Overview of Delegation in Managed Care

I. Overview of Delegation
A. Definition of delegation
1. A formal process by which the organization gives another
entity the authority to perform certain functions on its behalf.
Although the organization may delegate the authority to
perform a function, it may not delegate responsibility for
ensuring that the function is performed appropriately.
B. When evaluating a delegation agreement, a credentialing specialist
must determine:
1. If the delegation agreement contains all the required
elements for compliance with accreditation entity, federal
and state laws
2. Mutually agreed upon
3. describes the responsibilities of the organization and the
delegated entity
4. describes the delegated activities
5. requires at least semiannual reporting to the organization
6. Describes the processes by which the organization
evaluates the delegated entitys performance
7. Describes the remedies available to the organization if the
delegated entity does not fulfill its obligations, including
revocation of the delegation agreement
II. Constructing a Delegation Agreement
A. Written Delegation Agreements Content
1. Provisions for PHI (Protected/Private Health Information)
2. Right to Approve & Terminate
3. Responsibilities of Organization and Delegate
4. Delegated Activities
5. Semi-Annual Reporting
6. Evaluation of Performance
7. Remedies for Revocation
III. Pre-delegation Evaluation Process
A. The organization must have a systematic method for conducting
this evaluation, especially if more than one delegation agreement is
in effect.
1. Evaluation usually involves a site visit and a written review
of the delegates understanding of the standards and the
delegated tasks, staffing capabilities and performance
records, but it may also be accomplished through the
exchange of documents or through pre-delegation meetings.
2. The organization must evaluate the delegates credentialing
system and schedule for compatibility with its own.

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 B. The organization audit must include either 5 percent or 50 of its
practitioners files, whichever is less to ensure the information is
appropriately verified.
1. At a minimum, an audit must include at least 10
credentialing files and 10 re-credentialing files.
2. The organization may use the NCQA 8/30 methodology
available at www.ncqa.org/updates to review the delegate
files for both credentialing and recredentialing.
C. Exception to PreDelegation Audit Requirement:
1. If the delegate is an NCQA accredited or certified
organization in the areas of credentialing and
recredentialing.
D. Pre-Delegation Audit
1. When evaluating a delegates credentialing system to
ensure compatibility with your own, it is important to ensure
their practice standard is equivalent with your own. This can
be done by a thorough review of their policies and
procedures.
IV. Delegation Oversight/Annual Audit
A. There must be yearly documentation of substantive evaluation and
actions plans, if needed.
B. The annual audit and evaluation must be based on the
responsibilities stated in the mutually agreed-upon delegation
document and the appropriate NCQA standards.
C. The evaluation must include a review of the delegates
credentialing policies and procedures
D. An organization that conducts annual file audits of delegates one
year is not required to conduct annual file audits when the delegate
does not credential or re-credential any practitioners until the next
file audit is scheduled to occur.
E. The organization is required to meet all other delegation oversight
requirements and provide documentation that the delegate did not
credential or re-credential practitioners between the audit cycles
F. Exception to Annual Audit Requirement: If the delegate is and
NCQA accredited or certified organization in the areas of
credentialing and re-credentialing.
V. Evaluation Reporting
A. The organization must receive and evaluate reports from its
delegates at least semiannually.
1. At a minimum the following must be included in the reports:
a. progress in conducting credentialing and
recredentialing activities
b. performance improvement activities, if applicable
B. Findings from the organizations pre-delegation evaluation, annual
evaluation and file audit or ongoing reports can be sources to
identify areas of improvement for reporting.

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 1. Areas can be related to NCQA credentialing standards or to
the organizations expectations
C. Reporting may be limited to lists of credentialed and re-
credentialed practitioners if no performance issues are identified
and that is the only other requirement specified in the delegation
agreement.

VI. Reporting
A. What to report
1. Progress in conducting credentialing and recredentialing
activities
2. Performance improvement activities
B. Sources to identify improvement
1. Findings from predelegation evaluation
2. Findings from annual evaluation and file audit
3. Ongoing Reports
4. Credentialing Committee Minutes
5. Data Analysis
6. Reports designed specifically for relationship
C. NCQA-Certified or NCQA-Accredited Entities
1. Delegate must be NCQA-certified or NCQA-accredited prior
to the implementation of the delegation agreement
2. For certification, the benefits are awarded for those
elements/categories for which the delegate has achieved
certification
3. Activities must be covered in the agreement
D. Why use NCQA-Certified or NCQA-Accredited Entities?
1. Relief from pre-delegation assessment requirements
2. Relief from the annual performance evaluation
3. Automatic credit on certain delegated activities
E. Scope of NCQA Evaluation
1. Within scope
a. Primary care
b. Specialty care
c. BH organizations
d. CVOs
e. PBMs
f. DM
2. Out of scope
a. Home health agencies
b. Vision service providers
c. Lab organizations

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