CP PINsProcedures 0617 2016CredentialingFileReviewWorksheet1

Surveyor Credentialing File Revi
Table of Contents
Applies to HPA, MBHO, NHP, and U
Submission Instructions
Worksheet Instructions
Abbreviations
Credentialing Universe from Organization
Recredentialing Universe from Organization
Final List
CR Worksheet for Surveyors
Summary Sheet
503516851.xlsx 1 Revised: 06/03/13 AFC

Surveyor Credentialing File Review Worksheet
Table of Contents
Applies to HPA, MBHO, NHP, and UMCR Certification
Submission Instructions
Worksheet Instructions
Abbreviations
Credentialing Universe from Organization
Recredentialing Universe from Organization
Final List
CR Worksheet for Surveyors
Summary Sheet
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2016 Credentialing File Review Submission Instructions for Organizations
Applies to HPA, MBHO and UM/CR Certification
Organizations are strongly encouraged to print and thoroughly review these instructions before preparing
the lists according to the instructions below.
Before preparing lists, please save a copy of this workbook to your network or local drive.
Any data entered to this workbook while it is still linked to the Survey Tool will not be saved.
Summary of Changes for Surveys

Credentialing and recredentialing verification requirements have been merged into a single standard (CR 3). Recredentialing Cycle
Length remains as a separate standard (CR 4).
To evaluate these two standards, NCQA will generate a single, stratified file list of 80 files, comprised of 40 Initial Credentialing and 40
Recredentialing files. NCQA will review files using the 8/30 rule, evaluating each file on the applicable factors until the following is met
for each factor:
l A rate of 8/8 is achieved based on the first 8 applicable files, or
l A denominator of 30 is achieved, or
l All applicable files have been reviewed.
Practitioners to Include and Not Include in Credentialing/Recredentialing File Lists
Please do not rely solely on these instructions to determine practitioners to be included or excluded in the file lists sent to
NCQA. Any recent updates or clarification are provided in the Survey Tool and in Policy Clarification documents and may not
be included here. Refer to the applicable standards for the comprehensive guidelines on practitioners that should be included
and excluded.
Practitioners to include:
Include all the following medical and behavioral healthcare practitioners credentialed by the organization or any delegate -
including a rental network - except as noted below in Practitioners to exclude.
l Medical practitioners
─ Medical doctors.
─ Osteopaths.
─ Oral surgeons. *
─ Chiropractors. *
─ Podiatrists. *
─ Nurse practitioners who are licensed, certified or registered by the state to practice independently.
* Include only podiatrists, chiropractors and oral surgeons who provide care under the medical benefit plan.
l Behavioral healthcare practitioners
─ Psychiatrists and other physicians.
─ Addiction medicine specialists.
─ Doctoral or master's-level psychologists who are state certified or licensed.
─ Master's-level clinical social workers who are state certified or licensed.
─ Master's-level clinical nurse specialists or psychiatric nurse practitioners who are nationally or state certified or licensed.
─ Other behavioral healthcare specialists who are licensed, certified or registered by the state to practice independently.
l Terminated Practitioners
Include all terminated practitioners of those specified above who have been part of the organization's network any time during the
look-back period, whether or not they are still currently in the network.
l Telemedicine Practitioners who have an independent relationship with the organization and who provide treatment services under
the organization's medical benefit.
l Rental Networks
Practitioners credentialed by rental networks are included in the credentialing file review, except as specified below. Because of the
large number of practitioners in rental networks, NCQA has specific instructions for how to provide the practitioner lists for these. If
you use a rental network that will be included in the file samples, discuss this with your ASC during you initial phone call with
him/her, usually 9-12 weeks before your survey submission.
For examples of practitioners to include by degree and abbreviation, see Appendix 1 at the end of this document.
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Practitioners to exclude:
Do not include the following practitioners:

l Practitioners who practice exclusively within the inpatient setting and who provide care for the organization’s members only as a
result of the members being directed to the hospital or another inpatient setting (e.g., pathologists, radiologists, anesthesiologists,
neonatologists, emergency room physicians, hospitalists, telemedicine consultants).
l Practitioners who practice exclusively within freestanding facilities and who provide care for organization members only as a result of
members being directed to the facility (e.g., mammography centers, urgent care centers, surgi-centers, psychiatric and addiction
l disorder clinics).
Oral surgeons who do not provide care under the organization's medical benefit plan.
l Dentists who are not oral surgeons.
l Pharmacists who work for a pharmacy benefits management (PBM) organization to which the organization delegates utilization
management (UM) functions.
l Covering practitioners (e.g., locum tenens). Locum tenens who do not have an independent relationship with the organization are
outside NCQA's scope of credentialing.
l Practitioners who do not provide care for members in a treatment setting (e.g., board-certified consultants).
l Rental network practitioners that are specifically for out-of-area care, and there are no incentives communicated to members;
members have no obligation to seek care from rental network practitioners and may see any out-of-area practitioner.
l Practitioners terminated for noncompliance with credentialing process (i.e. failure to submit requested information).
For examples of practitioners to exclude by degree and abbreviation, see Appendix 1 at the end of this document.
Look-Back Periods and Designating Files as "Credentialing" and "Recredentialing"
An organization must include on its file list all practitioners specified above who were credentialed or recredentialed during the look-
back period.
The look-back period is the period for which the organization must demonstrate performance against NCQA requirements (or
standards). NCQA measures the look-back period from the point of the organization’s submission of the completed Survey Tool. Unless
otherwise noted, the organization must meet requirements throughout the look-back period. Under certain circumstances, NCQA may
expand the look-back period.
l The look-back period varies by the Accreditation/Certification program and the Evaluation Option or survey type, as specified below.
l For credentialing and recredentialing files, a file is considered within the look-back period if the credentialing or recredentialing
decision (as applicable) was made during that specified date. If you delegate decision-making to another organization, use the
date the delegate made the decision.
l The organization will submit two separate lists - one for Initial Credentialing files and one for Recredentialing files; look-back periods
are specified distinctly for each.
l Organizations undergoing surveys for multiple entities or products that include a combination of un-accredited and previously
accredited entities/products should contact their ASC for specific instructions about look-back periods.
Health Plan Accreditation
Survey Type Lookback Period Include on the Include on the

