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.
The reviewer also will talk with your credentialing staff about the delegation oversight process.

  • Independent Review Organization: Internal Review 5.0 / 11.28.2017

    IR-INT 5 - Internal Review: Additional Reviewer Qualifications for Appeals

    IROs must have more rigorous qualifications for reviewers handling appeals. In addition to the requirements outlined in the previous standards, reviewers handling appeals must be board certified, if an MD, DO, or DPM.

  • Independent Review Organization: Internal Review 5.0 / 11.28.2017

    IR-INT 4 - Reviewer Qualifications

    Under this standard, the IRO must establish qualifications for its reviewers. At a minimum, those requirements must include the following:Current, non-restricted license or certificate as required under U.S. law for clinical practice;At least five years FTE experience with direct clinical care;Must be a clinical peer (i.e., "a physician or other health professional who holds an unrestricted licens...

  • Independent Review Organization: Internal Review 5.0 / 11.28.2017

    IR-INT 3 - Credential Status Changes

    This standard requires that the IRO have and implement policies and procedures that both require the IRO's staff members to notify the IRO in the event there is an adverse change in the status of the staffer's license or certification (including board certification) andprovide a procedure to implement a corrective action plan in the event of such an adverse change.In other words, if a member of th...