What You Should Know About NCQA Credentialing Standards


Introduction to NCQA Credentialing Standards

The National Committee for Quality Assurance (NCQA) is one of a number of accreditation agencies that maintain standards for provider credentialing. Although NCQA credentialing standards serve as the benchmark for payers and regulators when they assess healthcare providers, they’re also aimed at helping practitioners credential efficiently by providing an accessible standard to follow. 

Not only do following NCQA credentialing standards open pathways to securing and keeping the trust of payers (as well as federal and state regulators), they’re also best practices that reflect positively on the health systems and practitioners that apply them.


NCQA Credentialing Standards Explained

1. All Practitioners Should Be Credentialed

The NCQA requires that all practitioners who are licensed to practice independently be credentialed. Provider types will vary by organization, as well as by state law for who is authorized to practice independently, but may include MDs, DOs, NPs, DDS/DMD, LCSW, LMFT, etc. However, to ensure highest compliance and superior patient safety standards, it is best practice to credential all of your practitioners who will be delivering patient care. 

2. Verify Credentials Using Primary Sources

The NCQA requires you to verify the following credentials using a primary source:

  • License to practice
  • Drug Enforcement Administration (DEA) or Controlled Dangerous Substances (CDS) certification
  • Education and training
  • Work history
  • Professional liability claims settlement history
  • State sanctions
  • Medicare and Medicaid sanctions
  • Application with attestation

Primary sources are issuing agencies or governing bodies that hold the original source of information, including but not limited to:

  • State licensing boards
  • Medical Boards like (AMA, AOA, ABMS, ABIM)
  • National Provider Identifier (NPI) registry
  • Drug Enforcement Administration (DEA) license
  • Social Security Administration’s Death Master File (DMF)
  • OIG (Office of Inspector General)
  • SAM (System for Award Management)
  • OFAC (Office of Foreign Assets Control)
  • National Practitioner Data Bank (NPDB)
  • National Student Clearinghouse (NSC)
  • Military Personnel Record
  • State Certifications List of Excluded Individuals/Entities
  • Medicaid Sanctions list
  • Medicare Opt-Out list
  • Medicare Preclusion List
  • Medical Malpractice loss runs report

To avoid delays in acquiring or verifying information, consider using software and automation tools for PSV. This way, you can readily access a large volume of primary sources and verify the information quicker and without the risk of errors, incomplete data, etc. 

3. Processes for Credentialing and Recredentialing

The NCQA requires organizations to re-credential their providers a minimum of once per three-year period. It’s recommended to have a 34 or 35 month recred cycle to ensure compliance.  Using automation tools to manage ongoing monitoring as well as recredentialing timeframes help you ensure nothing slips through the cracks.

4. Document Credentialing Decisions

For health networks and payers: Set standards for evaluating providers and your own decision-making processes. Work with your compliance team to create clear-cut criteria; when you deny providers, you can provide clear and measurable reasons and avoid any accusation of discrimination. 

5. Form Credentialing Committees

Establish clear guidelines for what provider applications can be sent to a credentialing committee for privileging. Designate a director or qualified practitioner to review and to approve applications for forwarding to the credentialing committee.

6. Delegation Credentialing Agreements

If organizations are delegating their credentialing work, the NCQA requires that they have formal delegation agreements to clearly explain the partner’s scope of work. To reduce the risk of non-compliance, you should work with NCQA-certified CVOs, or bring credentialing in-house and get accredited yourself. 

7. Non-Discrimination

For health networks/plans: The NCQA requires clear documentation of your organization’s non-discrimination policies (e.g., sex, race, age, etc). You should also clearly state that you don’t exclude providers with Medicaid or Medicare users. If relying on a CVO, then ensure you’re forwarding provider applications to a credentialing committee. You must also inform applicants about the committee’s decision and provide pathways for appeals, if required.

8. Notify Practitioners About Discrepancies

Establish a process for notifying providers in case the information in their application forms differs from what’s contained in the primary source. Work to identify these issues within 30 days of the provider submitting the application (note: this may require software tools if you are working across a large number of applications). 

9. Notify Practitioners About the Final Decision

Establish a process for informing the provider about the final credentialing decision – and maintain clear appeal processes in case of denials. Ensure you’ve communicated the final decision to the provider within 60 calendar days of the credentialing committee’s decision.

10. Assign a Lead Practitioner for Your Credentialing Efforts

NCQA credentialing standards require organizations to assign a physician or comparable provider to lead their credentialing efforts. Moreover, the credentialing committee should comprise of providers with diverse professional expertise.

11. Maintain Confidentiality

The organization and their CVO must ensure the privacy and confidentiality of all provider information. Only authorized persons should be able to access and query primary sources.

12. Keep Provider Information Up-to-Date

Health plans are responsible for having the most up-to-date information about their doctors and other providers in their networks. This information must be consistent with credentialing data, such as the provider’s education, training, certifications, etc.

Meeting NCQA Standards with Verifiable

Need an NCQA-certified CVO to outsource credentialing to? Or want to get your in-house team NCQA-certified? Verifiable can help you with both.

arrow right icon

Next Steps: Efficiently Meeting NCQA Credentialing Standards

Complying with the NCQA’s credentialing standards involves both airtight processes and robust tools. The latter are especially important as they’re vital assets to ensuring that the information you’re acquiring and reviewing are correct, and that you’re making decisions within the required timelines set by the NCQA. 

This is especially true if you’re working through large numbers of provider applications. It isn’t efficient to verify hundreds of primary sources manually, much less keeping your information up-to-date in time for re-credentialing. Thus, automation is essential for internal processes and delegated credentialing partners alike. 

Verifiable empowers organizations to bring credentialing in-house with software tools to automate much of the NCQA-certified credentialing process. In addition to its very own NCQA-certified CVO to supplement credentialing needs.