Everything You Need to Know About Delegated Credentialing

Everything You Need to Know About Delegated Credentialing

Aug 4, 2021
  • Author:
    Noelle Abarelli

Delegated Credentialing is increasing in popularity because it can improve enrollment turnaround times for providers, decrease paperwork for practitioners and staff, and reduce lost or delayed revenue. If this sounds good to you, read on to find out what Delegated Credentialing is, what it requires, and what is involved in forming a Delegated Entity Credentialing Committee.

What is Delegated Credentialing?

Delegated Credentialing is when an organization, most often a large health system, is given authorization by a specific payor to perform credentialing in-house. Delegated Credentialing goes beyond credentials verification, because the delegated health care entity (e.g. the health system) is responsible for evaluating practitioners' qualifications and making credentialing decisions on behalf of the delegating health care entity (e.g. the payor). In this arrangement, the delegated entity does all the work necessary to complete the credentialing process, but at the end of the day, the delegating organization still has the authority to veto any decision made by the delegated party.

Delegated Credentialing requires there to be a mutually agreed-upon arrangement that provides an explanation of obligations in keeping with regulatory bodies, like the NCQA, URAC, CMS, and federal and state laws. Delegation agreements can be a separate agreement or an amendment to an existing parent contract/agreement. The entity that is granted permission to perform delegated credentialing is commonly referred to as the Delegated Entity, Delegate, or Client.

Types of Delegated Credentialing Bodies

There are a couple of options for Delegating Credentialing. Credentialing Accreditation and CVO Certification are most common. Both have policies in place to ensure internal continuous quality improvement and protect credentialing information and practitioner data throughout the application process. However, there are a few differences between Credentialing Accreditation and CVO Certification.

Credentialing Accreditation CVO Certification

The organization completing Credentialing Accreditation is usually a provider group. Eligible organizations:

  • Must not be licensed as an HMO, POS, PPO or EPO.
  • Must not be eligible for NCQA Accreditation as a health plan or an MBHO.
  • Must preform credentialing functions directly or through a contract.
  • Must preform credentialing activities for at least 50% of a practitioner network.

These organizations provide the full scope of credentialing, including the committee approval process, and they have quality standards that make them stand out. For example, Credentialing Accreditation receives automatic credit for certain activities when contracting with health plans that are NCQA-accredited.

The organization completing CVO Certification verifies the practitioners’ credentials for a health plan, a healthcare organization, or a physician’s organization. These organizations can be a health system or a commercial CVO. CVO Certification allows the CVO to send and receive the application on behalf of the delegating party, but it does not provide the authority needed for the committee approval process.

This difference between Credentialing Accreditation and CVO Certification means more and more organizations are turning to Credentialing Accreditation, as it grants them the freedom to implement an evaluation process with peer review by forming a Delegated Credentialing Committee. This committee is responsible for ongoing monitoring and taking action against practitioners with quality issues.

Delegation Requirements

The NCQA has many requirements and different standards that organizations must abide by, one of the main ones being certain time frames for the primary source verifications (PSV) listed below. The time frame is based on the date written on the practitioner’s application.

  • Current License:
    • PSV time limit is 180 days.
  • Federal DEA and/or CDS Certificate:
    • There is no set PSV time limit, but it needs to be obtained prior to the committee decision date.
  • Education and Training:
    • There is no set PSV time limit, but it needs to be obtained prior to the committee decision date.
    • If the practitioner is board-certified, that alone meets the requirements for education and training. If they are in the process of getting their board certification, then verification of that physician’s residency needs to be completed.
  • Board Certification:
    • PSV time limit is 180 days.
    • The NCQA does not require board certification. However, the delegated organization verifies any certification that states a practitioner is board-certified, documenting the expiration date of the board certification on file.
  • Malpractice History:
    • PSV time limit is 180 days.
    • The delegated entity obtains confirmation of the past five years of malpractice settlements from the practice or national practitioner data bank.
  • Work History:
    • PSV time limit is 365 days.
    • If a gap in employment exceeds six months, the practitioner needs to clarify the gap verbally or in writing. The delegated organization includes the written notice in the practitioners’ credentialing file.

This is a high-level overview of the many requirements the NCQA has for Delegated Credentialing. A lot more goes into the process than what is listed above, which is why having a centralized source for all your credentialing needs, like CredentialStream, is crucial in ensuring you stay ahead of the curve.

Best Practices for Forming a Delegated Entity Credentials Committee

The NCQA doesn’t provide a set number of how many members need to sit on a Delegated Entity Credentials Committee, but it should be composed of individuals who have knowledge of the physicians/practitioners who will be reviewed by that committee. More importantly, these members need to be active practitioners who have the necessary expertise to render a review of the file. Medical Directors should also be included in the Delegated Entity Credentials Committee.

Every committee will have varying thresholds to meet in order to consider a file “clean”. For example, any licensure action, Medicaid, or Medicare sanctions are automatically reviewed at the time of initial credentialing before a file can be considered “clean”. Once the file is clean, the Medical Director reviews and approves them as defined by the Delegated Entity Policies. Throughout the committee meeting, minutes are kept documenting any important notes, which the NCQA refers to as a “report”, and those minutes are included in the final application to the NCQA.

Getting Started with Delegated Credentialing

Most health plans are eager to delegate credentialing work today because it helps them lower administrative costs. But before they will agree to delegate you will need to implement a robust ‘in-house’ credentialing process. With a solution like CredentialStream in place your organization can be confident that your credentialing procedures will meet the standards of today’s payors. Reach out today to schedule a demo and see what CredentialStream can do for you.