Credentialing Services

NCQA-related Q&A with Amy M. Niehaus, MBA, CPMSM, CPCS

In late June 2022, industry expert Amy M. Niehaus, MBA, CPMSM, CPCS, presented a webinar titled NCQA Credentialing Standards and Associated 2022 Updates, as part of the free AMA Credentialing Insights Webinar Series. The following recaps questions and answers that resulted from that webinar.

The statements, analysis, opinions, and conclusions in this webinar presentation and any related written materials are those of the speaker and not of the AMA or any of its agents, directors, employees, or advisors. AMA acts in the capacity as conveyor of the webinar presentation only. The information contained in the webinars and related materials is not intended to constitute legal advice or the rendering of legal, consulting, or other professional services of any kind.


Q: Is it required in Texas to check the SSA/Death Master File at initial credentialing and re-credentialing?

A: I do not know if Texas has a state requirement for checking the Social Security Death Master File (SSDMF), but this is a CMS requirement for Managed Medicaid.


Q: How do you audit for approvals? I understand how to audit for denials and terminations, but if a provider is approved, how would they be discriminated against?

A: Typically, an organization would audit complaints for denials or terminations, not approvals. However, it may be possible to identify that a provider with a specific history was approved and a similar provider was denied. If such a case is identified, the organization should determine whether to change a decision to maintain consistency within its decision-making process and avoid discrimination.


Q: Our group is provider based and does not have a specific directory for patient review. We submit credentialing to payers and the provider is listed in the payer’s directory. Does this mean the directory section is not applicable to us?

A: If that is the case, it is a good idea to state in your policies that providers are not listed in directories or other member materials in which case CR 1, Element A, factor 11 would be N/A.


Q: I’ve heard from several hospital systems with delegation agreements that “Credentialing System Controls” are becoming overwhelming. As a credentials verification organization (CVO), we’ve been doing this for years. Is this something new or larger for the health plans?

A: Yes, NCQA introduced a new standard (effective July 1, 2022) that organizations must audit for any unauthorized changes to practitioner credentialing information. Due to the many changes that occur to practitioner credentialing information on a regular basis, this requirement can be overwhelming. Thankfully, NCQA released its FAQ stating that sample auditing can be used as an alternative to reviewing all changes.


Q: The new CR 2 standard now states Credentialing Committee members are external to the organization. Can you provide more detail?

A: NCQA added a note to CR 2 to clarify its expectations that members of the Credentialing Committee should be external to the organization. This is to avoid having a Credentialing Committee comprised entirely of internal medical leaders, such as employed medical directors, which could lead to bias in decision-making towards business needs rather than patient care needs.


Q: How can a CVO incorporate the locked computers requirement with work-from-home employees?

A: Not all activities occurring in the workplace can be applied to staff working from home, such as ensuring computers are locked when not in use. Instead, a Facetime or Zoom review via phone can be conducted during which the employee shows his/her workspace and demonstrates how he/she secures and keeps confidential credentialing information.


Q: How many physicians or how many types of physicians are needed for a Credentialing Committee?

A: The composition of the Credentialing Committee will be unique to each organization depending upon its size and type of network. Typically, a committee should be a mix of primary care providers (PCP) and medical and surgical specialists who represent your network with the number of members based on the network size. Your policies should allow for additional subject matter expertise when needed. For example, should a neurosurgeon apply and your committee lacks this specialty, you want to be able to access this additional review without adding to the committee.


Q: If you have a primary source verification (PSV), must you also have a copy of the physical license?

A: Copies of documents are not required. The PSV provides all the necessary information and more value.


Q: To meet the requirement, must the organization primary source verify completion of residency?

A: Verification of residency is only required if the physician is not board certified in his/her specialty.


Q: It seems many payers will not start the credentialing process while a physician is in a fellowship even though residency is completed. Why is this?

A: Each payer has its own requirements, making it difficult to know each payer’s individual process. However, because physicians will most likely practice in their fellowship-trained specialty, payers may want to verify completion of fellowship as part of their credentialing process. While NCQA does not recognize fellowship verification as the highest level of training, it is a leading practice to verify fellowship in addition to residency if the physician is not board certified.


Q: Our facility trains fellowship for addiction medicine. The university credentials them. What should we be doing for credentialing when they are training at our facility?

A: Even though the training program may be provided through your organization, it is a good practice to obtain verification that training was completed if that is the specialty in which the physician will be practicing. While NCQA does not recognize fellowship verification as the highest level of training, it is a leading practice to verify fellowship in addition to residency if the physician is not board certified.


Q: Do we need to verify residency from outside of the United States?

A: If the foreign residency is the highest level of training and the physician is not board certified, then it should be verified. But keep in mind, NCQA only recognizes residency programs accredited by the following:

  • Accreditation Council for Graduate Medical Education (ACGME)
  • Accreditation Council for Graduate Medical Education—International
  • American Osteopathic Association (AOA) in the United States
  • College of Family Physicians of Canada
  • Royal College of Physicians and Surgeons of Canada


Q: What constitutes clinical competencies? At initial, what is the expectation to satisfy NCQA?

