Nothing creates more anxiety in a credentialing department than an upcoming payer oversight audit. Files get pulled. Policies get dusted off. Someone realizes a re-credentialing was due six months ago.
It doesn’t have to work that way.
Organizations with strong delegated credentialing programs stay audit-ready year-round. This checklist gives you the framework to do exactly that.
What Payer Auditors Actually Review
Before diving into the checklist, it helps to understand what a delegation oversight audit covers. For NCQA and payer compliance, most payer auditors evaluate:
- Provider credentialing files
- Credentialing committee minutes
- Policies and procedures
- Re-credentialing timeliness
- Sanction and exclusion screening
- Information Integrity elements
- Delegation agreement compliance
The Audit Checklist
Initial Credentialing Provider File Checklist
- Completed, signed, and dated application
- Primary source verification of medical licenses
- DEA registration verification (if applicable)
- Board certification verification (if applicable)
- Education and training verification
- NPDB query verified
- Malpractice insurance verified
- OIG exclusion check documented
- SAM.gov exclusion check documented
- State licensing board sanction check documented
- Work history gaps explained
- Hospital privileges verified (if applicable)
- Credentialing committee approval documented
Re-Credentialing Provider File Checklist
- All providers re-credentialed within 36 months
- Re-credentialing initiated 90–120 days before expiration
- Updated PSV completed
- NPDB query repeated
- Ongoing monitoring elements documented
- Committee approval documented
Credentialing Committee Checklist
- Committee meets at required frequency
- Quorum requirements documented
- Minutes reflect discussion and outcomes
- Conditions, deferrals, or denials documented
- Committee chair credentials current
- Confidentiality and Non Discrimination in place
Policy & Procedure Checklist
- Policies reviewed within last 12 months
- Policies reflect current NCQA standards
- Leadership approval documented
- All credentialing elements addressed
- Due process and appeals addressed
- Policies consistently followed
Sanction Screening & Ongoing Monitoring Checklist
- OIG screening conducted
- SAM.gov screening conducted
- State sanctions board monitoring in place
- Licensure expiration monitoring
- Complaints and Adverse events monitoring requirements
How to use this checklist
Monthly: Run sanction screenings and identify upcoming re-credentialing files.
Quarterly: Audit provider files and review committee documentation.
Annually: Complete policy reviews, larger file audits, and metric analysis.
When your audit reveals problems
If your internal audit turns up deficiencies, address them before the payer auditor arrives. Document what you found, what you changed, and when.
Need help getting audit-ready?
If your internal audit reveals gaps—or if you’ve already received a corrective action plan from a payer—Delegated Credentialing Pros can help you get your program back on track.
Schedule a Credentialing Program Assessment today!
