The Journey to Achieving Delegated Credentialing

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Have you been thinking about applying for delegated credentialing? Not sure where to start? Going through the process of achieving delegated credentialing might seem like a huge undertaking, but with the right preparation and partner, it can be a straightforward process. We’ve created a guide for you, outlining the basics of achieving delegated status.


When do I know that my organization is ready to start the Delegated Credentialing process?

If you check off one or more of the below boxes, you may be ready to begin the process of applying for delegated credential status: 

  • You have at least six months documented history of following NCQA credentialing standards
  • You are a large provider group or health system (in excess of 100 providers)
  • You are a national, statewide, or regional provider network

What will we need to begin the process? 

  1. A formal Policies and Procedures manual.
  2. An established Credentialing Committee Peer-Review process.
  3. A historical record of convening Credentialing Committee meetings

What does the process consist of? 

Your first step to becoming a delegated provider is to answer a set of questions from the health plan’s delegation oversight or credentialing department(s). These questions will ask you about the above assets – specifically, information regarding your Policies & Procedures and your Committee – and will ask you to verify if any part of your process is sub-delegated. They will also want to ensure that you follow NCQA guidelines. 

After this initial review is completed, the plan will request that you complete a Pre-Assessment Questionnaire, to verify that your Policies & Procedures meet all of their requirements. At this time, you can also expect the health plan to request copies of your historical Credentialing Committee meeting notes. 

Following the initial review, the health plan will approve or deny your request for delegation.  Once approval is granted, you will execute a delegation agreement with the plan and determine a timeframe of how often to submit a provider roster and Committee meeting minutes (it’s standard to submit once a month). 

When can I expect a decision?

Although the time frame depends entirely on the health plan, you can typically expect a decision in approximately six weeks. 

What challenges could potentially arise during this process? 

Occasionally, the health plan may request clarification or revisions to your policies or procedures. Common critiques include: 1) the peer-review process is not fully formed, or there are specific points of contention with the process itself, 2) missing  anti-discrimination policy, or 3) a lack of clear delineation between what your organization does versus what the CVO does (if you sub-delegate). 

In some cases, the health plan may decline your request to become a delegated provider. The most common reasons organizations are declined are because they do not follow NCQA guidelines, or they lack a track record of meeting NCQA standards. 

How we can help with this process:

  1. By partnering with us, you are ensuring that you meet NCQA standards, which will help streamline your delegation review process.. 
  2. If you have existing Policies and Procedures, we will assess them, and make recommendations, helping ensure that you meet the standards set forth by the health plan’s decision-making body.  For those organizations just getting started, we can collaborate with you to develop and document compliance policies and procedures.
  3. Finally, our platform makes it easy to obtain and share a lot of the information needed as you submit your application as well as perform ongoing credential and monthly monitoring. 

 

As you can see, the process of becoming a delegated provider requires advanced planning and preparation. If you have any questions about how andros can help you with this process, please reach out to us.

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Mike Simmons

Mike leads a team dedicated to each other, our clients, and our mission to make healthcare administration work better. His vision is to provide an end-to-end solution designed for 21st century healthcare organizations. Mike is a student of Brazilian jujitsu, enjoys road cycling, paddling, and surfing, and aspires to be a true ally to people across the entire spectrum of diversity.