A Summary of What NCQA Looks for When It Reviews an MBHO

Note:  Some standards found within other NCQA programs are not a part of the MBHO Accreditation.  Standard numbers that have been are not a part of MBHO 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.    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.    Health Services Contracting (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 assure their free communication with patients about treatment?

4.    Availability of Practitioners and Providers (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 behavioral health care, including non-life-threatening emergency, urgent care, and routine office visit?
• Does the plan measure its performance in these areas?
• Does the plan improves the accessibility of behavioral health services and customer needs by identifying opportunities for improvement, implementing interventions and measuring effectiveness of the interventions?

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.    Clinical Practice Guidelines (QI 8)

• Does the plan establish practice guidelines for its practitioners to follow?
• Is there a clinical basis to the guidelines?
• Are the guidelines reviewed at least every two years?
• Are the guidelines distributed to appropriate practitioners?
• Does the plan measure its performance against the guidelines annually?

8.    Continuity and Coordination of Behavioral Health Care (QI 9)

• Does the plan monitor the continuity and coordination of care between practitioners; for example, between a psychiatrist and a non-physician behavioral health practitioner?
• Does the plan measure its performance in these areas and make improvements when needed?
• Does the plan or practitioner notify enrollees affected by the termination of a behavioral health practitioner?
• Under certain circumstances, can enrollees continue to see a practitioner whose contract is terminated?

9.    Continuity and Coordination Between Behavioral Health and Medical Care (QI 10)

• Does the plan monitor the coordination of medical delivery systems or PCPs?
• Does the plan collaborate with its behavioral health specialists in collecting and analyzing data and implementing actions to improve the coordination of behavioral health with general medical care?

10.    Clinical Measurement Activities (QI 11)

• Does the plan identify at least three clinical care issues relevant to its enrollees?
• Does the plan measure and demonstrate improvement in the quality of clinical care?

11.    Effectiveness of the QI Program (QI 12)

• Does the plan measure and demonstrate improvement in the quality of service?
• Does the plan demonstrate meaningful improvements in the quality of clinical care and service it renders to enrollees?

12.    Standards for Treatment Record Documentation (QI 13)

• Does the plan establish and distribute treatment record policies that address confidentiality, documentation standards, record keeping and availability?
• Does the plan have methods to improve treatment record keeping where appropriate?

13.    Delegation of QI (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.    Utilization Management Structure (UM 1)

• Does the plan have a written description of its program for managing care?
• Is the program evaluated and approved annually?
• Does the plan involve a designated behavioral health care practitioner in the implementation of the behavioral health care aspects described in the program?

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

5.    Timeliness of UM 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?

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 technologies and new applications of existing technologies, and has it implemented the process?

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

• 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?

14.    Delegation of UM (UM 15)

• 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 Credentialing Verification (CR 3)

• Prior to allowing network participation, does the plan verify practitioners’ credentials, including a valid license to practice medicine; education and training, 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.    Initial Credentialing Site Visits (CR 6)

• Does the plan verify through an onsite visit that all high-volume behavioral health care practitioners’ offices meet its standards?
• Does the plan take necessary steps when an office does not meet its standards, and does it evaluate those steps regularly until the office improves?

7.    Recredentialing 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?

8.    Recredentialing Cycle Length (CR 8)

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

9.    Ongoing Monitoring (CR 9)

• Between recredentialing cycles, does the plan conduct ongoing monitoring of practitioner sanctions, complaints and quality issues?
• Does the plan take appropriate action when issues are identified?

10.    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?

11.    Assessment of Organizational Providers (CR 11)

• Does the plan confirm that psychiatric hospitals, clinics, addiction disorder facilities and residential treatment centers for psychiatric and addiction disorder are in good standing with state and federal agencies and accrediting organizations?
• Does the plan re-review these standings at least every three years?

12.    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.    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 Statement 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.    Privacy and Confidentiality (RR 5)

• 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?

6.    Delegation of Enrollees’ Rights and Responsibilities (RR 7)

• 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?

Preventative Health (PH)

1.    Implementing Preventative Behavioral Health Programs (PH 1)

• Has the plan established preventative health programs based on the needs of its covered population, if so, does the program cover at least two groups?

2.    Distributing Preventative Health Information (PH 2)

• Does the plan distribute and communicate preventative health program information and updates to practitioners and providers?

3.    Promoting Enrollee Health (PH 3)

• Does the plan ensure that enrollees are aware of available health promotion and preventative health services?
• Does the plan annually distribute information about preventative health programs to all enrollees?
• Does the plan target outreach to at least one specific group of enrollees identified as an at-risk population?

4.     Delegation of PH (PH 4)

• If the plan delegates behavioral preventative health activity, 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 ability to perform these services beforehand, and on a regular basis?