The complexities of managed care credentialing
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The Complexities of Managed Care Credentialing. Mei Ling Christopher, UnitedHealthcare Sallye Marcus, Anthem Blue Cross. Session Objectives. What are the benefits of delegated credentialing Regulatory/Accreditation Survey process Electronic audit process. Definitions .

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The complexities of managed care credentialing

The Complexities of Managed Care Credentialing

Mei Ling Christopher, UnitedHealthcare

Sallye Marcus, Anthem Blue Cross

Session objectives
Session Objectives

  • What are the benefits of delegated credentialing

  • Regulatory/Accreditation Survey process

  • Electronic audit process


  • Delegation occurs when an organization gives another entity the authority to carry out a function that it would otherwise perform.

  • Sub-delegation occurs when the organization’s delegate gives a third entity the authority to carry out a delegated function.

    • For example, the organization may delegate credentialing (CR) activities to a provider hospital organization (PHO), who then delegates some of those activities to an Management Services Organization (MSO). In this case, the MSO is the sub-delegate.

Definitions continued
Definitions (continued)

  • Annual Audit: A health plan must conduct an audit at least every 12 months; 2-month grace period allowed (14 months).

  • Documented Process: Policies and procedures, process flow charts, protocols, and other mechanisms that describe the methodology used by the organization to complete a task.


  • The delegate has been given the power to carry out a specific function, within the parameters agreed to.

  • The organization gives a delegate the authority to act on its behalf, but it remains responsible for the function to be carried out properly.

  • The organization must conduct annual oversight activities of the delegate.

  • NCQA requires the presence of a mutual agreement between the delegating organization and its delegate.

Who are they
Who are they?

  • Delegates may be:

    • Medical Groups

    • Hospitals

    • Medical Universities

    • Independent Physician Associations (IPA)

    • Physician Hospital Organizations (PHO)

    • Management Service Organizations (MSO)

    • Credentialing Verification Organizations (CVO)

Benefits of delegation
Benefits of Delegation

  • Reduce duplicate credentialing efforts

  • Allow practitioners to become effective with the organization sooner

  • Patients can be seen sooner by new practitioners

  • Cost Savings – Better use of resources

Survey process
Survey Process

  • Please ensure the health plan knows your organizations correct status:

    • Is your organization NCQA certified or accredited?

    • Does your organization sub-delegate to a NCQA certified CVO?

    • Is your organization delegated for Organizational Providers/Health Delivery Organizations?

Survey process continued
Survey Process (continued)

  • NCQA and the health plans retain the right to request the verification documents as evidence, regardless of certification or accreditation status.

  • The look back period is 36 months prior to the survey date.

  • Once notified by NCQA of the files selected the timeframe to collect the files and submit to NCQA is short.

Survey process continued1
Survey Process (continued)

  • Rosters are required from all delegated groups for submission to NCQA

    • Roster should be in Excel spreadsheet, with two sheets/tabs

    • Include all date ranges of practitioners that have been processed with your organization

    • Do not include hospital based or allied health providers

Survey process continued2
Survey Process (continued)

  • For NCQA roster submission the following fields are required:

    • Last name

    • First name

    • Degree

    • Specialty

    • Initial credentialing date

    • Most recent recredentialing date

    • State

    • Name of organization

Contents of a file

Application/Signed Attestation

State License Primary source verification (PSV)


Education/Board Certification

Work History

Contents of a File

  • Professional Liability Insurance

  • Malpractice Hx. (or NPDB)

  • License Sanction Review

  • Medicare/Medicaid Sanction review

  • Cred. Committee Date

  • (CMS Audits) - Hospital Privileges, Medicare Opt-Out and Performance Review for recredentialing

The copies should either be dated/signed or initialed, or a checklist should be dated/signed.

Electronic audits
Electronic Audits

  • Many Health Plans are moving to a desktop audit process

    • Reduces health care costs

    • Frees up time you would normally spend during the onsite audit

    • Notification well in advance of the audit outlining which files are needed, allowing time to gather and send the files

    • Provide electronic copies of the files via secure email or website, or conduct audit live via a webex/web meeting

Electronic audits continued
Electronic Audits (continued)

  • The auditor will request:

    • Policies and Procedures, Evidence of reporting, sub-delegation agreements

    • A full roster to select 30 initial and 30 recredentialing files

      • The auditor will request the first 10 initial and 10 recredentialing files from the delegate

      • Additional files will be requested if there is a deficiency within the first 8 elements