information
Signed (or initialed) and dated checklist that includes, for each verification:
o The source used
o The date of verification
o The signature or initials of the person who verified the information
o The report date, if applicable
Automated Credentialing System – Unique electronic staff identifier
Refer to Appendix A
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CR 1-A Continued
Factor 3, 4: Decision-making criteria and process Practitioners credentialed before they provide care to members
Process for making credentialing decisions
Defined criteria required to reach a credentialing decision
o Criteria are designed to assess a practitioner’s ability to deliver care
Determine the scope of practitioners who may participate in the network
CR 1-A Factor 3, 4 Related Information
Provisional Credentialing
One-time use for practitioners applying for the first time
Required verifications:
o Current, valid license to practice
o Past 5 years malpractice claims/settlement history
o Current signed application with attestation
Follows the same decision making process
Not eligible if credentialed by a delegate for the organization
Maximum provisional status 60 calendar days
Verification time limits: HP – 180/365, CVO – 120/305, G/MA – 180/180
CR 1-A Continued
Factor 5: Managing credential files that meet
established criteria
Process used to identify files that meet criteria (e.g. clean files)
Process used to approve files that meet criteria
Related information:
Practitioner Termination
Practitioner Reinstatement
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CR 1-A Continued
Factor 6: Delegation If the organization delegates credentialing activities
What credentialing activities may be delegated
How the organization decides to delegate
CR 1-A Continued
Factor 7: Nondiscriminatory credentialing and
recredentialing
Does not base credentialing decisions on an applicant’s race, ethnic/national identify, gender, age, sexual orientation or patient type
Process for preventing discriminatory credentialing practices
Process for monitoring discriminatory credentialing practices
CR 1-A Continued
Factor 8: Discrepancies in credentialing information Process of notification when information obtained from other
sources varies substantially from that provided by the practitioner
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CR 1-A Continued
Factor 9: Notification of decisions Time frame for notification of applicants – 60 calendar days
What decisions require notification
Initial credentialing decisions (approval or denial)
Recredentialing denials
CR 1-A Continued
Factor 10: Participation of a medical director or
designated physician
Description of the overall responsibility in the credentialing process
Description of participation in the credentialing process
CR 1-A Continued
Factor 11: Ensuring confidentiality Paper credentials information
Electronic credentials information
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CR 1-A Continued
Factor 12: Practitioner directories and member
materials
Process to ensure information provided to network is consistent with information obtained during the credentialing process
CR 1-B Practitioner Rights
The organization notifies practitioners about their right to:
Factor 1: Review Information
Factor 2: Correct erroneous information from other sources
Factor 3: Application status
CR 2 Credentialing Committee
The organization designates a Credentialing Committee that uses a peer-review process to make
recommendations regarding credentialing decisions.
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CR 2 Continued
Factor 1: Uses participating practitioners to provide
advice and expertise for credentialing
decisions
Representation from a range of participating practitioners in the organization’s network
May have separate review bodies for different practitioner type or specialty
CR 2 Continued
Factor 2: Committee Review Reviews credentials of practitioners who do not meet the
organization’s criteria
Gives thoughtful consideration to credentialing information
Documents discussions about credentialing in meeting minutes
CR 2 Factor 2 Related Information
Appropriate meeting venues
In-person
Virtual – conference call, video conference or web conference with audio
Meetings may no be conducted only through email.