Credentialing List Recredentialing List
Interim NA NA NA
Surveys No file review No file review No file review
First Credentialing or recredentialing Initial credentialing decision Recredentialing decision within
Surveys decisions in the 6 months prior to the within 6 months prior to the the 6 months prior to the survey
survey survey submission date submission date
Renewal Surveys Credentialing or recredentialing Initial credentialing decision Initial credentialing decision more
decisions in the 36 months prior to the within the 36 months prior than 36 months prior to the survey
survey to the survey submission submission date
date
Follow-Up Surveys Credentialing or recredentialing Initial credentialing decision Recredentialing decision within
decisions in the 3 months prior to the within the 3 months* prior the 3 months* prior to the survey
survey* to the survey submission submission date
date
*If there are less than 40 files available in this period, NCQA will increase the look-back period to 12 months.
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MBHO Accreditation

Initial Credentialing or recredentialing Initial credentialing decision Recredentialing decision within
date
Follow-Up Surveys Credentialing or recredentialing Initial credentialing decision Recredentialing decision within
decisions in the 3 months prior to the within the 3 months* prior the 3 months* prior to the survey
survey* to the survey submission submission date
date
UMCR Certification

Initial Credentialing or recredentialing Initial credentialing decision Recredentialing decision within
date
Look-back Period Calculator

l To assist you in determining the lookback period for your survey, this workbook contains a Look-Back Period Calculator as
Appendix 2 at the end of this worksheet.
Determining the Correct Credentialing Date for the Lookback Period and File List
l If your organization performs all primary source verification functions and your Credentialing Committee makes the credentialing
decision, use the date that your committee first credentialed the practitioner.
l If your organization delegates primary source verification functions (e.g., licensure, DEA, malpractice history) but your organization's
Credentialing Committee makes the credentialing decision, use the date that your committee first credentialed the practitioner.
l If you delegate all primary source verification functions and the committee decision making, use the date that the delegate’s
committee first credentialed the practitioner, even if this is before you contracted with the delegate.
If you cannot obtain the delegate’s initial credentialing date, work with the delegate to determine whether each practitioner was first
credentialed more or less than 36 months before the survey submission date. This will ensure that practitioners are identified
appropriately as initially credentialed or recredentialed on the practitioner list submitted to NCQA.
If 100% of Credentialing and Recredentialing is delegated

If the organization delegates 100% of credentialing and recredentialing, a file universe is still required. Exception - if the
organization delegates 100% of the functions to an NCQA-Accredited or Certified delegate(s), please complete the '100% AC Files'
tab of this workbook instead. Evidence of sister or delegation arrangements will need to be provided with submission.
Format for Submitting Practitioner Lists
To ensure that NCQA can accurately generate the list of selected files in the necessary format, organizations are required to submit the
lists of practitioners exactly as indicated below.
Credentialing lists submitted in a format inconsistent with the specifications below will be returned to the organization for
correction and resubmission, which may result in a delay in providing the final list of selected files to the organization.
l Using the criteria described previously, please compile two lists - one for initial credentialing files and one for recredentialing files.
l Files for all practitioners credentialed by delegates and sister organizations (including NCQA Accredited and Certified delegates and
sister organizations) must be included on the two lists; do not provide delegate files in separate lists.
l Prepare the two lists, in an Excel format, exactly as depicted in the example below.
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l When complete, please copy the resulting records into the worksheets labeled "Credentialing" and "Recredentialing" in this
workbook. These worksheets are protected and will only allow data entry in the specified columns.
Credentialing list format (example assumes Renewal Survey with a 9/1/2013 survey submission date)
Initial Delegate/Sister Co
Credentialing Name
Last Name First Name Degree Specialty Date (if necessary) Cred
Jones Bill MD Internal Medicine 10/1/2010 Cred
Miller Jane MD Cardiologist 1/15/2013 Max IPA Cred
Smith May MD Pediatrics 4/27/2011 Cred
Recredentialing list format (example assumes Renewal Survey with a 9/1/2013 survey submission date)
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Initial Delegate/Sister Co
Credentialing Name
Last Name First Name Degree Specialty Date (if necessary) Recred
Williams Mary MD Gastroenterologist 4/3/2006 Recred
Reed John MD Internal Medicine 5/17/2009 Recred
Smith Fred PhD Psychologist 3/3/2003 ABC MBHO Recred
About the data fields
l If applicable, provide a list defining specialty abbreviations (e.g., CD = cardiologist, PD = pediatrician) in the worksheet tab labeled
Abbreviations.
l Include the initial credentialing date for the practitioner for both the Credentialing and Recredentialing lists. If you cannot obtain
the delegate’s initial credentialing date, work with the delegate to determine whether each practitioner was first credentialed more or
less than 36 months before the survey submission date. This will ensure that practitioners are identified appropriately as initially
credentialed or recredentialed on the practitioner list submitted to NCQA.
l The Initial Credentialing date must be formatted as a date. Please be sure that this field is not formatted as text.
l Include the names of any delegates, sister companies or other organizations that perform any aspect of cedentialing on your behalf
even if NCQA does not formally call these organizations delegates. This is to help track and provide any auto cedit.
l Each record on the Credentialing list must have the designation "Cred" in the last column; each record on the Recredentialing list
must have the designation "Recred" in the last column. The exact term must be used.
Submitting the Lists to NCQA with the Survey Tool

