Be Confident in the Driver’s Seat with NCQA File Reviews

By Nancy Ross Bell, RN

Estimated time to read:  4 minutes

If you are chosen to present your organization’s files to the surveyor during the NCQA file reviews, you want to avoid issues such as not knowing how to respond to a question, why a file did not meet requirements, fumbling around your IT systems, missing delegate files, putting the files in alpha, numeric or date order, or having a wrong file in the Universe. File reviews are high points and generally are must-pass elements for accreditation.   

When working with MHR Consultants, you gain the knowledge, practice, and confidence to be in the “driver’s seat” when it’s time for your NCQA Accreditation survey. Let’s see how this is done.

Where Do We Start?

Remember, we are your partner! We strive to help you be successful and confident! Consider us as having attorney/client privilege, as that is how sensitive and important that candor is. MHR Consultants wear two hats during an audit: that of your consultant and that of a potential surveyor.

• Here’s where our consultant hat is needed. Before and at the beginning of the audit, you must encourage transparency among your teams on any known issues or ones that may arise during our audits. Being forthright with us helps us to collaborate on the best strategy to minimize the impact on your survey score early enough to make an impact. You’ve heard of the “No Surprises Act”? It should apply here, as that’s a bill you don’t want to pay during a survey when you’re not forthright with us!
• Have the appropriate individuals in the room for all audits, including:
  • Leads whom you expect to present the files
  • Backups to the Leads
  • Departmental Subject Matter Experts (SME) for specific insight
  • IT system representatives who know your systems
  • Department Management who oversees the area(s)
• Here’s where our surveyor hat comes in. MHR Consultants will challenge you with details about your files to help you respond to questions that may be asked during your survey to see how you respond to issues and whether the answer should be posed differently. Write these down!
  • With what the MHR President calls “Susan’s law of adverse file pulls during surveys,” it is likely that one or more problematic files will be chosen. Having a method of responding positively without misleading the surveyor is critical. We will never, ever direct you to respond in a false way or mislead the surveyor. Not only is it fraudulent, but you want the surveyors on your side when they are sitting on the fence trying to decide if something meets or does not meet the standard.
  • Establish trust. If it’s very clear that something is missing that is required, acknowledge it and do not tap dance around it. Be clear with leadership that your surveyor consultant has instructed you this way so trust is not jeopardized with the surveyor. Not-so-great things happen when that path is chosen, so “choose wisely”!
• While we emphasize what is minimally necessary to meet a standard, we may also discuss best practices that could help improve quality.
  • For example, you may score 8 of 10 factors, receiving a score of Met, but consistently miss the same two factors. We may question your process and why the organization did not meet the other two. Are your systems not set up to take in the information, or does the staff need further training? Why do the MHR Consultants do that? Isn’t 8 good enough? While it is for scoring, what if you miss an additional factor for one of the files? Then, there is a problem that can lead to a corrective action plan (CAP) for the must-pass elements.

Know What NCQA Accreditation Standards Require File Reviews

Depending upon your NCQA program, there are separate file reviews for:

1. Case Management (CM) – Initial & Ongoing Assessment: one for all product lines
2. Credentialing/Recredentialing (CR/RR): one for all product lines
3. Utilization Management (UM) Denials – Non-Behavioral Healthcare (BH)
4. UM Denials – BH
5. UM Denials - Pharmacy
6. UM Appeals – (Non-BH, BH & Pharmacy – Medical Necessity and Benefits)

If you are a health plan, you will likely have minimally six file reviews if you have one product line! 

However, if your organization is accrediting Commercial, Exchange, Medicare, and Medicaid, you will likely have 14 file reviews!  While NCQA allows Commercial and Exchange to be combined for Denials and Appeals, Medicare and Medicaid must be assessed separately. 

How Can You Interpret the Standards on File Reviews?

Be attuned to keywords within the NCQA standards.

• An Element may describe that NCQA reviews a sample
• File reviews are listed as a Data Source
• Explanations describe what will be assessed for each factor. (Remember that all bulleted items must be addressed in your files!)
• Scores of Met, Partially Met, or Not Met list the number of factors and percent of files that must be present for the specific standard
• Your look-back period (LBP) is the timeframe by which your files will be pulled; for example, 6 months for Initial surveys and 12 months for Renewal surveys are common, but for credentialing and recredentialing, the LBP is 6 months for Initial and 36 months for Renewal.

But that is not all!

What is the NCQA’s File Review System?

While the NCQA standards address the information that must be included in each file to demonstrate quality, NCQA’s File Review System (FRS) found within the Interactive Review Tool (IRT) is the online tool whereby your file Universes (file samples) are submitted.

Examining the FRS instructions carefully is crucial to avoid any point loss. MHR has found that helping clients navigate the file review procedure is vital for their survey success. Failing to follow instructions in the FRS will result in errors when submitting to NCQA.

