Delegated Credentialing 101: NCQA Standards, File Build, and Audit Trails

At ACCORDPRO, we help healthcare practices navigate the complexities of delegated credentialing with systems and support that meet regulatory and payer expectations. Here’s a quick-start guide to understanding and managing delegated credentialing the right way.

How to Stay Compliant While Gaining Control of the Credentialing Process

As healthcare organizations grow, managing provider credentialing through each payer becomes increasingly time-consuming. That’s where delegated credentialing comes in—a model that allows your organization to handle credentialing internally, with approval from payers. But to earn and keep that privilege, you must meet NCQA standards, maintain clean credentialing files, and be ready for detailed audit trails at any time.

What Is Delegated Credentialing?

Delegated credentialing is when a payer (e.g., a commercial insurance company, Medicare Advantage plan) gives a healthcare group permission to conduct the credentialing of its own providers, in accordance with NCQA or URAC standards.

Instead of submitting applications and waiting for payer approval, you maintain full control over:

• Primary source verifications

• Credentialing file management

• Recredentialing and ongoing monitoring

• Timelines and internal approval processes

This model reduces administrative burden—but adds responsibility.

Key NCQA Standards You Must Follow

To be approved for delegated credentialing, your process must meet National Committee for Quality Assurance (NCQA) standards, including:

1. Credentialing Policies and Procedures You must have a written, board-approved policy that outlines:

• Credentialing criteria

• Review timelines

• Oversight bodies (e.g., Credentialing Committee)

• Recredentialing frequency (every 36 months)

2. Primary Source Verification You must verify (not just collect) required elements from primary sources, including:

• Medical license

• DEA registration

• Board certification

• Sanctions/exclusions (OIG, NPDB, etc.)

3. Timely Recredentialing Providers must be recredentialed every three years, with updated verifications and performance data reviews.

4. Ongoing Monitoring You must perform monthly exclusion checks (e.g., OIG, SAM) and monitor adverse events, licensure actions, or malpractice history continuously.

5. File Audit Readiness Credentialing files must be complete, well-organized, and accessible for payer audits—often on short notice.

The Credentialing File: What to Include

Each provider's credentialing file must contain:

• Completed application

• Current CV

• Valid state license, DEA, NPI

• Board certification(s), if applicable

• Malpractice insurance with adequate coverage

• Attestation forms (health status, history of sanctions, etc.)

• Results of primary source verifications

• Documentation of credentialing committee review and decision

• Recredentialing records (every 3 years)

Pro Tip: Organize files digitally by provider, with consistent naming conventions and timestamps for each verification.

Building and Maintaining the Audit Trail

Payers require documentation showing:

• Who verified what, and when

• What sources were used (e.g., state license lookup tool, NPDB query)

• When committee decisions were made

• That your policy was followed for each step

Best Practices:

• Use digital credentialing software that records time-stamped actions

• Create audit-ready reports by provider or credentialing period

• Maintain updated documentation of policies and training logs

Steps to Start Delegated Credentialing

1. Create a Delegation-Ready Infrastructure Build out your credentialing policies, file templates, committee structure, and verification tools. Consider working with a credentialing expert like ACCORDPRO to ensure NCQA compliance from day one.

2. Request Delegation from Payers Apply to payers with your full credentialing policy, recent credentialing files, and a readiness to undergo a delegation audit. Each payer has its own process and timelines.

3. Sign Delegation Agreements If approved, you'll enter into a Delegation Agreement that outlines responsibilities, audit frequency, and file sharing protocols.

4. Track Performance and Re-Audit Schedules Payers will conduct annual or semi-annual audits. You'll need to prove that your credentialing remains timely, accurate, and complete.

How ACCORDPRO Can Help

We support healthcare organizations in:

• Building NCQA-compliant credentialing programs

• Creating digital credentialing files and audit trails

• Managing primary source verifications and recredentialing

• Preparing for and passing delegation audits

• Serving as a delegated credentialing partner with scalable support

Whether you want to build an in-house team or outsource credentialing under your brand, we help you stay compliant and in control.

Final Thoughts

Delegated credentialing gives your organization speed, control, and efficiency—but it requires precision and constant oversight. By following NCQA standards, maintaining airtight credentialing files, and building clean audit trails, you can reduce payer delays and scale your provider onboarding with confidence.

Thinking about implementing delegated credentialing?

 📞 Call ACCORDPRO at 425-215-0517 or visit www.accordpros.com to schedule a credentialing strategy consultation.