NCQA credentialing accreditation validates a credentialing service provider as having met the high measurement and standards of NCQA credentialing accreditation requirements. NCQA credentialing accreditation can help ensure adherence to a set standard of care and help increase the authority and effectiveness of a CVO.

Organizations that seek NCQA credentialing accreditation must be evaluated every two or three years. Healthcare is an industry that warrants constant monitoring. Patient safety should be paramount and not left to occasional discretionary measures.

Introduction to NCQA Credentialing

The National Committee for Quality Assurance (NCQA), established in 1990, is a nonprofit organization dedicated to enhancing healthcare quality through evidence-based standards, programs, and accreditation. By evaluating the performance of health plans and physicians against scientifically recommended care, NCQA propels healthcare improvement.

Adhering to the NCQA Code of Conduct, the organization is esteemed within the healthcare sector, attracting both government and private sector clients to measure and elevate their care quality. With over 173 million individuals enrolled in NCQA Accredited health plans and more than 10,000 practice sites alongside 50,000 clinicians owning the NCQA PCMH Recognition seal, its impact is profound.

Benefits of NCQA Certification

NCQA continually refines its standards through feedback from healthcare stakeholders including consumers, employers, and government officials. The objective is to reduce costs and enhance patient experience, with the belief that publicizing survey results can set higher industry benchmarks for care quality.

  • Earning NCQA certification is advantageous for organizations aiming for a leadership position in patient safety and quality care, offering industry recognition, trust, consistency, and oversight for clients requiring practitioner verification.

It not only validates the integrity of an organization’s provider credentials process but also facilitates a more efficient, reliable credentialing process, ensuring compliance with state, federal, and various program accreditations like Medicare, Medicaid, and TRICARE.

  • Despite the rigorous certification process, CVOs with NCQA certification see a substantial return on investment as it instills confidence in organizations seeking a credible CVO for provider credentialing assistance.

The accreditation provides a framework for organizations to implement industry best practices. It is a recognized symbol of quality and confidence within the healthcare industry. It signals to patients and providers that healthcare organizations are committed to providing high-quality care. Credentialing is essential for every healthcare provider who wants to practice medicine and be enrolled in a health plan or network option.

NCQA Credentialing and Accreditation

NCQA Credentialing Standards 2023

To maintain exemplary healthcare standards, providers are required to undergo a credentialing process every three years, although it’s advisable for provider organizations to re-credential biennially to uphold optimal practices. The essence of credentialing standards is to rigorously assess and validate the qualifications of healthcare professionals. This practice aids organizations in readying for NCQA evaluation, typically spanning 12 months from the submission of the application to the decision.

NCQA’s evaluations scrutinize plans against over 60 standards, segmented into six categories:

  1. Quality management and enhancement constitute 40% of a plan’s score,
  2. Credentialing and re-credentialing represent 10%,
  3. Members’ rights and responsibilities cover 17.5%,
  4. Preventive health services account for 10%,
  5. Utilization management comprises 17.5%,
  6. Medical records contribute 5%.

Organizations adhering to the stipulated functions in the standards for CM accreditation are bestowed with an Accredited status for two years by NCQA.

Discover the latest Healthcare Credentialing Trends to stay ahead in maintaining compliance and enhancing your organization’s credentialing processes.

Organizational Requirements for NCQA Standards

NCQA mandates healthcare institutions to maintain clear credentialing and re-credentialing mechanisms to vet and select licensed independent practitioners for member care.

  • Practitioner Types

All licensed independent practitioners (LIPs) need credentialing, encompassing MDs, DOs, and independent practice APNs. Though NCQA audits LIPs’ credentialing files, it’s advisable to credential all practitioners uniformly for optimal patient safety and organizational risk mitigation.

  • Verification Sources

Employ authorized primary sources (e.g., state medical board, DEA, ABMS) for provider credential verification during the process.

  • Credentialing Criteria

Recredential providers every three years, while provider organizations should aim for biennial re-credentialing. Payers should re-credential triennially.

  • Decision-making Process

Draft provider standards and decision-making bases to clarify network participation denial reasons, avoiding discrimination allegations. Collaborate with the compliance unit to formulate baseline criteria inclusive of licensure, disciplinary history, and malpractice specifics.

  • File Management

Establish “clean file” criteria for efficient management, entrusting a medical director or qualified practitioner for clean file approvals.

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  • Delegation Process

Ensure proper delegation agreements delineating the delegated work scope. Consider assigning primary source verification (PSV) application processing to an NCQA-certified CVO for better efficiency.

  • Non-discrimination Assurance

Document non-discrimination policies for network selection, emphasizing inclusivity even for providers serving Medicaid or Medicare patients. Ensure a thorough review by the credentialing committee, granting providers the right to know and appeal decisions.

  • Notification Process

Create a procedure to inform practitioners of discrepancies between the provided information and the organization’s findings, aiming for issue resolution within 30 days post-application submission.