l After completing the workbook, save it using the file name Credentialing File Review.xlsm.
l Load the workbook into your Survey Tool and link it to the Org File Submission Instruction tab in the Organization Background.
l Score each credentialing and recredentialing file review elements (CR 3A-C & CR 4A) "NA."
Appendix 1: Examples of Practitioners to Include and Exclude by Degree
Practitioners that must be on the list include, but are not limited to:
Degree/Specialty Abbreviation
l Advanced Registered Nurse Practitioner ARNP
l Certified Family Nurse Practitioner CFNP
l Certified Nurse Midwife CNM
l Certified Social Worker CSW
l Doctor of Chiropractic DC
l Doctor of Medicine MD
l Doctor of Oral Surgery (Oral Surgeons) OS
l Doctor of Osteopathy DO
l Doctor of Philosophy PhD*
l Doctor of Podiatric Medicine DPM
l Doctor of Psychology PsyD
l Licensed Marriage & Family Therapist LMFT
l Licensed Professional Counselor LPC
l Licensed Social Worker LSW
l Nurse Practitioners, practicing independently NP
l Registered Addiction Specialist RAS
l Physical Therapist PT**
* Include for MBHO only
** Include for UMCR only
Practitioners who should not be on the list include, but are not limited to:
Degree/Specialty Abbreviation
l Audiologist AUD
l Certified Massage Practitioner CMP
l Certified Registered Nurse Anesthetists CRNA
l Clinical Nurse Specialist CNS
l Dental Assistant DA
l Dentists who are not oral surgeons
l Doctor of Optometry OD
l Licensed Massage Practitioner LMP
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l Licensed Practical Nurse LPN
l Master of Science in Nursing MSN
l Occupational Therapist OT
l Physician Assistant/Certified PA or PA-C
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Appendix 2: Look-Back Period Calculator
The following calculator will help you determine the look-back period for your survey.
l Select your Accreditation or Certification program and survey type from the drop-down list.
l Enter your survey start (submission) date.
l The grid will automatically tabulate the date ranges that should be included in your file review.
Survey Type Survey Start Date Look-Back Period (months)
Initial Credentialing List
Recredentialing List
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Abbreviation Full Description of Specialty
2016 Credentialing Surveyor File Review Workbook
Combined Credentialing/Recredentialing File Review Worksheet
Instructions
Applies to HPA, MBHO and UM/CR Certification
File Review Worksheet Overview

Purpose
The Credentialing/Recredentialing File Review Worksheet assists surveyors in the evaluation of the
organization’s credentialing and recredentialing files against NCQA’s Credentialing Standards.
NCQA will generate one final list comprised of credentialing and recredentialing files and it will have 80 files.
Athough the final list will have 80 files the 8/30 rule still applies.
PLEASE DO NOT SOLEY RELY ON THESE INSTRUCTIONS TO PERFORM THE FILE REVIEW. THE
SURVEYOR MUST REFER TO THE STANDARDS IN ADDITION TO THESE INSTRUCTIONS IN ORDER
TO PERFORM THE FILE REVIEW.
Helpful Worksheet Features
The final list will be prepopulated by NCQA in the Final List tab of this workbook with the Last Name, Degree and Specialty of the
practitioner. The worksheet will also indicate the file type (Cred or Recred) and whether or not it is a delegate's file.
Organizations desiring to use the worksheet to prepare for a survey by auditing a sample of their own files should enter the selected
files on the "Final List" tab. The worksheet reads directly from this list and is protected from entry in the referring cells.
In is important that the files be desiganted with the exact words "Cred" or "Recred" as applicability of some factors is determined by
this desigantion.
1. The worksheets are color-coded as follows:
 Gray or colored cells indicate no surveyor input is required.
 Non-shaded or white cells indicate that surveyor input is required.
 The workbook will indicate with "Stop" or "Continue" whether you have completed the required number of files for a factor.
Note that cells will remain shaded for each factor until you need to review them.
2. The worksheets are protected from invalid input. Surveyors are prompted by ERROR or #VALUE! messages when invalid
entries are made.
3. Fill out the worksheet by: (a) choosing one of the valid responses provided in a drop down list in each cell or (b) typing in any
one of the valid responses included in a cell's drop down list verbatim.
 The drop down list for a cell can be accessed by clicking on the downward pointing arrow that appears to the right of the cell
when the cell is selected. If no arrow appears when the cell is selected, then no drop down list is available for that cell.
 Please do not copy and paste or cut and paste responses from one cell to another as doing so will overwrite the
original validation criteria and formatting for the affected cells. Please use the cell drop down lists or hard enter the
appropriate valid responses, which are delineated below.
 To delete the contents of a cell either (a) choose the blank entry from the drop down list of valid responses or (b) use the
Backspace or Delete keys. Do not use the space bar to empty the contents of a cell as it is an invalid entry and results in
an error message.
4. The file review worksheets have been formatted so that the element/factor information and basic file information remains visible
as row and column headers as you scroll through the worksheet.
 To freeze the row and column headers on these worksheets in a different manner choose Unfreeze Panes under the Window
menu at any time. Click the cell below and to the right of where you want the new "freeze" to occur. On the Window menu, click
Freeze Panes.
5. The file review worksheet has a yellow hyperlink-button (labeled Instructions) in the File Number cell of the column header that,
when clicked on, will take you to these instructions.
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File Review Instructions
NCQA selects 80 files (credentialing and recredentialing combined) and the files selected appear in the Final List tab of this
worksheet. The final list is provided to the organization at least ten business days prior to first day of the onsite survey. Only review
files on the NCQA credentialing list and in the order listed. If problems arise on site, call NCQA at 202-955-3500 and speak with
the accreditation survey coordinator (ASC) assigned to the survey or with the appropriate director of accreditation operations.
Applicabilty of credentialing file review standards per survey type
The ASC will advise the survey team in the initial notification email if it is an Interim, First or Renewal survey.
CR 3A - 3C (Credentialing Verification)
Interim Surveys - HPA only: NA
First Surveys/Initial Surveys: NCQA reviews a random sample of credentialing files selected from initial credentialing and
recredentialing decisions made by the organization within 6 months prior to the survey date.
Renewal Surveys: NCQA reviews a random sample of credentialing files selected from initial credentialing and recredentialing
decisions made by the organization within 36 months prior to the survey date.
CR 4A (Recredentialing Cycle Length)

