Delegated Credentialing & CVO Operations Flashcards

Which elements must typically be included in a delegation agreement between a health plan and a CVO?

Answer: Scope of delegated activities, performance standards, and audit requirements

Delegation agreements must specify the scope of delegated functions, performance expectations, and how the delegating entity will monitor and audit the CVO's performance.

What does 'sub-delegation' mean in the context of credentialing?

Answer: When a CVO further delegates credentialing functions to another organization

Sub-delegation occurs when a CVO that has received delegated credentialing authority further delegates those functions to another organization, which typically requires approval from the original delegating entity.

A health plan reviews a CVO's file audit and finds that 15% of files are missing primary source verifications. What is the most appropriate next step?

Answer: Issue a corrective action plan requiring the CVO to remediate deficiencies within a specified timeframe

A corrective action plan with specific remediation timelines is the appropriate response to audit deficiencies, giving the CVO the opportunity to correct issues before more drastic action is taken.

Which NCQA standard element specifically addresses the requirements for credentialing delegation in health plans?

Answer: CR (Credentialing and Recredentialing)

NCQA's CR (Credentialing and Recredentialing) standards include specific requirements for delegation arrangements, including delegation agreement content and oversight audit requirements.

What is URAC's primary role with respect to delegated credentialing?

Answer: Providing accreditation standards for health plans and CVOs that include credentialing delegation requirements

URAC provides accreditation standards that health plans and CVOs can be measured against, including standards addressing credentialing delegation and oversight responsibilities.

In a delegated credentialing arrangement, which party is responsible for notifying providers of credentialing decisions?

Answer: The party specified in the delegation agreement, though the delegating entity remains ultimately accountable

The delegation agreement specifies which party handles provider notifications, but the delegating organization retains ultimate accountability for ensuring appropriate communication occurs.

What is the significance of NCQA's CVO certification or 'deemed status' in credentialing delegation?

Answer: A CVO with NCQA certification may be recognized as meeting certain delegation standards, potentially reducing duplicative auditing requirements

NCQA-certified CVOs may receive recognition where the delegating health plan can treat the CVO's accreditation as evidence of meeting certain standards, potentially streamlining oversight audit requirements.