A Summary of What NCQA Looks for When It Reviews a PPO

Note:  Some standards found within other NCQA programs are not a part of the PPO Plan Accreditation.  Standard numbers that have been are not a part of PPO Plan Accreditation.

Quality Management and Improvement (QI)

1.    QI Program Structure (QI 1)

• Does the plan have a written description of its QI program that is reviewed and updated annually?
• Is the plan’s governing body accountable for the QI program?
• Is behavioral health specifically addressed in the QI program?
• Does a QI Committee oversee the QI program?
• Are the roles, structures and functions of the QI Committee and other committees described in the QI program description?
• Is there an annual QI work plan?

2.    QI Program Operations (QI 2)

• Does the QI committee meet regularly and take action on quality improvement activities?
• Is there documentation of QI committee meetings?
• Are practitioners involved in the planning, design, implementation and review of the QI program?
• Are the plan’s practitioners and enrollees informed about its QI program?
• Is there a plan for collecting and providing information on provider and practitioner safety and quality?

3.    Physician Contract Requirements (QI 3)

• Are participating practitioners and providers required to cooperate with QI activities, provide access to their medical records and protect the confidentiality of enrollee information?
• Do contracts with practitioners and providers assure their free communication with patients about treatment?

4.    Availability of Practitioners (QI 4)

• Are plan practitioners located throughout its service area?
• In creating its provider network, does the plan consider special needs of its enrollees? For example, are there multilingual practitioners?
• Does the plan take steps to ensure that there are sufficient numbers of practitioners available to its enrollees?
• Does the plan measure its performance in these areas and make improvements when needed?

5.    Accessibility of Services (QI 5)

• Does the plan have standards to assure access to medical care, including routine primary care, emergency care, and after-hours care?
• Can enrollees who need behavioral health care obtain it when they need it?
• Does the plan measure its performance in these areas?

6.    Enrollee Satisfaction (QI 6)

• Does the plan evaluate enrollee complaints and appeals to assess enrollee satisfaction?
• Does the plan analyze results of enrollee satisfaction surveys?
• Does the plan take steps to improve performance in these areas?

7.    Continuity and Coordination of Care (QI 9)

• Does the plan or practitioner notify enrollees affected by the termination of a primary care practitioner?
• Under certain circumstances, can enrollees continue to see a practitioner whose contract is terminated?

8.    Effectiveness of the QI Program (QI 12)

• Does the plan measure and demonstrate improvement in the quality of clinical care and service?
• Does the plan demonstrate at least two improvements, including one in service?

9.    Delegation of QI Activity (QI 14)

• If the plan delegates QI activity, has it worked with the delegated party to develop a mutually agreed-upon document that outlines responsibilities, delegated activities, and evaluation processes?
• Has the plan evaluated whether or not the delegated party can perform the activities?
• Does the plan approve the delegated party’s QI work plan and review its performance annually?

Utilization Management (UM)

1.    UM Structure (UM 1)

• Does the plan have a written description of its program for managing care?
• Is the program evaluated and approved annually?
• Is a senior physician involved in the program’s operation?
• Are behavioral health aspects described in the program description, and if so, is a behavioral health practitioner involved in them?

2.    Clinical Criteria for UM Decisions (UM 2)

• Are criteria and procedures for approving and denying care clearly documented?
• Are practitioners involved in procedures development?
• Does the plan review and revise criteria regularly?
• Can practitioners obtain the criteria upon request?
• Does the plan evaluate the consistency with which the criteria are applied?

3.    Communication Services (UM 3)

• Are UM staff accessible to practitioners and enrollees to discuss UM issues?

4.    Appropriate Professionals (UM 4)

• Do qualified health professionals oversee all review decisions?
• Does an appropriate practitioner review any denial of care based on medical necessity?

5.    Timeliness of Medical Review Decisions (UM 5)

• Does the plan make decisions regarding coverage in a timely manner? Specifically, does it make preservice nonurgent decisions within 15 days; preservice urgent decisions within 72 hours; urgent concurrent decisions within 24 hours; and postservice decisions within 30 days?
• Does the plan notify enrollees of coverage decisions within the required time frames?

6.    Clinical Information (UM 6)

• When determining whether to approve or deny coverage based on medical necessity, does the plan gather sufficient information and consult with the treating physician?
• Does the plan assist with an enrollee’s transition to other care when benefits end?

7.    Denial Notices (UM 7)

• Does the plan clearly communicate the reasons for denials of service?
• Can a practitioner discuss the reason for the denial with the plan’s physician reviewer?
• Does the plan state to the enrollee and the practitioner its reasons for denial, in writing?
• Is the appeal process outlined clearly in all denial notifications?