Interim Surveys - HPA only: NA
First Surveys - HPA: NA
Initial Surveys - MBHO and CR Cert: 6 months
Renewal Surveys: NCQA reviews a random sample of credentialing files selected from recredentialing decisions made by the
organization within 36 months prior to the survey date.
CR 3A, factor 3 (education and training) is NA for recredentialing files. CR 3A, factor 4 (board certification), is NA if the
practitioners is not board certified or if the practitioner is board certified, but the organization does not communicate board
certification to members. CR 3A, factor 5 (work history) is NA for recredentialing files.
Important Notes
Not Applicable Files (NA): The file list provided by NCQA may contain the name(s) of practitioner(s) who do not need to be
credentialed under NCQA standards and for whom all credential elements are not applicable (e.g., practitioners who practice
exclusively within the inpatient setting and who provide care for organization members only as a result of members being directed to
the hospital or another inpatient setting, such as radiologists and pathologists). For a file that is fully Not Applicable in this manner,
mark all elements for the file as Not Applicable (NA) and go on to score the next file. Please indicate a reason for skipping
the file in the comment column (column AO) of the worksheet.
Not Applicable Elements/factors (NA): The file list provided by NCQA may contain the name(s) of practitioner(s) who should be
credentialed under NCQA standards but for whom some of the credential elements/factors are not applicable (e.g. non-physician
behavioral health practitioners who do not have DEA and are not board certified). For a file that has Not Applicable
elements/factors, score all applicable elements for the file and mark the appropriate elements as Not Applicable (NA). Please
indicate a reason for scoring an element/factor Not Applicable (NA) in the comment column of the worksheet.
Delegate Files (AC): Delegate credentialing files may be included in the file list NCQA provides to you, as appropriate. For a given
file, if decision-making and primary source verification are delegated (to CRs, HPs or MBHOs) and the organization is NCQA-
Accredited or NCQA-Certified, the file is considered compliant for all elements (provided that each element was delegated to the
NCQA-Accredited ot Certified entity). You do not need to review any individual elements/factors for the file. Instead, mark each
element/factor for the delegated file as "AC". Please note that an "AC" designation is counted in the Compliance row for each file as
compliant. Although NCQA does not consider sister organizatons or wholly owned subsidiaries as delegation, the
worksheet should be completed in the same manner as it is for delegates.
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If only primary source verification is delegated to an NCQA-Certified HP, MBHO, UMCR organization or CVO, the file review is
different in an important way. Elements in which the HP, MBHO, UMCR or CVO organization is certified in, are automatically
counted as present and current. However, NCQA still must review the file to determine whether these elements meet the time
limits. For example, if a certified CVO is delegated for license verification, assume that the verification is both Present and Current
but review the time between the verification and committee decision to ensure it was no longer than 180 days. Surveyors should
NOT enter "AC" for NCQA-certified CVO files, a date must be entered for each required field.
UMCRs delegates only: Automatic credit is granted for the following, if both primary source verification and committee
decisions are delegated:
Initial credentialing files selected from delegates NCQA-Certified in UMCR for Credentialing that have received an Initial or Renewal
Survey certification status.
Recredentialing files selected from delegates NCQA-Certified in UMCR for Credentialing that have received an Initial or Renewal
Survey certification status.
Automatic credit for recredentialing files is not available for delegates that have only completed an Interim or First Survey.
Note: Check the delegation agreement. The delegate may be delegated specific elements only.
Instructions for Filling out the Worksheets
In the upper left corner of the workbook, complete all the following fields. The workbook will not
function correctly if any are blank.
Pre-populated in the ● The name of the organization.
Final List tab
● The survey date(s) in the format mm/dd/yy (e.g. 10/15/16 - 10/16/16).
Surveyor Name Enter your name
Survey Type Select the type of Survey (HPA First, HPA Renewal, MBHO)
For each file, review each element individually according to the Standards and Guidelines and the directions provided
below.
Column A File number as it appears on the file list (pre-populated)
Column B Practitioner's Last Name, Degree, Specialty & whether or not file is for a delegate. Indicates "no deleg" or, if
applicable, delegate's name (pre-populated)
File Type - Indicates "Cred" or "Recred" (pre-populated by NCQA)

Column D - E Decision Date - Record the Decision Date (as defined below) in the format mm/dd/yy.
Decision Date: The date on which the organization or the delegate’s Credentialing Committee (which
includes participating practitioners from the organization’s network) made the decision to credential
or recredential the practitioner. All judgments of compliance with NCQA timeliness standards are
based on that date, whether or not the organization considers the committee meeting the final
decision point.
Column D - E Prior Decision Date (recred only) CR 4A: Enter date of the practitioner's prior credentialing decision using
the guidelines below.
Organizations should recredential practitioners within 36 months of the last credentialing/recredentialing

decision. Recredentialing does not have be within 36 months to the day. For example, a practitioner
recredentialed on May 12, 2012 and was previously credentialed on May 1, 2009, would be in compliance
for recredentialing timeliness.
Enter the Date of Previous Credentialing Decision in the format mm/dd/yy.