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CR 2 Continued
Factor 3: Review of files that meet established
thresholds
Submit all files to the Credentials Committee for review; or
Process for medical director or qualified physician review and approval of clean files
Evidence of review and approval
Handwritten signature
Handwritten initials
Unique electronic identifier
CR 2 Factor 3 Continued
Related Information Assessment of timelines
Decision date of Credentials Committee or Medical Director
Providing care to members
No care is provided to members prior to the practitioner being credentialed
CR 3 Credentialing Verification
The organization verifies credentialing information through primary sources, unless otherwise indicated
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CR 3-Element A Verification of Credentials
Factor 1 – Licensure
Valid and current license to practice at the time of the credentialing decision
Verify licensure in all states where practitioner provides care to members
Verification time limit –
HP/G/MA – 180 calendar days
CVO – 120 calendar days
Acceptable verification source
Directly from state licensing or certification agency
CR 3 – Element A Continued
Factor 2: DEA or CDS certificates
Applies only to practitioners who are qualified to write prescriptions
Valid and current in each state where the practitioner provides care to members
Verification time limit
HP/CVO – Prior to the credentialing decision
G/MA – 180 calendar days
Pending DEA certificates
DEA or CDS eligible practitioner who do not have a certificate
Refer to Appendix B
CR 3 Factor 2 - Element A Continued
Acceptable verification sources
DEA or CDS agency
Copy of the DEA or CDS certificate
Documented visual inspection of the original DEA or CDS certificate
National Technical Information Service (NTIS) database
American Medical Association (AMA) Physician Masterfile – DEA only
American Osteopathic Association ( AOA) Official Osteopathic Physician Profile Report or Physician Master File - DEA only
State pharmaceutical licensing agency
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CR 3 – Element A Continued
Factor 3: Education and Training
Verification of the highest of three levels of education and training
Board certification
Residency
Graduation from medical or professional school
Verification time limit
Medical/professional school or residency - None
Related Information:
Static information N/A for Recredentialing
CR 3 Factor 3 - Element A Continued
Education and training accepted verification sources
Medical School/Residency training program
State licensing agency, specialty board or registry– only if:
o Agency preforms primary source verification
o Annually obtain written confirmation from the Agency that if performs primary source verification
Sealed transcripts
AMA Physician Masterfile – includes AMA 5th pathway
AOA Physician Profile Report of Master file
Education Commission for Foreign Medical Graduates (ECFMG) – international graduates licensed after 1986
CR 3 Factor 3 – Element A Continued
Federation Credentials Verification Service – closed residency programs
Related Information:
Verification of fellowship does not meet the intent of this factor
Only recognizes the following residency accreditation programs:
ACGME
AOA
College of Family Physicians of Canada (CFPC)
Royal College of Physicians and Surgeons of Canada
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CR 3 – Element A Continued
Factor 4: Board Certification status Verify current certification status if practitioner states they are
board certified
Verification time limit
HP/G/MA – 180 calendar days
CVO – 120 calendar days
Related information: N/A if not board certified
N/A if board certified nurse practitioner or other health care professional if the organization does not communicate board certification to members
CR 3 Factor 4 – Element A Continued
Acceptable verification sources Appropriate specialty board (all practitioner types)
State licensing agency – if it primary source verifies board certification (all practitioner types)
ABMS or its member boards or an official ABMS Display Agent (MD/DO)
AMA Physician Masterfile (MD/DO)
AOA Physician Profile Report of Physician Master File (MD/DO)
Boards in the United States that are not members of the ABMS or AOA (MD/DO) if:
o Organization identified in policy which specialty boards it accepts
o Annual obtain written confirmation from board that it performs primary source verification
CR 3 Factor 4 – Element A Continued
Accepted Verification Sources – other health care professionals Registry that performs primary source verification of board
status
o Annually obtain written confirmation that the registry performs primary source verification of board certification status
Related information: Does not apply to nurse practitioner or other health care
professional if the organization does not communicate board certification to members
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CR 3 – Element A Continued
Factor 5: Work History (N/A for Recredentialig) Obtains a minimum 5 year work history as a health
professional
Verification time limit
HP – 365 calendar days
CVO – 305 calendar days
G/MA – 180 calendar days
Acceptable source – application or CV
Acceptable format – beginning and ending month and year
Documentation of work history gaps
6 months – verbally or in writing
12 months or greater – in writing
CR 3 – Element A Continued
Factor 6: Malpractice History 5 year confirmation of malpractice settlements
Verification time limit
HP/G/MA – 180 calendar days
CVO – 120 calendar days
Acceptable verification sources
Malpractice carrier
National Practitioner Data Bank (NPDB)
CR 3 – Element B Credentialing Application
Each file contains the application and attestation, and evidence of review by the organizations staff.
