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How is the PHO audited by payers?

November 16, 2017

PHO is audited annually by payers who have delegated credentialing to PHO. This includes a review of policies and procedures in addition to a sample of initial and re-credentialing files to verify that all national requirements are being met. Most payers follow NCQA guidelines (which are the same requirements used for PHO CVO accreditation) and at least one also follows URAC guidelines. A 100% score on PHO’s files means that all requirements were met for processing of a credentialing file – from the application and attestation content, to the details of the verifications ran, to the approval process for participation in the PHO network of providers. Typically, payers select 8 initial and 8 re-credentialing files. If no issues are found on review of those files, the audit is considered complete. If an issue is found, then the payer can request additional files for review, up to a total of 30 files. When NCQA comes to do PHO’s CVO file audit for accreditation renewal, they review a total of 75 files.

PHO received a 100% score from the following payers:

Amerigroup

AmeriHealth

Coventry

Health Partners

Humana

Midlands Choice

UnitedHealthcare

Wellmark

NCQA