Subdelegated Functions
Provider Type
- Participating Physician Groups (PPG)
For delegated entities that subcontract with another entity to carry out delegated quality management (QI), utilization management (UM), member connections, and credentialing and recredentialing functions, the Delegation Oversight Department is enforcing the following National Committee for Quality Assurance (NCQA) requirements:
- QI 13 for quality management
- UM 13 for utilization management
- MEM 9 for member connections
- CR 8for credentialing and recredentialing
The plan performs audits and requires that delegated entities demonstrate how they ensure that the subcontractor performing delegated QI, UM, member connections, and credentialing and recredentialing functions on the delegated entities behalf is meeting NCQA standards and any additional regulatory state and/or federal requirements. More specifically, the plan requires proof of an agreement between the provider group and subcontractor entity that delineates the rights and responsibilities of each party and requirements for review of subdelegated activities.
Definitions
The current Health Plan Standard and Guidelines, published by NCQA, define delegation and subdelegation as follows:
- Delegation - Occurs when the organization (Health Net) gives another entity (such as a participating physician group (PPG) or independent practice association (IPA) the authority to carry out a function that the organization would otherwise perform.
- Subdelegation - Occurs when the organization's delegate (such as a PPG or IPA that contracts with Health Net to perform a specific function) gives a third entity the authority to carry out a delegated function.