8.    Policies for Appeals (UM 8)

• Does the plan have written policies and procedures for the resolution of enrollee appeals?
• Does the plan have a process in place to respond to expedited appeals within three days?
• Do enrollees have at least 180 days to appeal denial decisions?
• Does the plan have procedures for providing enrollee access to all documents relevant to an appeal?
• Do enrollees have the opportunity to submit comments, documents or other information relating to an appeal?
• Are appeal reviewers disinterested parties (i.e., not involved in the initial denial decision)?
• Are same-or-similar-specialty reviewers (i.e., practitioners in the same or a similar specialty who treat the condition under appeal) involved in appeals?
• Does the plan have procedures for allowing an authorized representative to act on behalf of an enrollee?
• Does the plan have procedures for providing independent, external review of final determinations?
• Are enrollees notified of further appeal rights?

9.    Appropriate Handling of Appeals (UM 9)

• Does the plan have a full and fair process for resolving enrollee appeals?
• Does the plan follow the policies outlined in UM 8?

10.    Evaluation of New Technology (UM 10)

• Does the plan have a written description of the process it uses to determine whether or not it will cover new medical technologies or new applications of existing technologies, and has it implemented the process?

11.    Satisfaction with the UM Process (UM 11)

• Does the plan evaluate enrollee and practitioner satisfaction with its process for determining coverage, and does it address areas of dissatisfaction?

12.    Emergency Services (UM 12)

• Does the plan cover emergency services without precertification in cases where a prudent layperson, acting reasonably, would have believed that an emergency medical condition existed?
• Does the plan cover emergency services if an authorized agent of the plan has approved the provision of emergency services?

13.    Procedures for Pharmaceutical Management (UM 13)

• Are the plan’s procedures for drug coverage clearly documented, and is a clear process in place for applying the procedures?
• Are all procedures reviewed and updated regularly?
• Do the procedures cover patient safety issues?
• Are practitioners, including pharmacists, involved in developing and updating procedures?
• If the plan restricts pharmacy benefits, does it have an exceptions policy for allowing?

14. Triage and Referral for Behavioral Health Care (UM 15)

• Does the plan prioritize or make referrals for behavioral health care based on accepted definitions for the level of urgency and setting?
• Depending on the case, are these decisions made by qualified staff or a behavioral health professional?

15.    Delegation of UM (UM 16)

• If the plan delegates decisions on approval or denial of coverage to a third party, is the decision-making process—including the responsibilities of the plan and the delegated party—clearly documented?
• Does the plan evaluate and approve the delegated party’s plan on a regular basis?

Credentialing and Recredentialing (CR)

1.    Credentialing Policies (CR 1)

• Does the plan have clearly defined and documented procedures for assessing its practitioners’ qualifications and practice history?
• Does the plan identify which types of practitioners must be credentialed?
• Does the plan have policies and procedures that define practitioner rights to review and correct credentialing information?

2.    Credentialing Committee (CR 2)

• Has the plan designated a committee to make recommendations regarding decisions about practitioners’ credentials?

3.    Initial Primary Source Verification (CR 3)

• Prior to allowing network participation, does the plan verify practitioners’ credentials, including a valid license to practice medicine; education and training, board certification, malpractice history; and work history?

4.    Application and Attestation (CR 4)

• Do practitioners applications to the plan include a current and signed attestation about why they cannot perform certain tasks; a history of loss of medical license and felony convictions; a history of limitation of privileges or disciplinary actions; and current malpractice insurance coverage?

5.    Initial Sanction Information (CR 5)

• Before making a decision on a practitioner’s qualifications, does the plan receive and review information from third parties, such as information about any disciplinary actions?

6.    Recredentialing Primary Source Verification (CR 7)

• Does the plan reevaluate practitioners’ qualifications every 36 months?
• Before reevaluating its decision on a practitioner’s qualifications, does the plan receive information from third parties, such as information about disciplinary actions?

7.    Recredentialing Cycle Length (CR 8)

• Does the plan reevaluate practitioners’ qualifications every 36 months?

8.    Ongoing Monitoring of Sanctions, Complaints and Quality Issues (CR 9)

• Between recredentialing cycles, does the plan monitor sanctions and practitioner enrollee complaints and satisfaction?
• Does the plan take appropriate action when issues are identified?

9.    Notification to Authorities and Practitioner Appeal Rights (CR 10)

• Does the plan have a process for discontinuing the contracts of practitioners who demonstrate poor performance?
• Is there a process in place by which the practitioner can appeal the plan’s decision?
• Does the plan report to appropriate authorities when it suspends or terminates practitioners?

10.    Assessment of Organizational Providers (CR 11)

• Does the plan confirm that hospitals, home health care agencies, skilled nursing facilities, nursing homes and behavioral health facilities are in good standing with state and federal agencies and accrediting organizations?
• Does the plan re-review these standings at least every three years?

11.    Delegation of Credentialing (CR 12)

• If the plan delegates to a third party decisions on evaluating or reevaluating a provider’s qualifications, is the decision-making process—including the responsibilities of the plan and delegated party—clearly documented?
• Does the plan evaluate and approve the delegated party’s plan on a regular basis?