 If a Date of Previous Credentialing Decision is not present, type an "N" in the date field.
 If decision-making and primary source verification for the file are delegated to an NCQA-Certified or
NCQA-Accredited organization, enter (or choose from the in-cell drop down list) an "AC" in the
appropriate Current column. Please verify that the type of organization delegated to can receive
autocredit for decision-making: CVOs cannot. Please note that an AC designation is counted in the
compliance calculations as compliant. In order for the worksheet to accept the "AC" code column D
(delegated PSV and decision must be indicated as "Y." If not, the surveyor will receive an ERROR
message.
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Columns L - AD
Step 1: For each element/factor, verify whether or not the condition(s) of the element/factor is/are present and
current, as applicable, applying the definitions of Present, Current and the Verification Date provided
below.
Present: Verification of an individual credentials element is considered present if documentation of the

verification:
 is present in the file/report
 clearly indicates source of verification
 includes attestation by staff, where applicable (e.g., with phone or on-line verification)
 indicated source is appropriate, as defined by the standards.
If verification of an individual element meets the above criteria but does not include a date of verification, it
is still considered present but surveyors must seek another source of documentation (such as a checklist) to
determine timeliness of verification (as applicable).
If the organization compiles data from an aggregate source to produce summary reports (in lieu of paper
verification or files), surveyors must first verify the source(s) of that data and whether or not the data used is
timely, as required by the standards, before assessing compliance with the above criteria.
Aggregate sources include materials such as hospital rosters and electronic data tapes/downloads.
Aggregate sources should be updated quarterly.
Current: Verification of an individual credentials element is considered current if the credential had not yet
expired when the credentialing decision is made. Note: The Current column is included only for elements
CR3A.1 and CR3A.2.
Verification Date: The date on which the participating organization verified the element from the source.
 If verification is in the form of a written letter or similar correspondence, then the date of verification is
the date on which the letter was produced or sent by the issuing source.
 If verification is made by viewing or querying an aggregate source, such as the Medicaid/Medicare

sanctions and reinstatement report, the date of verification is the date on which the organization
accessed or viewed the source. This includes queries made to internal databases of aggregate
credentials information. If verification is made by viewing or querying aggregate sources, surveyors must
also verify that the data used was the most current available (as defined in Present, above).
Step 2: Document your findings for each file using the valid responses provided below .
Present Column - Valid Responses

Y  If the file meets the criteria for present, enter (or choose from the in-cell drop down list) a "Y" in the
appropriate Present column.
N  If the file does not meet the criteria for present, enter (or choose from the in-cell drop down list) an
"N" in the appropriate Present column.
AC  If decision-making and primary source verification for the file are delegated to an NCQA-Certified or
NCQA-Accredited organization, enter (or choose from the in-cell drop down list) an "AC" in the
appropriate Present column. Please note that an AC designation is counted in the compliance
calculations as compliant.
NA  If the criteria for present is not applicable for a particular file (e.g. DEA for a social worker), enter (or
choose from the in-cell drop down list) an "NA" in the appropriate Present column.
Current Column - Valid Responses

Y  If the file meets the criteria for current, enter (or choose from the in-cell drop down list) a "Y" in the
appropriate Current column.
N  If the file does not meet the criteria for current, enter (or choose from the in-cell drop down list) an "N"
in the appropriate Current column.
AC  If decision-making and primary source verification for the file are delegated to an NCQA-Certified or
NCQA-Accredited organization [CR, MBHO,or HP], enter (or choose from the in-cell drop down list) an
"AC" in the appropriate Current column. Please note that an AC designation is counted in the
compliance calculations as compliant.
NA  If the criteria for current is not applicable for a particular file (e.g. the present criteria has been
deemed NA and therefore the Current criteria is NA), enter (or choose from the in-cell drop down list) an
"NA" in the appropriate Current column.
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Response Rules CR 3A.1 & 3A.2
If any of the following rules are violated in filling out the worksheet for these factors an ERROR
message will appear in the Compliance field.
 If Present is marked as "Y" then Current has to be marked as "Y" or "N"
 If Present is marked as "N" then Current has to be marked as "N"
 If Present is marked as "NA" then Current has to be marked as "NA"
 If Present is marked as "AC" then Current has to be marked as "AC"
Verification Date - Valid Responses

 Enter the Verification Date in the format mm/dd/yy, as required by the factor/element.
 If the Verification Date is not present for a file, leave the cell blank to indicate the absence of the data.
 If the file is indicated as NA for the factor/element, the Verification Date field will become shaded gray
to indicate that no input is required.
 An ERROR message will appear in the Compliance Field for a file if the date entered for the Previous
Decision Date is on or after the decision date. The Previous Decision Date must be a date prior to the
Decision Date.
Column AO A column for comments is included in each file review worksheet. Please briefly explain findings of non-
performance and/or provide the reason(s) why a factor/element has been scored Not Applicable in this
column.
As appropriate information is entered into the Present, Current, and Date fields of the file review worksheets as described above, a
compliance determination automatically calculates in the Compliance field for each file/element combination. For details on the
specific criteria and timeliness requirements used to determine compliance for each element, please refer to the Standards and
Guidelines document.
Scoring Credentialing & Recredentialing Files
Step 1
Review the scoring notes at the bottom of the table
DENOM <8: Evaluate the first 8 applicable files for all factors/elements from the list provided by NCQA. Files must be
reviewed in the order they appear on the list provided by NCQA.
STOP For any factor/element that the organization demonstrates compliance (Yes in the Compliance row) for
each of the first 8 files, indicated by an 8/8 Compliance Ratio, you may stop reviewing files for that
factor/element and enter a score of HIGH in the Survey Tool. You may leave the rest of the
files/worksheet blank for that element.
RATIO <8/8: If, because of NA files, you have not gotten at least 8 applicable files for a factor/element within the first
8 files on the list (e.g. you may have a Compliance Ratio of 7/7 6/6, 6/7, etc.), review additional files until
you have reviewed at least 8 applicable files for the factor/element.
STOP When you have reviewed at least 8 applicable files for the factor/element, if the organization
demonstrates a Compliance Ratio of 8/8, you may stop reviewing files for that factor/element and enter
a score of HIGH in the Survey Tool. You may leave the rest of the files/worksheet blank for that
factor/element.
NOTE: In addition to the cumulative compliance score for each factor/element appearing at the
bottom of the woksheet the cumulative scores will also appear in the Summary Sheet tab of the
workbook. The Summary Sheet allows the surveyor to review the file review results in a more
user-friendly table format.
Review Files… For any factor/element in which the organization scores a Compliance Ratio less than 8/8, continue to
review files (including those in the oversample) for the factor/element until you have a denominator of 30
applicable files or you have exhausted the oversample.
Since some files may be NA for a factor/element, you will need to continue to review files (including
those in the oversample) for the element until you have a denominator of 30 applicable files or you have
exhausted the oversample. In some cases, surveyors may have fewer than 30 applicable files to review
for some factors/elements, even after a review of the entire oversample. In this case, there will be fewer
than 30 files in the final denominator. A denominator of less than 30 is only appropriate if the
oversample is exhausted.
COMPLETE(30) Once you have reviewed 30 applicable files, stop and enter the resulting Score in the Survey Tool. You
may leave the rest of the files/worksheet blank for that element.
or
COMPLETE(80) Once you have exhausted the oversample, stop and enter the resulting Score in the Survey Tool.
503516851.xlsx 15 Revised: 06/03/13 AFC

