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

Note: Some standards from other NCQA programs are not part of the NHP Accreditation; these standards are numbered but do not contain text.  Additionally, QI 10 – QI 15 and RR 5 – RR 8 , listed below, are listed as QI 9 – QI 14 and RR 5 – RR 7 in the 2007/2008 Standards and Guidelines, effective through June 30, 2009.

Quality Management and Improvement (QI)
Utilization Management (UM)
Credentialing and Recredentialing (CR)
Members’ Rights and Responsibilities (RR)
Preventive Health (PH)
Medical Record Review (MR)

Quality Management and Improvement (QI)

1.    QI Program Structure (QI 1)

• Does the plan have a written description of its quality improvement (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 QI activities?
• Is there documentation of QI Committee meetings?
• Are practitioners involved in planning, designing, implementatining and reviewing the QI program?
• Are the plan’s practitioners and members 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 member information?
• Do contracts with practitioners ensure free communication with patients about treatment?
• Do contracts with specialty groups require timely notification to members about termination of a specialist or specialty group?

4.    Availability of Practitioners (QI 4)

• Are the plan's practitioners located throughout its service area?
• Does the plan's practitioner network consider members' special needs? For example, are there multilingual practitioners?
• Does the plan take steps to ensure that there are enough practitioners available to its members?
• 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 member access to routine primary care, emergency care and after-hours care?
• Can members who need behavioral health care obtain it when they need it?
• Does the plan measure its performance in the area of accessibility?

6.    Member Satisfaction (QI 6)

• Does the plan evaluate member complaints and appeals?
• Does the plan perform and analyze results of member satisfaction surveys?
• Does the plan take steps to improve performance?

10.    Continuity and Coordination of Medical Care (QI 10)

• Does the plan monitor the continuity and coordination of care between practitioners; for example, between a primary care physician and a specialist?
• Does the plan or practitioner notify members affected by the termination of a primary care practitioner?
• Under certain circumstances, may members continue to see a practitioner whose contract is terminated?
• Does the plan assist with a member’s transition to other care when benefits end? 
• Does the plan measure its performance in these areas and make improvments when needed?

11.    Continuity and Coordination Between Medical and Behavioral Health care (QI 11)

• Does the plan monitor the coordination of general medical care and behavioral health care?
• Does the plan collaborate with its behavioral health specialists to collect and analyze data and implement actions to improve coordination of behavioral healthcare and general medical care?

12.    Clinical Quality Improvements (QI 12)

• Does the plan measure and demonstrate improvement in the quality of its clinical care?
• Does the plan demonstrate at least three clinical care improvements, including one in behavioral health?

15.    Delegation of QI Activity (QI 15)

• 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 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)

• Is there clear documentation of criteria and procedures for approving and denying care?
• 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 members to discuss UM issues?

4.    Appropriate Professionals (UM 4)

• Do qualified health professionals oversee all review decisions?
• Does an appropriate practitioner review all denials of care based on medical necessity?
• Does the plan have written job descriptions with qualifications for practitioners who review denials of care based on medical necessity? 

5.    Timeliness of UM (UM 5)

• Does the plan make decisions regarding coverage within the time frames specified in the NCQA Standards and Guidelines?
• Does the plan notify members and practitioners 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 relevant clinical information and consult with the treating physician?

7.    Denial Notices (UM 7)

• Does the plan clearly communicate the reason for denial of services in written notification to both the member and treating practitioner?
• Does the plan give the treating practitioner the opportunity to discuss a denial with an appropriate practitioner reviewer? 
• 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 appropriate handling of preservice, post service and expedited member appeals?
• Does the plan have procedures for providing member access to all documents relevant to an appeal?
• Do members 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 a member?
• Does the plan have procedures for providing independent, external review of final determinations?
• Are members notified of further appeal rights?

9.    Appropriate Handling of Appeals (UM 9)

• Does the plan have a full and fair process for resolving member 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 technology or new applications of existing technology, and has it implemented the process?

11.    Satisfaction with the UM Process (UM 11)

• Does the plan evaluate member 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, believe that an emergency medical condition exists?
• Does the plan cover emergency services if an authorized agent of the plan approves 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 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?

14.    Triage and Referral for Behavioral Healthcare (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?

15.    Delegation of UM (UM 15)

• If the plan delegates decisions on approval or denial of coverage, is the decision-making process clearly document and does it include the responsibilities of the plan and the delegated party?
• 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 practitioner 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 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 about practitioner qualifications, does the plan receive and review information from third parties, such as information about disciplinary actions?

6.    Initial Credentialing Site Visits (CR 6)

• Does the plan use onsite visits to verify that primary care practitioners, obstetricians/gynecologists and 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?

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 it identifies issues?

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 a 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 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?

12.    Delegation of Credentialing (CR 12)

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

Members’ Rights and Responsibilities (RR)

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

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

2.    Distribution of Rights Statement to Members and Practitioners (RR 2)

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

3.    Policies for Complaints and Appeals (RR 3)

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

4.    Subscriber Information (RR 4)

• Does the plan provide written information about benefits and charges for which members are responsible, including co-payments?
• Does the plan provide written information for members about how to obtain care?
• Does the plan provide written information for members about how to file a complaint or appeal?

6.    Privacy and Confidentiality (RR 6)

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

7.    Marketing Information (RR 7)

• Do the plan’s marketing 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 members’ understanding of its procedures, and update its marketing materials accordingly?

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

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

Preventive Health (PH)

1.    Adoption of Preventive Health Guidelines (PH 1)

• Does the plan establish preventive health (PH) programs based on the needs of its covered population, and if so, does the program cover at least four of the five specified groups?

2.    Distribution of Guidelines to Practitioners (PH 2)

• Does the plan distribute and communicate PH program information and updates to practitioners?

3.    Health Promotion With Members (PH 3)

• Does the plan ensure that members are aware of available health promotion and PH services?
• Does the plan annually distribute information about its PH programs to all members?

4.    Delegation of PH (PH 4)

• If the plan delegates PH activity, is the decision-making process clearly documented, and does it include the responsibilities of the plan and the delegated party?
• Does the plan evaluate and approve the delegated party’s ability to perform these services beforehand, and on a regular basis?

Medical Record Documentation (MR)

1.    Standards for Medical Record Documentation (MR 1)

• Does the plan establish standards that clearly address the confidentiality, documentation, and maintenance of medical records?

2.    Performance Against NCQA Medical Record Standards (MR 2)

• Does the plan encourage the use of technology to improve services, convenience and appropriate use of health benefits?
• Does the plan ensure that medical records are maintained according to NCQA standards of good professional medical practices and appropriate health management?