  • Decision Communication

Outline a method for timely communication of credentialing decisions to practitioners, establishing an appeals process for denied providers.

  • Program Leadership

Assign a physician or peer provider to steer the credentialing program, with a medical director engaging a diversified professional committee for a balanced and competent evaluation of enrolling providers.

  • Confidentiality Assurance

Maintain confidentiality of provider data, permitting only authorized agents like a CVO for primary source queries on the health plan’s behalf.

  • Directory Consistency

Ensure practitioners’ directory listings and other member materials align with credentialing data, particularly education, training, board certification, and specialty details.

Avoid over-complexity in policies and procedures documents, adapting NCQA guidelines to suit your organization. Employ a version-control system to record alterations, demonstrating consistency in documentation over the review period.

Credentialing Committee

The establishment of a credentialing committee is essential, leveraging the expertise of participating practitioners for sound credentialing decisions. Every health plan necessitates such a committee to oversee the physician enrollment process, ensuring peer reviews are conducted by similarly specialized physicians in real-time, either in person or via teleconferencing, not via email.

The committee diligently reviews practitioners failing to meet set thresholds, guaranteeing a fair and comprehensive evaluation of all credentialing data. All decisions, and their rationales, are meticulously documented during review meetings.

For files meeting the established criteria, a designated medical director or physician oversees their review and approval. Clean files, specifically, are expedited for approval, with the review documented via a unique electronic identifier or handwritten signature. This practice, endorsed by NCQA, facilitates prompt turnaround times, streamlining the credentialing process.

To further enhance timeliness, simplifying the review process is recommended. Permit medical directors or qualified physicians to approve straightforward cases, categorizing providers for automatic approval or review based on defined criteria. Ensure comprehensive verification information is available to minimize communication delays. Systematic recording of committee decisions is crucial for auditing purposes, and requisite actions should be taken to keep the provider roster updated, embodying a seamless, expertly managed credentialing process.

Credentialing Requirements

Initially, it’s crucial to present a credentialing application adhering to the baseline standards. The application should encompass:

  • Explanation for any incapability to fulfill the core duties of the designated position
  • Assurance of no current illicit drug use
  • Documentation of license losses, felony convictions
  • Record of privilege limitations or disciplinary actions
  • Up-to-date malpractice insurance coverage (as per NCQA, insurance must be current at attestation)
  • A recent and signed attestation verifying the accuracy and completeness of the application

Subsequently, it’s vital to demonstrate to surveyors a robust credential verification system, underscoring that practitioners possess the legal authorization, pertinent training, and experience to deliver high-quality care.

Having ensured that the initial application is in compliance with the necessary standards and the organization has showcased its robust verification program, it’s now imperative to delve into the specifics of the verification process. The following elements demand meticulous verification to uphold the integrity of the credentialing endeavor:

LicenseProviders must hold a valid, active license at the time of credentialing assessment. The respective state’s medical board is the authoritative source for validating this criterion.
DEA permit or CDS certificateA current DEA or CDS certificate is essential to authorize practitioners for prescription writing. Verification is mandated across all states where the practitioner prescribes and practices.
EducationThe apex level of education and training must be verified, encompassing board certification, residency, and medical school credentials. For instance, board certification suffices to meet NCQA standards, negating the need for further verification at lower levels.
Board certification statusVerification of a practitioner’s claim of board certification, though not a mandatory step for credentialing, is obligatory when claimed. The American Board of Medical Specialties (ABMS) or state licensing agencies—given that initial verification was performed with the specialty board—are recognized sources for this verification.
Work historyVerification encapsulating a minimum of five years’ work history is essential. Employment timelines should detail month and year, with any hiatus exceeding six months necessitating an explanation.
MalpracticeA retrospective of up to five years of malpractice history, inclusive of residency and fellowship periods, is required. The National Provider Data Bank (NPDB) serves as the primary source for this information.
SanctionsVerification of state, Medicare, and Medicaid sanctions, or any licensure restrictions or practice limitations is imperative. The NPDB is a highly recommended source for a thorough and trustworthy verification of this aspect.

The design of the application is crucial. A user-friendly application expedites the process for busy providers. Offering an intuitive application, especially online ones, can enhance goodwill among providers and reduce turnaround times. A comprehensive application should include a recent, signed attestation from the provider, within the last 305 days for a CVO and 365 days for a health plan.

Explore the intricacies of Provider Enrollment & Credentialing Timeframes to streamline your operations and reduce administrative bottlenecks.

Practitioner Office Site Quality

This provision aims to ascertain a provider’s office adheres to the plan’s quality criteria. It necessitates the formulation and execution of a monitoring regimen outlining standards for:

  • Sufficient accessibility
  • Presentable appearance
  • Ample space
  • Proper record maintenance

Should the office fall short of the plan’s established benchmarks in these facets, it becomes the plan’s duty to conduct regular evaluations until compliance is achieved.