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CR 3 – Element B - Continued
Factor 1: Inability to perform essential functions Inquiry may vary depending on the organization’s
interpretation of ADA
CR 3 – Element B Continued
Factor 2: Illegal Drug Use May use language other than “drug”
May use more general or more extensive language
Not required to refer exclusively to the present
Not required to refer exclusively to illegal substances
CR 3 – Element B Continued
Factor 3: History of loss of license and history of felony
convictions
Initial credentialing – attest to loss of license and any felony convictions since initial licensure
Recredentialing – attest to loss of license and any felony convictions since the last credentialing cycle
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CR 3 – Element B Continued
Factor 4: Limitation of privileges or disciplinary
actions
Initial credentialing – attest to any loss or limitation of privileges or disciplinary actions since initial licensure
Recredentialing – attest to any loss or limitation of privileges or disciplinary actions since the last credentialing cycle
CR 3 – Element B Continued
Factor 5: Current malpractice coverage States amount of coverage (even if the amount is $0)
States the date coverage expires
Federal tort coverage – attestation or copy of federal tort letter
May obtain a copy of the insurance face sheet in lieu of attestation in the application
CR 3 – Element B Continued
Factor 6: Correctness and completeness of the
application Only the practitioner can attest to the correctness and
completeness of the application
Attestation verification time limit
HP – 365 calendar days
CVO – 305 calendar days
G/MA – 180 calendar days
Acceptable signatures
Faxed, digital, electronic, scanned or photocopied
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CR 3 – Element B Continued
Related Information: Associated elements do not count if not signed and dated within the
required time frame
May conduct verifications and queries prior to receipt of the attestation
Send copy of the application when attestation exceeds time limit for practitioner to re-attest
State applications/applications from other entities must contain attestation
CR 3 – Element C Sanction Information
Scope of review for sanctions or limitations on licensure
Verify the most recent 5 year period
Verification time limit
HP/G/MA – 180 calendar days
CVO – 120 calendar days
CR 3 Factor 1 – Element C
Licensure sanction accepted verification sources NPDB
Other sources based on practitioner type Physicians – Appropriate state agencies, Federation of State Medical
Boards (FSMB)
Chiropractors – State Board of Chiropractic Examiners, Federation of Chiropractic Licensing Boards’ Chiropractic Information Network-Board Action Databank (CIN-BAD)
Oral Surgeons – State Board of Dental examiners or State Medical Board
Podiatrists – State Board of Podiatric Examiners, Federation of Podiatric Medical Boards
Non-physician health care professionals – State licensure or certification board, appropriate state agency
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CR 3 Factor 2 – Element C
Medicare/Medicaid sanctions accepted verification sources NPDB
State Medicaid agency or intermediary
Medicare intermediary
List of Excluded Individuals and Entities (maintained by OIG)
Medicare Exclusion Database (maintained by SAM)
Federal Employees Health Benefits Plan (FEHB) Program department record (published by the Office of Personnel Managed, OIG)
FSMB
CR 4 Recredentialing Cycle Length
The organization formally recredentials its practitioners at least every 36 months.
CR 4 Continued
Recredentialing Elements Applies to practitioners in the scope of credentialing defined in
CR 1
Requires an application and attestation
Applicable verifications as defined in CR 3
Each file contains the Credential Committee decision date
The 36 month cycle begins on the date of the previous Credential Committee decision
The 36 month cycle is to the month not to the day
4/20/2017
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CR 4 Continued
Acceptable reasons to extend beyond 36 months Active military assignment
Maternity leave
Sabbatical
Practitioner must be recredentialed within 60 calendar days of a return to practice.
CR 4 Continued
Termination and reinstatement Termination for administrative reasons (e.g. failure to timely
submit a complete application)
o Can perform recredentialing to reinstate if done within 30 calendar days of termination
o Must perform initial credentialing if reinstated after 30 calendar days of termination
CR 5 Practitioner Office Site Quality
The organization has a process to ensure that the offices of all practitioners meet its office-site
standards.
