The Art & Science of NCQA File Reviews

By Nancy Ross Bell, RN

Estimated time to read: 4 minutes

NCQA File Reviews can be daunting but are not insurmountable! What MHR has found in its long history of guiding organizations for NCQA surveys are five practices for a successful file review:

• Timely implementation of changes to the standards impacting files
• Knowing how to prep files for review by the NCQA Surveyor
• Testing the process to correctly identify files for each file universe before submission to NCQA
• Conducting mock file audits of each file type by product line, if necessary
• Training and coaching

 Let’s see how MHR does it and some common problems to avoid.

Timely implementation of changes to the standards impacting files

Take, for example, NCQA’s changes to the 2025 Health Plan Accreditation standards, where the timeframe for the verification of practitioners' work history (now CR 3, Element A, Factor 5)  changed from 365 days to 120 days for files on or after July 1, 2025, and the timeframe for the verification of malpractice history (now CR 3, Element A, Factor 6)  changed from 180 days to 120 days for files on or after July 1, 2025. These new timeframes must be promptly implemented because the look-back period for credentialing and recredentialing files is 36 months, except as noted.

It is imperative that organizations purchase and examine all new NCQA standards when released. NCQA publishes free Corrections, Clarifications, and Policy Changes on its website three times a year in March, July, and November. Most people are not aware that when they purchase the E-Pubs, NCQA does not update the standards at the same time as these releases.

We also recommend tuning in to MHR’s webinars through our Events page, during which we highlight new or changes to standards. If you Contact Us from the Events page, we will reach out to you to finish registration.

Knowing how to prep files for file review by the NCQA Surveyor

Prepping files can be both a science and an art!  Having the correct information in the files to meet each Factor is the “science,” how you present the portion of the file to the Surveyor, demonstrating it meets requirements, is an “art!”

Prepping files to present to NCQA for formal assessment is commonly done by subject matter experts (SME) and non-clinical support staff who are most familiar with the content in the files and know how to use Adobe^® to apply a series of bookmarks, text boxes, underlines, labels, and annotations to highlight the required information for each Factor.

Common problems we see are:

• Not annotating all the information noted in the Explanation.
  • Example: Appeal language in denial files. UM 7C, F, & I Factor 2 has five bullet points; all must be annotated.
• Not knowing why something is not applicable (NA) to a file.
  • Example: Work History is NA for recredentialing files.
• Not ensuring files are identified for UM 9E & F when appropriate.
• Not ensuring all pharmaceutical files are included in the pharmacy file. This includes pharmaceuticals covered under the medical benefit and reviewed by a medical director.

Prepping files can be arduous, considering the number of files to be bookmarked and annotated, particularly for NCQA Health Plan Accreditation. The steps for building and preparing a file are mechanically similar yet unique to each standard set (i.e., Denials, Appeals, Complex Case Management, and Credentialing and Recredentialing). These steps are listed in detail in MHR’s valuable Tools and Guides on File Review Prep.

Conducting mock file audits of each file set

How better to know if your organization and non-accredited delegates are ready for your NCQA survey than to conduct mock file audits against the standards included within your look-back period? Files are assessed against each Factor to decide if the file is compliant. If not compliant, the organization decides how to resolve it.

Common problems we see are:

• Not sending denial notifications to the attending or treating practitioner
• Not including the titles and qualifications of all participants in the appeal review process
• Not providing annual written confirmation of primary source verification of education from a state licensing agency, specialty board (i.e., Nurse Practitioner board), or registry ( i.e., National Student Clearing House)

Because file reviews are high stakes, MHR developed a Bundle of File Audit Tools customized for each type of file review by Product. Conducting audits is the only way to know if you are on track.

When using MHR’s File Audit Tools with the File Review Prep Guides, you have all you need for your NCQA survey preparation on files and tools to monitor compliance between surveys.

MHR’s Consultants conduct audits of a sample of files as one of their first assessments because of the critical look-back periods and Must-Pass Elements.

Conducting audits of each file universe

File review universes are provided to NCQA, from which a sample of files to examine is selected.  They can be complex because of the different universe sets, products, and files to include and exclude from submission.

Ensure the following with file universes:

• The file is appropriate for the file universe.
  • Example: Pharmacy exception requests are not to be included in the pharmacy denial file universe.
• Each universe contains files in the appropriate timeframe for the look-back.
• The health plan and delegate universes are appropriately combined to avoid adverse selection.

When working with MHR, we request that universes be run before we start our mock file audits to validate the accuracy of your file pulls. There are no resubmissions to NCQA if you upload an inaccurate or non-valid file list.     

Training and coaching

File reviews are hard!  Updates to NCQA standards resulting from regulatory changes or raising the bar on quality, such as health equity, trigger enhancements to operational processes, committee oversight, and sometimes IT systems to accommodate new data fields.

For example, NCQA’s proposal to add a Factor for Practitioner race, ethnicity, and language to the credentialing application, which is scored by file review, can involve staff from network management, credentialing, IT systems, provider services, and audit or compliance departments.

If your goal is to achieve Met for your file reviews, then a plan for training, coaching, and ongoing monitoring is needed for those responsible for the quality of the information and integrity of the files for the following:

• Complex Case Management
• Credentialing & Recredentialing
• UM Appeals (non-BH, BH, pharmacy) – medical necessity and benefits
• UM Denials-behavioral health
• UM Denials-non-behavioral health
• UM Denials-pharmacy

When working with MHR, we evaluate a sample of your files and identify any gaps. However, the organization risks losing points if gaps exist before a look-back period and are not corrected in time, such as implementing a new Factor on timeliness. 

Ongoing monitoring of files through MHR’s Train-the-Trainer programs can mitigate file review risks.  For this program, we train you to review files like an NCQA surveyor and share all the nuances and details that surveyors are trained to use.

Call to Action:

• Conduct a mock file audit under the most recent standards and identify gaps.
• Let your MHR Consultant know if you need training on file reviews or are interested in purchasing MHR’s File Review Prep Guides & File Audit tools.  
• Read MHR’s Blogs from:

March 19, 2024:  Be Confident in the Driver’s Seat with NCQA File Reviews

June 6, 2023: NCQA File Reviews for Dual-Eligible Members

MHR follows a quality review process for all blogs. This blog was written with insights from Sheila Petras, RN, and Kim Carpenter Petit.  Please read more about Sheila, Kim and MHR’s other Independent Consultants at ManagedHealthcareResources.com/About Our Consultants.  

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