What are the NCQA Primary Source Verification Requirements?

The National Committee for Quality Assurance (NCQA) is an accreditation agency that sets standards for provider credentialing. It seeks to ensure that organizations use high-quality internal processes when receiving, managing, reviewing, and deciding on their providers’ applications during and after the credentialing process.

NCQA offers both accreditation and certification services to organizations working to align with best industry credentialing standards.

Let’s unpack NCQA’s primary source verification (PSV) requirements.

NCQA Primary Source Verification Requirements

As we explained in Primary Source Verification Requirements You Should Know About, PSV is the process of verifying a provider’s information (e.g., degrees, certifications, work history, etc) by consulting the originating source of that information. The following are NCQA’s recommendations for what you need to verify across each PSV requirement.

To learn more about efficiently performing PSV (so as to meet NCQA and other industry standards for credentialing), see our complete guide.

Licensure

The organization must ensure that the provider/practitioner maintains a valid or current license to practice at the time of the credentialing decision. NCQA requires them to verify directly with the medical board of the state the provider is practicing in for this information.

DEA Permit / CDS Certificate

To allow practitioners to write prescriptions, organizations must verify a current/active Drug Enforcement Administration (DEA) and Controlled Dangerous Substance (CDS) certificate (if applicable - please see the DEA’s list of states requiring an additional CDS registration). They’ll need to consult the DEA database in addition to the state registry in which the provider is practicing in order to verify this information.

Education

The organization needs to verify the provider’s education and training using the highest level. To meet NCQA requirements, if the provider’s board certification is verified, then the organization doesn’t need to directly review the provider’s residency or medical school. The levels of education that are verified are ranked in this order:

1. Board Certification
2. Residency
3. Graduation from Medical/Professional School

Board Certification Status

If the provider states that they’re board certified, then the organization must verify that via primary sources. NCQA accepts the following as primary sources for this check for providers:

• American Board of Medical Specialties (ABMS)
• The Joint Commission accept the following DES
• American Medical Association (AMA)
• Educational Commission for Foreign Medical Graduates (ECFMG)
• American Osteopathic Association (AOA)
• American Academy of Physician Assistants (AAPA)
• Federation of State Medical Boards (FSMB) Disciplinary Action Databank

Work History

NCQA requires the organization to verify the provider’s work history via a resume/CV. It must include at least five years of work history with employment dates specifying the month and year of each post. Gaps of more than six months between positions must be explained, either in writing or verbally. Any gap of more than 12 months requires a written explanation.

Malpractice

The organization must obtain the provider’s malpractice history for up to five years (including fellowship and residency). NCQA allows organizations to acquire this information via the National Provider Data Bank (NPDB).

Sanctions & Exclusions

Sanctions (e.g., state, Medicare, Medicaid, restrictions on licensure, and limitations on the scope of practice) must be reviewed via primary sources.

How to Meet NCQA Primary Source Verification Requirements

In general, PSV is an intensive process, especially when organizations need to review large numbers of provider applications. Manually carrying out PSV is tedious, especially when you’re aiming to avoid delays in privileging providers, enrolling with payors, and engaging health plans or networks. Not only do you need immediate access to many – and often disparately placed – primary sources, but a monitoring and reporting system to ensure your records are up-to– date for re-credentialing every 2-3 years.

This is where leveraging NCQA-compliant software solutions can accelerate credentialing without compromising your ability to adhere to best practices and regulatory requirements. For example, you can use these tools to perform PSV tasks instantly, monitor for changesin your providers’ status or information and other NCQA-required tasks.

Why you should continue to monitor PSVs

PSVs are not a single time occurrence. They need to be consistently monitored to make sure that providers have stayed in compliance. This helps your organization mitigate risk and catch anything out of line before it can cause any bigger problems.

How Verifiable Helps

Verifiable automates the primary source verification and monitoring process necessary to be NCQA-compliant. We integrate with thousands of sources to shorten the verification process down to seconds and allow for automated monitoring across sources to ensure you stay compliant and audit ready at any time. We also provide screenshots, audit logs and other trails to meet PSV requirements using powerful and convenient automation