Step 2
The following Summary Statistics are automatically calculated at the bottom of the worksheet and on the Summary Sheet.
The columns in the worksheet are not in the same order as the factors appear in the Survey Tool, so it is recommended
you score from the Summary Sheet.
 Files Compliant: A count of the files scored Yes in the Compliance fields above.
 Files Not Compliant: A count of the files scored No in the Compliance fields above.
 Files Not Applicable A count of the files scored NA in the Compliance fields above.
 Total Files Reviewed: A count of the files scored as Yes, No and NA in the Compliance fields above.
In addition, the following Scoring information is also calculated at the bottom of the worksheet:
 Compliance Ratio: The count of the Files Compliant (Yes) over the count of the Total Applicable
Files (Yes + No).
 Percentage Compliant: The Compliance Ratio (defined above) displayed as a percentage.
 Scoring Notes: Notes for how to proceed with the file review given the results of the files reviewed
to that point. Explanations of each of the notes are provided below the scoring section of the
worksheet.
 Score: High, Medium or Low is returned based on the files reviewed as follows:
 If the Files Compliant is 27–30 for an element, or 90 - 100%, the score is HIGH for that
element
 If the Files Compliant is 18–26 for an element, or 60–89%, the score is MEDIUM for that
element
 If the Files Compliant is 0–17, or 0 - 59%, the score is LOW for that element.
 An X in the Score field indicates that no Score is available - please see the Scoring Notes for
an explanation of how to proceed with the file review to achieve a Score.
 An "ERROR" message appears in the "Scoring Notes" and "Score" fields for an
element/factor if a response for one or more of the files is not consistent with the response
rules provided herein. An "ERROR" message will also appear in the Compliance field of the
affected file.
Step 3
After completing the file review for all factors/elements, confirm all findings with the credentialing manager or
the appropriate staff. If a factor/element is not present, you must allow the organization staff the opportunity
to locate the information.
Step 4
Enter your name and the name of the staff member with whom you reviewed the file in the space provided
at the bottom of the worksheet.
Step 5
Save the worksheet as "CR and RR results.xls"
Step 6
The score for each factor/element must be entered into the Survey Tool as follows.
1. Log into the Interactive Review Tool.
2. Score each file review factor/element (CR 3A-C and CR 4A) by clicking the appropriate scoring radio
button (High, Medium, or Low) based on the Score information at the bottom of the Credentialing and
Recredentialing worksheets.
Step 7
Attach the "CR and RR results.xls" file to the Interactive Review Tool by:
1. Attach the worksheet to the "Manage Workbook" section located at the top of the navigation in IRT. You can also
access this section under the Actions button.
2. Use the browse function (Choose File) to locate the Worksheet
3. A path file box will open up, go to where your Worksheet is saved and select your file.
4. Select "Open"
5. Be sure that the file name is "CR and RR results"
6. Click save.
To confirm: your e-mail for IRT should be listed under the last uploaded column and the file name is listed after the
"Choose File" button.
Step 8 Have the other member of the survey team or the ASC review the worksheet for accuracy while you are still
onsite.
503516851.xlsx 16 Revised: 06/03/13 AFC

Initial
Credentialing
Last Name First Name Degree Specialty Date
503516851.xlsx 17 Revised: 06/03/13 AFC

Delegate Name
(if necessary) ← MUST USE
Include sister companies and any EXACT TERM
organisation where AC may be
applicable, even if NCQA does not "Cred"
call it delegation Cred Copy to all records
503516851.xlsx 18 Revised: 06/03/13 AFC

Initial
Credentialing
Last Name First Name Degree Specialty Date
503516851.xlsx 19 Revised: 06/03/13 AFC

Delegate Name
(if necessary) ← MUST USE
Include sister companies and EXACT TERM
any organisation where AC may
be applicable, even if NCQA "Recred"
does not call it delegation Recred Copy to all records
503516851.xlsx 20 Revised: 06/03/13 AFC

List all Accredited/Certified delegates that co
Cred Org/Sister/Delegate/Sub-
List Delegate Name
1
2
3
4
5
d delegates that comprise 100% of universe
Org/Sister/Delegate/Sub-
Recred List Delegate Name
1
2
3
4
5
Organization Name:
Submission Date:
On-Site Date(S):
← MUST USE
Credentialing Delegate/Sister Co Cred or EXACT TERMS
0 Last Name First Name Degree Specialty Date Name (if necessary) Recred "Cred" or "Recred"
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
503516851.xlsx 23 Revised: 06/03/13 AFC