A: NCQA credentialing standards address clinical competency through the required application elements and verification of education, training, certification, licensure, work history, malpractice history, and sanctions.


Q: Is the board certification requirement applicable to physicians only? Our mental health organization does not require board certification for licensed professional counselors, licensed mental health counselors, doctors of psychology, and others. However, some say they are board certified in their specialty.

A: For nonphysicians, NCQA only requires that board certification be verified if the organization displays the board certification status in an online directory or other member materials.


Q: Do we need to verify employment from previous employers?

A: NCQA does not require verification of work history from employers. A review of at least five years of work history must be documented, and gaps of six months or more must be explained.


Q: Does NCQA require verification from the Federation of State Medical Boards (FSMB)?

A: NCQA does not require an FSMB query. The FSMB is, however, a recognized source for verification of physician license sanctions and Medicare/Medicaid sanctions.


Q: If we obtain continuous query from the National Practitioner Data Bank (NPDB), does this cover Medicare/Medicaid sanctions entirely or do we need to query multiple sources, such as NPDB, the Office of Inspector General (OIG), and the System for Award Management (SAM)?

A: NCQA accepts the use of the NPDB Continuous Query for ongoing monitoring of Medicare/Medicaid sanctions. The OIG is also an acceptable source. NCQA does not require the SAM, but a check of SAM is required by CMS for Managed Medicaid.


Q: Does NCQA require updating attestation question answers if credentialing finds the applicant answered incorrectly?

A: If the application and attestation must be updated, only the practitioner may attest to the update; organization staff may not.


Q: Do we need to query CMS opt out and General Services Administration (GSA) SAM per our payer delegations? Is that only if delegated?

A: CMS for Medicare Advantage requires that the Medicare Opt-Out reports be checked on a regular basis. CMS for Managed Medicaid requires the GSA SAM query. This applies to any health plans or delegated entities that participate in these contracts.


Q: What if the delegate is NCQA accredited?

A: Credentialing (CR) accreditation or CVO certification is accepted by NCQA in lieu of the health plan performing any oversight activities that are covered by the delegate's accreditation or certification.


Q: What type of quality improvement programs can take place in credentialing?

A: Examples include auditing of files to ensure compliance with verifications and timeliness, auditing for timely decision notifications, auditing for recredentialing timeliness, and auditing for timely review of ongoing monitoring reports.


Q: I believe you mentioned that only the highest level of education needs to be verified and Board Certification is the highest level. Therefore, if I verify board certification, I do not have to verify colleges. Is that correct?

A: That is correct. NCQA recognizes American Board of Medical Specialties (ABMS) and AOA board certification as the highest level. Boards in the United States that are not members of the ABMS or AOA (e.g., National Board of Physicians and Surgeons) are also accepted if the organization documents within its policies and procedures those specialty boards it accepts and obtains annual written confirmation from that the board performs primary source verification of completion of education and training.


Q: For CR 1D what does NCQA consider credentialing information?

A: Credentialing information is anything that is required under NCQA credentialing standards to be collected or verified.


Q: How often do you have to perform this audit?

A: For credentialing system controls, auditing must occur at least annually; however, it may be easier to manage the process if done more frequently.


Q: Does the 5% or 50-file audit process of a credentialed network include delegated providers?

A: For credentialing system controls, the 5% or 50-file audit would include the entire file universe which may include delegated providers.


Q: Do we have to change all of our agreements or only those agreements effective after July 1, 2022?

A: Delegation agreements dated Jan. 1, 2022, or later must have the credentialing systems controls language included. Agreements dated prior to Jan. 1, 2022, have until July 1, 2024, to be updated.


Q: I do verification for an ambulatory surgery center. You mentioned that the NPDB report could be used for malpractice history. Does this mean we do not have to reach out to the insurance carrier for a loss report?

A: For verification of malpractice history, NCQA accepts the NPDB or query of the malpractice carrier. An organization is not required to do both.


Q: How do you get IT or your credentialing software vendor to give you access to modification logs? Can they provide the logs if you don't have access?

A: Reviewing modifications logs is required to meet NCQA’s credentialing system controls. Noncompliance with this standard may result in loss of accreditation status or delegation status.


Q: More providers are choosing not to sign documents and instead use a Word or PDF font. Is this considered an acceptable signature by NCQA?

NCQA accepts faxed, digital, electronic, scanned, or photocopied signatures. I have seen a typed signature preceded by the letter “s” between slashes, being accepted by some organizations, but do not know if that is acceptable to NCQA.


Q: You mentioned the approval date is the date the medical director signs off on an application. What does that mean in respect to other committees like the Credentials Committee and Medical Executives Committee?

A: If an organization has approved the medical director to sign off on clean files, NCQA does not require any additional review or approval.


Q: To what degree do NCQA standards apply to a medical services organization or to a coordinated care organization?