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CR 5 – Element A Performance Standards and Thresholds
The organization sets site performance standards and thresholds for:
Physical accessibility o Handicapped accessible o Ease of entry
Physical appearance o Well-lit waiting room o Posted office hours
Adequacy of waiting and examining room space o Adequate seating o Appropriate size
Adequacy of medical/treatment record keeping o Secure/confidential filing system o Legible file markers o Records are easily located
CR 5 – Element B Site Visits and Ongoing Monitoring
Factor 1 – Monitor members complaints Establishes a reasonable complaint threshold for an office-site
visit that takes the severity of an issue into account
Has a process to monitor and investigate members complaints
CR 5 – Element B Continued
Factor 2 – Site Visits Uses a standardized survey form that incorporates the
organizations established performance standards and thresholds
Conducts a site visit for complaints if the complaint threshold is met
Performs site visit within 60 calendar days of the complaint threshold being met
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CR 5 – Element B Continued
Factor 3 – Instituting actions
Factor 4 – Effectiveness of actions
Factor 5 – Follow-up visit
Office site meets the complaint threshold for a different standard
Follow-up visit performed within 60 calendar days on the performance standards pertaining to that complaint
Implements an action plan for improvement
CR 5 – Element B Continued
Methods for identifying deficiencies Complaint monitoring
Practice-specific member surveys
Reports from Provider Relations staff visits
Staff audit
CR 6 Ongoing Monitoring
The organization develops and implements policies and procedures for ongoing monitoring of practitioner
sanctions, complaints and quality issues between recredentialing cycles and takes appropriate action
against practitioners when it identifies occurrences of poor quality.
4/20/2017
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CR – 6 Continued
Factor 1 - Accepted verification sources for licensure and Medicare/Medicaid sanctions Same verification sources as identified in CR 4 – Element C
Factor 2 - Time frame for reviewing sanction information Within 30 calendar days of its release by the reporting entity if
the information is published on a set schedule
Queries for information at least every six months if documentation that the entity does not release in formation on a set schedule
Query every 12-18 months if the entity does not release sanction information reports
CR 6 Factor 2 Continued
Sanctions alert services Review information within 30 calendar days of a new alert
Shows evidence of subscription to the sanctions alert service
CR 6 Continued
Factor 3 - Investigating complaints Investigates practitioner specific complaints upon receipt
Evaluated practitioner’s history of complaints
Evaluates history of complaints for all practitioners at least every six months
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CR 6 Continued
Factor 4 – Adverse events
Monitor adverse events at least every six months
May limit adverse event monitoring to primary care practitioners and high-volume behavioral healthcare practitioners
Factor 5 – Implementing interventions
Interventions are identified in policies and procedures
Implemented for evidence of poor quality that could effect the health and safety of its members
CR 7 Notification to Authorities and Practitioner Appeal Rights
An organization that has taken action against a practitioner for quality reasons reports the action to
the appropriate authorities and offers the practitioner a formal appeal process.
CR 7 – Element A Actions Against Practitioners
Factor 1 – Range of actions available Policies and procedures specify that the organization will
o Review participating practitioners whose conduct could adversely affect members’ health or welfare
o Outline the actions that may be taken before termination
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CR 7 –Element B Reporting to authorities
Reporting to authorities Factor 2 – Element A Policies describe:
o What incidents are reportable
o How and when reporting will occur
o To whom incidents are reported
o The organization staff person responsible for reporting
Reporting authorities include NPDB, state agency or other regulatory body
CR 7 – Element C Practitioner Appeal Process
Factor 3- Element A – Policies describe the appeal process Written notification of the reasons for the professional review action
and a summary of the appeal rights process
Allowing practitioner to request a hearing and the specific time period for submitting the request
Allowing at least 30 days after notification for the practitioner to request a hearing
Allowing practitioner to be represented by an attorney or another person of their choice
Appointing a hearing officer or a panel of individuals to review the appeal
Written notification of the appeal decision with specific reasons for the decision
CR 7 – Element A Continued
Factor 4 – Making the appeal process known Process is detailed in policies and procedures
Practitioner is provided with the appeal rights and process at the time a professional review action is brought against a practitioner
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CR 8 Delegation of Credentialing Activities
If the organization delegates any NCQA-required credentialing activities, there is evidence of oversight
of the delegated activities.