Organization Name:
Submission Date:
On-Site Date(S):
← MUST USE
Credentialing Delegate/Sister Co Cred or EXACT TERMS
0 Last Name First Name Degree Specialty Date Name (if necessary) Recred "Cred" or "Recred"
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
503516851.xlsx 24 Revised: 06/03/13 AFC

Credentialing File Review Workbook
Organization
Name: Enter on 'Final List' Worksheet Fill out the Y= N= AC = NA =
Click for worksheet using Documentation Documentation requirement is is Decision-making and PSV delegated to Documentation requirement not
the following requirement is not present or current as defined NCQA Certified/Accredited org. applicable as defined in standards
Onsite Date(s): Enter on 'Final List' Worksheet Worksheet valid responses: present as defined in in standards; e.g. has not been DO NOT USE FOR CVOs OR OTHER
Instruction standards verified, is not current ORGS DELEGATED ONLY PSV.
Surveyor: s
Survey Type:
CR 4A CR 3A.1 CR 3A.2 CR 3A.3 CR 3A.4 CR 3A.5 CR 3A.6 CR 3B.1 CR 3B.2 CR 3C.5 CR 3C.1 CR 3C.2 CR 3C.3 CR 3C.3 CR3C.3 CR 3C.4 CR 3C.6
Comments
NOTE BELOW THAT YOU CONFIRMED ALL FINDINGS

WITH CREDENTIALING OR OTHER APPROPRIATE
STAFF State Sanctions, Medicare/ History of Loss or
Recred Cycle Education & Board Cert- Malpractice Restrictions on Medicaid Current Malpractice Reasons for Inability Lack of Present History of Loss of History of Felony Loss of License and Limitation of
Length License to Practice DEA/CDS Certificate Training ification Work History History License/Practice Sanctions Coverage to Perform Illegal Drug Use License Convictions Felony Convictions Privileges Attestation
Present? Present? Current? Present? Current? Present? Present? Present? Present? Present? Present? Present? Present? Present? Present? Present? Present? Present?
A CONTINUE CONTINUE CONTINUE CONTINUE CONTINUE CONTINUE CONTINUE CONTINUE CONTINUE CONTINUE CONTINUE CONTINUE CONTINUE CONTINUE CONTINUE
Continue Continue Continue CONTINUE CONTINUE CONTINUE CONTINUE CONTINUE CONTINUE CONTINUE CONTINUE CONTINUE CONTINUE CONTINUE CONTINUE CONTINUE CONTINUE
Last Name File Type Approp Verification
Degree Decision Date Verification Date

1
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
Delegated? Compliance
decision making?

2
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

3
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

4
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

5
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

6
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

7
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

8
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

9
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

10
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?
11
503516851.xlsx 25 Revised: 06/03/13 AFC
Organization
Surveyor: s
Survey Type:
Comments

11
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

12
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

13
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

14
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

15
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

16
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?
503516851.xlsx 26 Revised: 06/03/13 AFC

Organization
Surveyor: s
Survey Type:
Comments


17
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

18
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

19
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

20
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

21
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

22
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

23
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

24
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

25
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

26
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

27
503516851.xlsx 27 Revised: 06/03/13 AFC

Organization
Surveyor: s
Survey Type:
Comments

27
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

28
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

29
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

30
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

31
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

32
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?
503516851.xlsx 28 Revised: 06/03/13 AFC

Organization
Surveyor: s
Survey Type:
Comments


33
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

34
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

35
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

36
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

37
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

38
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

39
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

40
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

41
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

42
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

43
503516851.xlsx 29 Revised: 06/03/13 AFC

Organization
Surveyor: s
Survey Type:
Comments

43
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

44
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

45
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

46
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

47
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

48
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?
503516851.xlsx 30 Revised: 06/03/13 AFC

Organization
Surveyor: s
Survey Type:
Comments


49
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

50
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

51
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

52
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

53
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

54
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

55
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

56
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

57
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

58
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

59
503516851.xlsx 31 Revised: 06/03/13 AFC

Organization
Surveyor: s
Survey Type:
Comments

59
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

60
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

61
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

62
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

63
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

64
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?
503516851.xlsx 32 Revised: 06/03/13 AFC

Organization
Surveyor: s
Survey Type:
Comments


65
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

66
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

67
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

68
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

69
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

70
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

71
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

72
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?
503516851.xlsx 33 Revised: 06/03/13 AFC

Organization
Surveyor: s
Survey Type:
Comments


73
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

74
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

75
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

76
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

77
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

78
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

79
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?

80
Prior Decision Date
Specialty Days
(for Recred)
Delegated PSV AND
decision making?
503516851.xlsx 34 Revised: 06/03/13 AFC

Organization
Surveyor: s
Survey Type:
Comments

Files Compliant (Yes): 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Files Not Compliant (No): 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Files Not Applicable (NA): 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Total Files Reviewed (Yes + No + NA): 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Total Applicable Files (Yes + No): 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Compliance Ratio: 0/0 0/0 0/0 0/0 0/0 0/0 0/0 0/0 0/0 0/0 0/0 0/0 0/0 0/0 0/0
Percentage Compliant: 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%
Scoring Notes: (see below for note explanations) Denom <8 Denom <8 Denom <8 Denom <8 Denom <8 Denom <8 Denom <8 Denom <8 Denom <8 Denom <8 Denom <8 Denom <8 Denom <8 Denom <8 Denom <8
Score: X X X X X X X X X X X X X X X
DENOM <8: The DENOMINATOR in the RATIO is <8 for the element. Review additional files until you
have reviewed at least 8 files for the element.
RATIO <8/8: The RATIO for the element is <8/8. Review additional files until you have reviewed 30
applicable files for the element. I reviewed and discussed the file review results with
STOP: The RATIO for the element is at least 8/8, stop and enter a score of HIGH in the Survey Tool. (Surveyor's name)
Review Files...: Continue to review files (including those in the oversample) for the element until you have
a denominator of 30 applicable files or you have exhausted the oversample. , a member of the organization's staff.
COMPLETE(30): You have reviewed 30 applicable files. Stop and enter the score in the Survey Tool. (Organization staff member's name)
END: You have exhausted the oversample. Stop and enter the score in the Survey Tool.
ERROR: An "ERROR" message will appear in the "Scoring Notes" and "Score" fields for an element/factor
if a response for one or more of the files is not consistent with the response rules provided in the
Directions for Completing the Worksheets tab of this workbook. An "ERROR" message will also appear in
the Compliance field of the affected file.
503516851.xlsx 35 Revised: 06/03/13 AFC