A: I would recommend contacting NCQA to discuss your organization’s specific status. Please note that adherence to NCQA standards is only required of the following:

  • NCQA-accredited organizations
  • Organizations seeking delegation from NCQA-accredited health plans
  • Organizations performing credentialing services on behalf of their clients that follow NCQA standards


Q: You mentioned recredentialing every three years. I handle recredentialing every two years. Should I change to every three years?

A: Health systems or other integrated organizations may follow a two-year cycle to keep providers in sync with their hospital reappointment schedule.


Q: CR1.D applies to an organization’s universe but it states the audit must include 10 credentialing and 10 recredentialing files. How do you select sample files within your universe and determine which files are part of credentialing and recredentialing during an annual audit?

A: Organizations that use auditing as the monitoring method in CR 1, Elements C and D, may use the 5% or 50-files audit process. At a minimum, the sample includes at least 10 credentialing files and 10 recredentialing files. The organization identifies both initial and recredentialing files when selecting the sample.


Q: There are FAQs regarding boilerplate language. Can you clarify what NCQA is referring to?

A: Boilerplate language means template or standard language.


Q: Does use of a CVO for primary source verification only have to meet the delegation oversight requirements?

A: If the CVO is NCQA certified, oversight is not required for any of the elements for which the CVO is certified.


Q: What are best practices for starting credentialing and recredentialing prior to a license being issued?

A: Organizations can choose to begin the credentialing process prior to the applicant receiving licensure. This reduces delays in completing the file after the license is received.


Q: We require a 10-year lookback for claims activity. Does NCQA expect us to abide by our policies and procedures or will they only look for five years?

A: NCQA will only survey an organization against NCQA standards.


Q: Must it be a physician who signs off on files that meet clean file standards?

A: Clean files can only be approved by the medical director or an equally qualified practitioner. If your organization is comprised of only nonphysicians (such as dentists or optometrists), then the medical director would be a like practitioner.


Q: How often do we have to go through the NCQA Credentialing certification? Is that every year?

A: NCQA Credentialing accreditation is valid for three years. NCQA CVO certification is valid for two years.


Q: The reason why a change is made to a credentialing file is not generally tracked in an audit log. Given these new requirements, how would an organization begin tracking this?

A: The “why” for some changes is intuitive, such as updating expiration dates. However, if a change is made to specific credentialing information that is not intuitive, a note should be placed in the file for reference.


Q: We are a federally qualified health center and do not use a software. How do you recommend we track changes?

A: Without software, the only alternative I am aware of is to track changes manually on a spreadsheet or other tracking tool.


About the Author

Amy M. Niehaus, MBA, CPMSM, CPCS, is a credentialing and medical staff services consultant with more than 30 years of experience. As president of AMN Consulting, LLC, she advises clients in the areas of accreditation, regulatory compliance, credentialing, privileging, credentialing technology, CVO certification and CR accreditation, enrollment, and delegation. Amy has worked in multiple environments, including hospitals, CVOs, and health plans, providing her with a diverse insight into all facets of the profession. Amy has authored and contributed to a variety of industry-related publications and develops and presents various programs to state and national audiences.


Questions Regarding AMA Products

Webinar attendees also posed product-specific questions. Answers to the following are provided by the AMA Credentialing Services Team.

Q: What specialties can we verify via the AMA Profile?

A: AMA Profiles can be used to verify the following:

  • The specialty in which a physician trained. Only ACGME-accredited programs are provided on an AMA Profile.
  • Specialty board certification as reported by ABMS. The AMA Profile is designated an official ABMS display agent of member board certification data.

A recently updated AMA document titled Description of AMA Physician Masterfile data for AMA Physician Profiles provides this detail as well as an explanation for data used in each section of the AMA Profile.


Q: Should you run an AMA Profile upon recredentialing or only initial credentialing? Is it considered best practice to purchase AMA Continuous Monitoring Service when initially credentialing?

A: AMA offers both an initial profile and a reappointment profile for recredentialing (view samples of each online). Although similar to the initial profile, the reappointment profile focuses only on changeable data elements and does not include more static elements such as education, training, and ECFMG applicant number. Reappointment profiles are also available at a lower price point.

AMA recommends adding continuous monitoring when purchasing both types of profiles. Continuous monitoring covers these sections of the profile: state licensure, national provider identifier (NPI), state and federal action notification, DEA registration, ABMS® board certification, medical school, and postgraduate medical training.


Q: AMA monitoring does not auto renew, correct?

A: Correct. AMA Continuous Monitoring Service lasts for a period of two years from the date of purchase of a physician initial or reappointment profile. At the time of monitoring expiration, it is recommended that a new reappointment profile be purchased.


Q: I noted in the AMA response to The Joint Commission principles document that the “AMA Physician Masterfile is deemed an ‘equivalent source’ for physician medical school and postgraduate medical training.” Is this true for international graduates as well? Or is this for domestic graduates only?

A: The Joint Commission standards identify the AMA Physician Masterfile as a designated equivalent source for US and Puerto Rican medical schools only (the standards cite ECFMG for foreign medical schools). The AMA Physician Masterfile is also deemed equivalent source for training completed by domestic and international graduates; however, an AMA Profile only reports ACGME-accredited training programs.


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