NC Medicaid Credentialing Committee Questions and Answers

Providers will have full appeals rights for adverse decisions, just as they do today.

The OA must direct the attestation to be sent to the provider to attest. An NCID is not required. The provider will receive an email to complete the attestation. Once the provider completes the attestation, a notice will be sent to the OA to submit the application. If the provider does not sign the application, the OA will receive a notice once the application is rejected.

Due to the volume of files and to avoid holding up approvals, the committee will meet weekly, if only to ratify clean applications.

Applications with no adverse actions will be signed off by the Medical Director from our Fiscal Agent, General Dynamics Information Technology (GDIT,) and shared as a list to the Credentialing Committee to be ratified officially. They will not be up for discussion at the Credentialing Committee.

Yes, the Credentialing Committee will be held to NCQA standards.

Delays in transmission of provider enrollment file data are not expected.

No changes will be made to current provider enrollment files.

The criteria for the Provider Penalty Tracking Database will not change and will be written into the bylaws for review at a future meeting.

Not at this time. Currently, the department has a waiver to keep reverification at every five years.

Yes, before files reach the Credentialing Committee they will be sent out for review. As we are still structuring the Credentialing Committee, it is not yet known if the file will be historically available or no longer available after a decision is made.

GDIT is creating a portal for Credentialing Committee members to access, as well as training materials for the portal. More information will become available as this is developed and will be shared in upcoming stakeholder meetings.

Current processing times for clean applications can be found on the NC Medicaid Provider Enrollment web page. The Department does not anticipate a significant change to current processing times, as clean files will only be subject to weekly ratification by the committee.

The Credentialing Committee will review applications for every type of provider.

The PDM/CVO implementation has been paused. Please stay tuned for communication updates pertaining to the continuation of PDM/CVO.

For more information, visit the Provider Data Management/Credentialing Verification Organization web page.

GDIT performs Primary Source Verification but NCTracks requires providers to complete an MCR to upload the necessary information unless there is a feed from the board, such as the medical board, to process. This will be noted as an enhancement for the PDM/CVO system.

The process of becoming a peer reviewer is still in development. More information to come soon.

There is more information to come soon on this topic. Charter and bylaws are still in development.

Quality of care data from the plans will not be a factor in enrollment decisions unless performance of care issues (quality of care) are directly reflected in any adverse actions or criminal background findings flagged for a provider to be reviewed by the committee.

Not currently.

NC Medicaid is open to having conversations in our stakeholder meetings about who will represent each plan in the Credentialing Committee. No, the participating Tailored Plan committee representative is not required to be a Medical Director. There will be a Medical Director from GDIT serving on the committee.

NC Medicaid is open to feedback on health plan representatives, as roles for these representatives have not been mandated.

NC Medicaid and the Prepaid Health Plans are currently operating under NCQA waivers and will continue to do so when the Credentialing Committee is implemented. At some point, the waivers may be revisited.

No, the PDM/CVO solution that was previously announced has been postponed. More information on that initiative will be announced later.

What are the appeals rights for practitioners that receive an adverse decision from the Credentialing Committee?

Will the individual clinician automatically have access to their National Provider Identifier (NPI) in the provider portal for the review and attestation, or will the Office Administrator (OA) have to assign them access in the user maintenance section?

What is the expected cadence of the Credentialing Committee meetings?

Will a Medical Director 'sign off' on 'clean' files or files with no adverse actions weekly and share that list at the Credentialing Committee meeting? Or will those files be approved on an ad hoc basis?

Will the Credentialing Committee act under the National Committee for Quality Assurance (NCQA) Standards since they are not accredited?

Will Credentialing Committee impact provider turnaround time with updating status in NCTracks?

Will there be any changes to the provider enrollment file that health plans currently receive and use to determine the credentialing status of Medicaid providers?

DHHS’s Provider Penalty Tracking Database identifies for each listed penalty if there is cause for NC Medicaid to restrict or terminate a provider’s Medicaid enrollment. Will the provider credentialing committee’s criteria be different from what is cur

Will the re-verification/recredentialing timeframe be changed from five years to three years to align with NCQA standards?

Will the data for 'unclean' files be accessible before and after the Credentialing Committee?

How will information be shared with/sent to the Credentialing Committee members?

How will the provider Credentialing Committee process affect the amount of time taken to process provider applications (for enrollment, re-verifications, manage change requests, etc.)?

Will the Credentialing Committee review individual practitioners only, or does this apply to all types of Medicaid providers?

Is Optum still the vendor for the Provider Data Management (PDM)/Credentialing Verification Organization (CVO) solution? What is the estimated date for that transition?

Will GDIT start performing the primary source verification of licenses, certifications, and Drug Enforcement Agency (DEA) registrations? Will GDIT automatically verify and update license renewals or will we still have to perform a full Managed Change?

How does one apply to be a peer reviewer?

Is there a plan of collecting quality of care issues prior to going to the committee?

Will the Tailored Plans have an opportunity to share any quality-of-care data that could potentially aid in rendering a vote for providers being presented at the Credentialing Committee?

With respect to quality-of-care concerns, the plans have responsibility for evaluating complaints and grade severity. Will there be a role for the Credentialing Committee to address substantiated complaints?

Will the Credentialing Committee review quality concerns related to credentialed providers/practitioners?

Will Local Management Entities/Managed Care Organizations (LME/MCOs) have an opportunity to share any quality-of-care data that could potentially aid in rendering a vote for providers being presented at the Credentialing Committee?

Is there a specific staff person from the Tailored Plan that NC Medicaid expects to serve on the Credentialing Committee? If so, should it be a Medical Director since clinical data will be reviewed/discussed or is the Department looking for another me

For health plan representatives to the Credentialing Committee, what are the recommended roles or credentials for those individuals? (e.g., Chief Medical Officer, etc.)

Managed care health plans are currently exempt from most of the NCQA credentialing accreditation standards. Will that eventually change now that the new Credentialing Committee is being put into place?

Is the Credentialing Committee part of the new PDM/CVO solution?