Credentialing Summary Score Sheet
Organization: Enter on 'Final List' Worksheet
Surveyor: Enter on 'CR Worksheet for Surveyors' Worksheet
Onsite Date(s): Enter on 'Final List' Worksheet
Not Not Total Total

Compliant Compliant Applicable Reviewed Applicable Compliance Percentage
(Yes): (No): (NA): (Yes/No/NA): (Yes/No): Ratio: Compliant: Score:
CR 3A.1 License to Practice 0 0 0 0 0 0/0 0% CHECK SHEET
CR 3A.2 DEA/CDS Certificate 0 0 0 0 0 0/0 0% CHECK SHEET
CR 3A.3 Education & Training 0 0 0 0 0 0/0 0% CHECK SHEET
CR 3A.4 Board Certification 0 0 0 0 0 0/0 0% CHECK SHEET
CR 3A.5 Work History 0 0 0 0 0 0/0 0% CHECK SHEET
CR 3A.6 Malpractice History 0 0 0 0 0 0/0 0% CHECK SHEET
CR 3C.1 Reasons for Inability to Perform 0 0 0 0 0 0/0 0% CHECK SHEET
CR 3C.2 Lack of Present Illegal Drug Use 0 0 0 0 0 0/0 0% CHECK SHEET
CR 3C.3 Loss of License and Felony Convictions 0 0 0 0 0 0/0 0% CHECK SHEET
CR 3C.4 History of Loss or Limitation of Privileges 0 0 0 0 0 0/0 0% CHECK SHEET
CR 3C.5 Current Malpractice Coverage 0 0 0 0 0 0/0 0% CHECK SHEET
CR 3C.6 Attestation 0 0 0 0 0 0/0 0% CHECK SHEET
CR 3B.1 State Sanctions, Restrictions on License/Practice 0 0 0 0 0 0/0 0% CHECK SHEET
CR 3B.2 Medicare/ Medicaid Sanctions 0 0 0 0 0 0/0 0% CHECK SHEET
CR 4A Recred Cycle Length 0 0 0 0 0 0/0 0% CHECK SHEET
503516851.xlsx 36 Revised: 06/03/13 AFC

CP PINsProcedures 0617 2016CredentialingFileReviewWorksheet1

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Surveyor Credentialing File Revi

Applies to HPA, MBHO, NHP, and U

503516851.xlsx 1 Revised: 06/03/13 AFC

Applies to HPA, MBHO, NHP, and UMCR Certification

503516851.xlsx 2 Revised: 06/03/13 AFC

Summary of Changes for Surveys

Practitioners to Include and Not Include in Credentialing/Recredentialing File Lists

503516851.xlsx 3 Revised: 06/03/13 AFC

Do not include the following practitioners:

Look-Back Periods and Designating Files as "Credentialing" and "Recredentialing"

Survey Type Lookback Period Include on the Include on the

503516851.xlsx 4 Revised: 06/03/13 AFC

Survey Type Lookback Period Include on the Include on the

Survey Type Lookback Period Include on the Include on the

Look-back Period Calculator

If 100% of Credentialing and Recredentialing is delegated

Format for Submitting Practitioner Lists

503516851.xlsx 5 Revised: 06/03/13 AFC

503516851.xlsx 6 Revised: 06/03/13 AFC

About the data fields

Submitting the Lists to NCQA with the Survey Tool

Appendix 1: Examples of Practitioners to Include and Exclude by Degree

503516851.xlsx 7 Revised: 06/03/13 AFC

503516851.xlsx 8 Revised: 06/03/13 AFC

Survey Type Survey Start Date Look-Back Period (months)

Initial Credentialing List

503516851.xlsx 9 Revised: 06/03/13 AFC

Applies to HPA, MBHO and UM/CR Certification

File Review Worksheet Overview

Helpful Worksheet Features

503516851.xlsx 11 Revised: 06/03/13 AFC

Applicabilty of credentialing file review standards per survey type

CR 4A (Recredentialing Cycle Length)

503516851.xlsx 12 Revised: 06/03/13 AFC

Instructions for Filling out the Worksheets

Surveyor Name Enter your name

Column A File number as it appears on the file list (pre-populated)

File Type - Indicates "Cred" or "Recred" (pre-populated by NCQA)

Organizations should recredential practitioners within 36 months of the last credentialing/recredentialing

Enter the Date of Previous Credentialing Decision in the format mm/dd/yy.

503516851.xlsx 13 Revised: 06/03/13 AFC

Present: Verification of an individual credentials element is considered present if documentation of the

 If verification is made by viewing or querying an aggregate source, such as the Medicaid/Medicare

Present Column - Valid Responses

Current Column - Valid Responses

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Verification Date - Valid Responses

Scoring Credentialing & Recredentialing Files

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1. Log into the Interactive Review Tool.

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NOTE BELOW THAT YOU CONFIRMED ALL FINDINGS

Degree Decision Date Verification Date

Last Name File Type Approp Verification

Degree Decision Date Verification Date

Last Name File Type Approp Verification

Degree Decision Date Verification Date