Credentialing & Privileging

Ask the expert: What are the NCQA requirements for verifying medical education?

Credentialing Resource Center Insider, November 15, 2007

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The highest of the three levels of education and training must be verified. The three levels are defined as:
1. Graduation from medical school
2. Residency
3. Board certification

Therefore, if a physician is board-certified, verification of board certification suffices. If the physician is not board-certified, verification of completion of residency suffices. If the physician did not complete a residency program, verification is required from one of the following sources:

  • The medical school.
  • AMA Physician Masterfile.
  • American Osteopathic Association (AOA) Official Osteopathic Physician Profile or AOA Physician Masterfile.
  • The Education Commission for Foreign Medical Graduates (ECFMG) for international graduates licensed after 1986.
  • An association of schools of the health profession (July 2003), if the association obtains its verification from the primary source. Annually, the organization must obtain written confirmation that the association performs primary source verification.
  • The licensing agency, as long as it conducts primary source verification. There must be written evidence on file, updated annually, that the state licensing agency performs primary source verification.

Note: NQCA requirements vary for dentists, podiatrists, and chiropractors. See NCQA MCO credentialing standards for specific information.

This advice was taken from Verify and Comply: A Quick Reference Guide to The Joint Commission and NCQA Standards for Credentialing, Fourth Edition, by Carol S. Cairns, CPMSM, CPCS, available here



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