Dental Plan with Health Insurance Marketplace (HIM) 7.2

DPHIM-CR 17 - Credentialing Delegation

Submited by: Tom Goddard

The Basics

Some organizations delegate credentialing to other organizations, like facilities, provider groups, or credentials verification organizations (the "CVOs"). URAC has four standards in the Core module that address delegation generally (Core 6-9).  
This standard establishes two requirements in addition to the requirements contained in those four standards. 

  • If your organization delegates credentialing to another organization, it must retain authority to make the final credentialing determination. Part of this process is likely to involve your organization comparing a list of approved providers forwarded from the delegate to add to your network against a historical list of providers previously terminated or denied in order to determine whether the providers are to added to your network.
  • In addition, no less frequently than three years, the organization must either
    • conduct surveys of its credentialing contractors, or
    • review randomly selected credentialing files.
Finally, the organization must provide the credentialing committee with an annual report on delegation oversight.  
The onsite surveys should be conducted according to your credentialing plan or a policy and procedure that directly addresses the performance of on-site surveys of delegated entities that conduct credentialing for your organization. Typically, a standardized audit form is used for such on-site audits. The on-site audit should involve a random sample of complete credentialing files that the contractor has administered on your organization' behalf. The sample size should be at least 10% of those files, but in no case fewer than 10 files nor more than 30 files.

Management Tips

Make sure that, if you take advantage of he option to conduct a review of randomly-selected credentialing files instead of conducting an onsite review, that your P&P specifies how long after the request the contractor has to provide the selected files.
Naturally, if your organization does not delegate credentialing, this standard is not applicable.

Accreditation Tips

Desktop Review
At the desktop review stage, you should submit your credentialing plan, a template delegation agreement, your on-site audit tool, sample credentialing committee meeting minutes in which the committee demonstrates that it retains final authority for credentialing decisions, and/or sample committee meeting minutes that document a decision to delegate or not to delegate credentialing to another entity.
If your organization does not delegate credentialing, submit an attestation to that affect, on organizational letterhead and signed by a senior executive.
Validation Review
Document review
The on-site reviewer will examine credentialing committee meeting minutes from the last four years. In addition, the reviewer will look at "delegation binders" for each of several of your contractors. Each delegation binder should contain the delegation agreement, reports submitted by the contractor, completed audit sheets from your on-site surveys, and documentation of other required oversight activity.
Interviews
The reviewer also will talk with your credentialing staff about the delegation oversight process.

  • Dental Plan with Health Insurance Marketplace (HIM) 7.2 / 10.17.2017

    DPHIM-NM 13 - Participating Provider Violation Mechanism

    The standard requires that your organization implement a means of addressing alleged violations by participating providers in its network of the organization's requirements for providers. The standard applies only to providers already in your network, not merely applicants for participation in the network. 

    READ FULL POST
  • Dental Plan with Health Insurance Marketplace (HIM) 7.2 / 10.17.2017

    DPHIM-NM 12 - Provider Network Disclosures

    The standard is intended to address the situation of "silent PPOs".  URAC provides the following definition and explanation of silent PPOs:[A] PPO brokers access to its provider network to other PPOs or payers without providers’ knowledge. For example, PPO X may sell access to its provider network to PPO Y. When an eligible person from PPO Y receives service from a physician in PPO X’s network, PP...

    READ FULL POST
  • Dental Plan with Health Insurance Marketplace (HIM) 7.2 / 10.17.2017

    DPHIM-NM 11 - Other Participating Provider Agreement Documentation

    This standard contemplates that not all of your existing contracts with participating providers contain all of the requirements of the previous several standards. Rather than forcing your organization to go back and amend all of the extant, noncompliant participating provider agreements, URAC allows you to "fix" to these agreements by using your provider manual or other similar document that descr...

    READ FULL POST
Top