North Carolina Department of Health and Human Services (NCDHHS) Credentialing Committee FAQs
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1. What is the Credentialing Committee?
The Credentialing Committee will review NCDHHS provider applications that contain adverse action items prior to final disposition of their enrollment, reenrollment and recredentialing applications as well as items discovered through ongoing monitoring.
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2. When will the Committee begin and how frequently will it meet?
The Credentialing Committee is scheduled to begin activities in October 2025. The committee will meet weekly to review adverse action items in depth and to ratify clean applications.
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3. Who serves on the Committee?
The Credentialing Committee is made up of voting and non-voting members. The voting members include:
- One Medical Director (employed by General Dynamics Information Technology (GDIT))
- Two NC Medicaid representatives
- One representative from each health plan
- Multi-payers (Division of Mental Health, Developmental Disabilities and Substance Use Services, Division of Public Health and Office of Rural Health) representatives
Non-voting members may include the Credentialing Coordinator, Peer Expert Specialists and Peer Expert Non-Physician Practitioners, as needed.
More information on how to apply to become a Peer Reviewer will be shared soon.
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4. Is the role of a Committee member a volunteer position?
Yes, they are volunteer roles.
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5. What types of application files will the Committee review?
The Committee reviews application files for all provider types, including individuals and organizations. Files with no findings are categorized as clean and ratified weekly. Files with adverse action items are reviewed in detail by the Committee.
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6. What is considered a "clean" file, and how is it handled?
A clean file has no adverse action findings. These are formally approved by the Credentialing Committee Medical Director and ratified during the Committee meeting. Clean files are not reviewed individually.
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7. Which standards are used for provider credentialing?
Credentialing and recredentialing standards are not changing and are based on current National Committee for Quality Assurance (NCQA) Federal and State guidelines. The official bylaws of the Credentialing Committee are available for reference on the Credentialing Committee website under Additional Resources.
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8. How will Committee activities affect processing times?
Current processing times for clean applications can be found on the NC Medicaid Provider Enrollment web page. The Department does not anticipate a significant change
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9. How are materials shared with Committee members?
GDIT is building a secure portal for file distribution and training. Details forthcoming in stakeholder sessions.
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10. What are the appeals rights for practitioners that receive an adverse decision from the Credentialing Committee?
Providers will have full appeals rights for adverse decisions, just as they do today.
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11. Will the re-verification timeframe change?
No. NC Medicaid currently operates under a waiver allowing five-year re-verification cycles.
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12. Who is responsible for credentialing activities?
The current Fiscal Agent continues primary-source verification; NCDHHS and NC Medicaid Credentialing Committee provides oversight.
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13. Will the Credentialing Committee require updates to provider enrollment files that health plans currently receive and use to determine the credentialing status of Medicaid providers?
No changes will be made to current provider enrollment files.
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14. Managed care health plans are currently exempt from most of the NCQA credentialing accreditation standards. Will that change now that the new Credentialing Committee is being implemented?
NC Medicaid and the Prepaid Health Plans are currently operating under NCQA waivers and will continue to do so when the Credentialing Committee is implemented. At some point, the waivers may be revisited.
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15. Will the committee be comprised of many different provider specialties?
Yes, the committee includes a diverse representation of provider specialties. While the core voting members include representatives from NC Medicaid, managed care plans, and other state divisions, the non-voting participants may include peer reviewers.
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16. Can you provide additional resources and education regarding NCQA criteria for enrollment and credentialing?
Please refer to the NCQA website for more information regarding NCQA requirements for health plans. Current requirements implemented by NC Medicaid for provider enrollment will continue to be subject to NCQA, Federal and State guidelines.
More information can be found on the NC Medicaid Credentialing Committee Questions and Answers webpage.
For specific questions related to the Credentialing Committee, please email medicaid.credcommittee.stakeholders@dhhs.nc.gov.