CR 8 – Element A Delegation Agreement
Factor 1 – Mutual agreement Delegation activities are mutually agreed on before delegation
begins
A dated binding document is signed by the organization and the delegated entity
CR 8 – Element A Continued
Factor 2 – Assigning responsibilities Delegation agreement outlines the credentialing activities to be
performed by the delegate
Delegation agreement outlined the credentialing activities retained by the organization
o Organization can choose to make a general statement (e.g. the organization retains all other credentialing activities)
4/20/2017
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CR 8 - Element A Continued
Factor 3 – Reporting Organization determines the method of reporting and the
content of the reports
o What information is reported by the delegate
o How and to whom the information is reported
Delegate reports at least semiannually
CR 8 – Element A Continued
Factor 4 – Performance monitoring
Policy review
Credential file audits
Factor 5 – Right to approve, suspend and terminate
Factor 6 – Consequences for failure to perform
CR 8 – Element B Provision for PHI
If the delegation agreement includes the use of protected health information (PHI) the agreement specifies:
Factor 1 – Allowed uses of PHI
Specifies PHI the delegate my use and disclose
Specifies whom PHI may be disclosed
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CR 8 – B - Continued
Factor 2, 3 – Delegate and Subdelegate safeguards Organization provides administrative, technical and physical
safeguards to ensure PHI:
o Confidentiality
o Integrity
o Availability
o Prevention of unauthorized or inappropriate access, use, or disclosure of PHI
CR 8 – Element B Continued
Factor 4 – Access to PHI Basic protections of physical facilities that store PHI
Protection of electronic systems from unauthorized access
Protection of electronic systems from internal and external tampering
CR 8 – Element B Continued
Factor 5 – Inappropriate us of PHI Agreement specifies procedures for delegates to identify and
report unauthorized:
o Access
o Use
o Disclosure
o Modification
o Destruction
Factor 6 – Disposal of PHI if delegation ends
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CR 8 – Element C Predelegation Evaluation
Organization evaluates the delegates ability to meet the NCQA standards:
Request for delegation determines:
o If delegate performs credentialing activities
o If delegate has credentialing policies and procedures
o If delegate will allow a review of the credential files
o If delegate is NCQA certified
CR 8 – Element C Continued
Policies and Procedures are reviewed for compliance with NCQA standards Credential files are audited for compliance with NCQA standards Effective date of the delegated credentialing agreement is determined after the organization has approved the delegate If effective date is greater than 12 months from the review a new review is conducted If new credentialing activities are added an audit is conducted to ensure NCQA compliance
CR 8 – Element D Review of Credentialing Process
Factor 1 – Review of the credentialing policies and
procedures
Factor 2 – Annual file audit
5% or 50 files whichever is less (at a minimum 10 initial credential files and 10 recredential files)
If less than 10 practitioners were credentialed/recredentialed all files are audited rather than a sample
NCQA 8/30 methodology
Factor 3 – Annual Evaluation
Factor 4 – Evaluation of reports
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CR 8 – Element E Opportunities for Improvement
Corrective action plan is required for: Policy and procedure deficiencies
Credential file deficiencies
Organization determines time frame to submit the corrective action plan
Failure to submit a corrective action plan is a breach
of contract
Effective Managed Care Tools
Appendix A – Sample Checklist
Appendix B – DEA Explanation/Waiver
Appendix C – Admit Privileges or Coverage
Arrangements
Appendix D – Verbal Verification
Appendix E – Sample Audit Tool Criteria
Best Practices
Appendix F – NAMSS Payor Credentialing Roundtable
Report
Appendix G – Managed Care Resource Tool Kit
Appendix H – NAMSS State of the Medical Services
Profession Report