ALL of the following

• Credentialing Department requests current documents from the entity (e.g., applications, credentialing/recredentialing policies and procedures, bylaws, list of Credentials Committee members, minutes from three CC meetings, complete provider roster, and quarterly credentialing system audit reports).
• Credentialing Department reviews documents for compliance with NHP/NHIC, state, federal and NCQA standards and documents findings on the NHP/NHIC Credentialing Delegation Audit Tool.

• If documents comply or do not comply

  • If documents comply, an on-site visit may be scheduled within 30 calendar days (if applicable).
  • If documents do not comply, audit results and a proposed corrective action plan (CAP) are sent to the entity; the entity has 30 calendar days to respond. If no response is received within 30 calendar days, credentialing/recredentialing functions may not be delegated.

ALL of the following

• When conducted, onsite reviewer will examine required elements and document results on the NHP/NHIC Credentialing Delegation Audit Tool.

• Audit methodology

  • Audit either 5% of practitioner files or 50 practitioner files, whichever is less; the sample must include at least 8 credentialing files and 8 recredentialing files (or audit the universe if fewer than 8 in the look-back period).
  • Or use the NCQA '8/30 methodology' to review delegate files for credentialing and recredentialing.

ALL of the following

• NHP/NHIC sends a Delegation Agreement that delineates which entity performs each activity, reporting requirements, term of agreement, and remedies including revocation if obligations are not fulfilled. The delegated entity must return a signed Delegation Agreement within 90 calendar days.
• If PHI is involved, the Delegation Agreement must include a Business Associate Agreement, allowed uses of PHI, description of safeguards, sub-delegate safeguards, obligations to provide individuals access to PHI, notification of inappropriate uses, and provisions for return/destruction/protection of PHI at agreement end.
• Delegation Agreement must identify how NHP/NHIC will evaluate the delegated entity's performance and specify remedies available to NHP/NHIC, including revocation. Delegated entity must submit a list of practitioners/providers and required practitioner information with the Agreement.

ALL of the following

• Delegated entity must provide reports at least twice a year describing activities carried out to improve performance; reports are reviewed by the Credentials Committee and reported to the QMC as applicable.
• Delegated entity must monitor and inform NHP/NHIC immediately, or as defined in the Delegation Agreement, of all practitioner/provider sanctions by state licensing agencies, Medicare and/or Medicaid. NHP/NHIC reserves the right to approve, suspend, or terminate individual practitioners/providers and to terminate delegation where appropriate.

ALL of the following

• If the delegated entity is NCQA-certified/accredited, NHP/NHIC is not required to conduct an annual onsite evaluation but will annually verify continued NCQA status; NHP/NHIC may evaluate at any time with reasonable notice.
• Credentialing Department will schedule a virtual audit or onsite visit with the delegated entity annually and request updated documents (including list of practitioners/providers within the scope of delegation).