Enrollees’ Rights and Responsibilities (RR)

1. Statement of Enrollees’ Rights and Responsibilities (RR 1)

• Does the plan have a written policy that states its commitment to treating enrollees in a manner that respects their rights?
• Does the policy state the plan’s expectations of enrollees’ responsibilities?

2.    Distribution of Rights Statements to Enrollees and Practitioners (RR 2)

• Does the plan distribute to enrollees and participating practitioners its policy on enrollees’ rights and responsibilities?

3.    Policies for Complaints and Appeals (RR 3)

• Does the plan have written policies and procedures for the timely resolution of enrollee complaints and appeals?

4.    Subscriber Information (RR 4)

• Does the plan provide written information about benefits and charges for which enrollees are responsible, including co-payments?
• Does the plan provide written information for enrollees on how to obtain care?
• Does the plan provide written information for enrollees about how to file a complaint or appeal?
• When a practitioner leaves the plan, does the plan provide affected enrollees with sufficient notice, and does it help the enrollees choose a new practitioner?

5.    Physician and Hospital Directory (RR5)

• Does the plan provide a searchable Web based directory of its physicians and hospitals?
• Does the directory contain the most current information on each physician and hospital?
• Does the plan test its directory for ease or use and understanding?
• Is the directory available in other formats such as print and telephonic?

6.    Privacy and Confidentiality (RR 6)

• Does the plan take steps to protect the privacy of enrollees’ information and records?
• Does the plan inform enrollees, practitioners and potential enrollees of these policies?

7.    Marketing Information (RR 7)

• Do the plan’s marketing communications materials describe its procedures for approving or denying coverage; covered benefits, including pharmacy benefits; noncovered services; availability of practitioners and providers; and any applicable restrictions?
• Does the plan monitor new enrollees’ understanding of its procedures, and update its marketing materials accordingly?

8.    Delegation of Enrollees’ Rights and Responsibilities (RR 8)

• If the plan delegates enrollee services activities to a third party, is the decision-making process—including the responsibilities of the plan and delegated party—clearly documented?
• Does the plan evaluate and approve the delegated party’s ability to perform these services beforehand, and on a regular basis?

Standards for Enrollee Connections (MEM)

1.    Health Risk Appraisal (MEM 1)

• Does the plan provide a health risk appraisal that can allow enrollees to assess their risk of morbidity and mortality and identify ways the risks can be reduced?
• Does the plan provide resources that can assist enrollees in reducing risks?
• Is the HRA available on the Web and in an alternative format?

2.     Consumer health tools (MEM 2)

• Does the plan provide Web-based interactive tools to assist enrollees in reducing risk of major health problems?
• Are the tools reviewed and kept current?
• Are the tools tested for usefulness and understanding?

3.   Functionality of Claims Processing (MEM 3)

• Does the plan have Web and telephone capability to allow enrollees to obtain information on their claims?
• Does the plan measure whether the claims are handled in a timely and accurate way?

4.    Pharmacy Benefit (MEM 4)

• Are enrollees able to query information about their pharmacy benefits, financial responsibility for medication and pharmacy operations on the Web and by telephone?
• Does the plan have a process to ensure the pharmacy information is accurate and current?

5.     Personalized Information on Health Plan Services (MEM 5)

• Are enrollees able to request or reorder an ID card or change a primary care practitioner on the Web?
• Can enrollees determine how and when to obtain referrals and benefit responsibility for services over the Web or by telephone?
• Does the plan ensure the accuracy of the benefit information it communicates?
• Does the plan assess enrollee satisfaction of its enrollee materials and the help they get through customer services over the telephone?

6.   Innovation in Enrollee Service (MEM 6)

• Does the plan encourage the use of technology to improve services, convenience and appropriate use of health benefits?

7.    Health Information Line (MEM 7)

• Can enrollees access a health information line to receive answers to health related inquiries?
• Is the Health Information Line available 24 hours a day by telephone?
• Does Health Information Line provide staff with the ability to follow up on cases and link enrollees’ contacts with a contact history?
• Does the plan track enrollees’ use of the Health Information Line?

8.    Encouraging Wellness and Prevention (MEM 8)

• Does the plan identify enrollees who are eligible for wellness programs?
• Does the plan provide follow-up to enrollees based on enrollee specific information?
• Does the plan offer incentives to enrollees for taking action on wellness and prevention?

9.    Delegation of Enrollees’ Rights and Responsibilities (MEM 9)

• If the plan delegates enrollee connections activities to a third party, is the decision-making process—including the responsibilities of the plan and delegated party—clearly documented?
• Does the plan evaluate and approve the delegated party’s ability to perform these services beforehand, and on a regular basis?

CAHPS 4.0H Data Submission

• NCQA does not evaluate PPO plans based on their CAHPS 4.0H results; instead, the standards require a PPO plan to field the survey. One standard awards points toward accreditation based only on submission of results, not performance.