Ongoing Monitoring

NCQA mandates that organizations engage in continuous monitoring of practitioner sanctions, grievances, and quality concerns, taking suitable measures upon the discovery of issues.

Post-credentialing and pre-recredentialing monitoring of providers is crucial as patient safety, client satisfaction, and organizational reputation are at stake. Given the lengthy three-year interval for payers and two-year span for provider entities, adverse incidents impacting providers and facilities could transpire within these durations.

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Monitoring for Red Flags

It’s important to know the background of the doctors you are recommending to your patients. Sanctions are one way to know more about your providers. A sanction is considered any penalty, punitive or disciplinary action imposed on providers when they are found in violation of a law or regulation governing the practice of medicine.

How to Monitor Sanctions

Understanding the background of the doctors you recommend is crucial. Sanctions, penalties or disciplinary actions, reveal important insights about providers. Monitoring sanctions is facilitated through the Office of the Inspector General (OIG), System of Award Management (SAM), and General Services Administration (GSA), which publish monthly lists of sanctioned entities.

The licensure status of practitioners may change between cycles due to expiration or adverse events, warranting regular monitoring via the National Practitioner Data Bank (NPDB), especially using its Continuous Query (CQ) feature for immediate alerts on licensure issues.

Uncover the Legal Consequences of Medical Malpractice to fortify your risk management strategies and ensure patient safety.

National Practitioner Data Bank

The National Practitioner Data Bank (NPDB) is a federal establishment tasked with aggregating adverse actions and malpractice information concerning healthcare practitioners. Crucial data for ongoing monitoring encompasses malpractice settlements, license revocations or exclusions from Medicare or Medicaid participation.

Data reporting by NPDB occurs through singular or continuous query methods, with the latter providing instant notifications to clients and healthcare establishments regarding any concerning indicators. NPDB divulges data encompassing:

  • Malpractice settlements
  • Licensure adversities or revocations
  • Negative clinical privileging occurrences
  • Professional society membership adversities
  • State licensing or certification authority negative determinations
  • Adverse findings by private accreditation organizations against healthcare entities
  • Publicly disclosed negative actions by federal or state licensing and certification agencies
  • Health-related civil judgments or criminal convictions
  • Exclusions from federal or state healthcare programs
  • Other formal adjudications impacting healthcare service delivery or payment.

Delve into our Guide for Healthcare Providers on NPDB Reporting to enhance your understanding and navigate the complexities of reporting, ensuring compliance, and fostering a culture of transparency within your organization.

Steps to take

Navigating the complex terrain of NCQA standards and credentialing requirements necessitates a partner well-versed in healthcare licensing and credentialing processes. At, we offer a suite of services tailored to meet the stringent demands of the healthcare sector, ensuring that your organization is well-poised to excel in NCQA evaluations.

  • State Medical License Service: Expedite the licensure process to meet state and NCQA regulations.
  • Hospital Credentialing Service: Streamline the credentialing process, ensuring meticulous management of credentialing files.
  • Medical License Renewal Service: Keep practitioners’ licenses current, a significant aspect of maintaining NCQA accreditation.
  • Telemedicine Licensing Service: Navigate diverse licensure requirements across states, aligning with NCQA’s focus on quality care access.

Reach out to us to navigate the rigorous demands of NCQA standards effectively, leveraging our expertise in licensing and credentialing to position your healthcare delivery at a pinnacle of excellence.

FAQs about NCQA Credentialing Standards

  • What is NCQA and why is its credentialing important in healthcare?
    The National Committee for Quality Assurance (NCQA) is a nonprofit organization aimed at enhancing healthcare quality through evidence-based standards, programs, and accreditation. Obtaining NCQA credentialing signifies a healthcare organization’s commitment to quality care, patient safety, and industry-recognized best practices.
  • How often is the NCQA credentialing process carried out?
    Healthcare providers are required to undergo a credentialing process every three years as per NCQA standards. However, it’s advisable for provider organizations to re-credential biennially to uphold optimal practices. This rigorous assessment validates the qualifications of healthcare professionals ensuring adherence to quality standards.
  • What are the key areas evaluated during the NCQA credentialing process?
    The NCQA evaluations scrutinize plans against over 60 standards categorized into six areas: Quality Management and Enhancement, Credentialing and Re-credentialing, Members’ Rights and Responsibilities, Preventive Health Services, Utilization Management, and Medical Records. These evaluations ensure healthcare organizations maintain high standards in these crucial domains.
  • How can healthcare organizations ensure compliance with NCQA standards?
    Compliance with NCQA standards requires maintaining clear credentialing and recredentialing mechanisms, continuous monitoring of practitioner sanctions and quality concerns, and adherence to the set guidelines in the NCQA Credentialing Standards document. Partnering with experienced entities in healthcare licensing and credentialing can simplify the navigation through the rigorous demands of NCQA standards, ensuring a pinnacle of excellence in healthcare delivery.
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