Key points:

• File Universes and Samples: Your list of files, called your Universes, should be periodically run and scrutinized to ensure your data is pulled according to the required format. Your IT professionals should know each data field needed for each product line and track system changes, such as dates affecting your files. We highly recommend running a universe before the MHR Consultant reviews your files so she can evaluate the accuracy of files in the universe. We have found many issues with client lists doing this and avoid last-minute stress and drama when finding issues just before survey submission or even erroneous files selected for the sample. NCQA’s position is that the accuracy of the listing is your responsibility and that they will not run another sample if your submission contains errors. Hence, MHR’s recommendation for the consultant to evaluate the listing. Otherwise, your sample denominator can be greatly lowered so that every numerator hit is very painful!
• Product Lines: Some file reviews are product-specific. For example, while Commercial and Exchange may be combined for some, Medicare and Medicaid are separate. Dual-eligible Members are included in Medicare and Medicaid for UM denials, as discussed in our June 2023 blog.
• Delegates: File lists are required from all delegates who perform the service and must be listed in the Universe. Ongoing collaboration with your delegates is necessary! Integrating the delegate files with your files in the list according to the recommendation by NCQA (by date opened or closed) instead of being added at the end of the listing is important for an accurate representative sample. This is especially important when having accredited delegates! Get the file listing early enough to prevent last-minute stress!
• Special instructions: Various standards have unique requirements, as described in our May 2023 blog on Deciphering NCQA UM File Reviews.
• Automatic credit: Automatic credit may be awarded for NCQA-Accredited delegates. Be sure to know your delegate’s accreditation status and the timeframes for which they are accredited.

Do Your Leads Have the Skills to Be in the Driver’s Seat During File Reviews? What Can You Expect When Working with MHR?

Leading NCQA file reviews during a survey (or even for consultant audits!) can be stressful, mainly if it’s the first time! We know! Our MHR Consultants have also been in the driver’s seat, presenting files for a survey, and that is why we know your pain.  That experience, along with most of the MHR Consultants being NCQA surveyors and having that perspective, is how we have honed our process with best practices to help you succeed!

When you work with MHR, you can expect that we will:

• Audit a portion of the files you identified as areas of concern, such as if you missed an implementation date of a new factor or discovered that new staff was not trained on or misunderstood expectations.
• Audit files that we identified as issues during our Full Gap Assessment. For example, if we find a conclusion not drawn on a case management file, we will likely dig deeper to detect if any patterns would put you at risk.
• Assess your documented processes (DP) or other reports associated with a standard. Many times, you can provide the DP as a backup for the language level of the denial or appeal rationale, or that specific content is evaluated for factors.  
• Ask you questions similar to what an NCQA Surveyor may do.
• Focus on your special needs, such as file reviews of comprehensive assessments for LTSS organizations (MHR blog Feb 2024) or on Physician Administered Pharmaceuticals (MHR blog Oct 2023).

It’s a Wrap!

You now have your driver’s license instead of your permit! Of course, new drivers need more experience to feel completely confident, but that’s what periodic file reviews with the consultants entail. The Prep for NCQA Onsite File Review is critical to your survey submission, and we recommend that these occur at least three months prior to the beginning of the LBP, at some point after corrections occur,  and before the survey, and that all stakeholders are present. This provides ongoing training and reinforcement to everyone and answers many questions that others may have.

Also, be aware that the credentialing and recredentialing cycle is continuous and never broken. Therefore, the LBP for Renewal Surveys is 36 months, meaning survey to survey without a break.

At the end of the file review, we will debrief any problematic files, discuss how to minimize organizational risk, strategize on presenting your files with known issues, and answer various lines of questioning that may come your way. As appropriate, we may also recommend other templates, tools, or training that could help you prepare for and sustain your NCQA accreditation.  

Key Takeaways for Successful NCQA File Reviews

• Select highly prepared staff for Lead presenters and their Backups
• Ensure IT systems are functioning and coordinated and any system changes are notated with effective dates. Internally conduct a file audit of a few files after system upgrades to ensure that file reviews are not impacted. We could tell you horror stories about this occurring!
• Identify risks, opportunities, and required changes before the look-back period begins
• Know what files should be included and excluded for the Universes according to NCQA guidelines within the FRS and test them periodically to ensure the correct data fields are being pulled
• Be consistent on file dates used such as, open, close, request, denial, and decision dates
• Include all delegates as appropriate to the standard under review and integrate them with your files in the Universe
• Follow the FRS instructions explicitly

Ask Us About Our New Tools and Templates On File Reviews!  

MHR’s proprietary tools, templates, and training on preparing for NCQA file reviews have been recently updated. The new file review tools that have been in development for a long time have been beta-tested for accuracy and comprehensiveness! These have been developed with a wealth of knowledge we have gleaned over the years, designed especially with you in mind! These have more room for comments that can be summarized into a report, have many reminders, and file review guidance for each product line, as appropriate.

Call to Action:     

• Schedule a Full Gap Assessment with MHR so you can uncover any issues
• Schedule training with MHR on your specific NCQA Accreditation program
• Purchase MHR file review tools for each type of file review required by NCQA on surveys
• Want to know more about a specific topic? Please let us know!

Managedhealthcareresources.com or email Susan K. Moore at

 Our blogs follow an internal quality process with expert review by one of the MHR Consultants in addition to Susan Moore. This blog on file reviews was written with input from Kimberly Carpenter Petit, who was also instrumental in developing other MHR guidelines on file reviews. Read more about Kimberly and our other consultants at About Our Consultants.