2008 MBHO Standards and Guidelines
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.  There are some differences in the content of Standards found in MBHO and other NCQA programs.

Quality Management and Improvement (QI)

1.    QI Program Structure (QI 1)

  • Does the organization have a written description of its QI program that is reviewed and updated annually?
  • Is the organization'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 organization’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 assure their free communication with patients about treatment?
4.    Availability of Practitioners and Providers (QI 4)

  • Are organization practitioners located throughout its service area?
  • In creating its provider network, does the organization consider special needs of its members? For example, are there multilingual practitioners?
  • Does the organization take steps to ensure that there are sufficient numbers of practitioners available to its members?
  • Does the organization measure its performance in these areas and make improvements when needed?
5.    Accessibility of Services (QI 5)

  • Does the organization have standards to assure access to behavioral health care, including non-life-threatening emergency, urgent care, and routine office visit?
  • Does the organization measure its performance in these areas?
  • Does the organization improve the accessibility of behavioral health services and customer needs by identifying opportunities for improvement, implementing interventions and measuring effectiveness of the interventions?
6.    Member Satisfaction (QI 6)

  • Does the organization evaluate member complaints and appeals to assess member satisfaction?
  • Does the organization analyze results of member satisfaction surveys?
  • Does the organization take steps to improve performance in these areas?
7.    Clinical Practice Guidelines (QI 7)

  • Does the organization 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 organization measure its performance against the guidelines annually?
8.    Continuity and Coordination of Behavioral Health Care (QI 8)

  • Does the organization monitor the continuity and coordination of care between practitioners; for example, between a psychiatrist and a non-physician behavioral health practitioner?
  • Does the organization measure its performance in these areas and make improvements when needed?
  • Does the organization or practitioner notify members affected by the termination of a behavioral health practitioner?
  • Under certain circumstances, can members continue to see a practitioner whose contract is terminated?
9.    Continuity and Coordination Between Behavioral Health and Medical Care (QI 9)

  • Does the organization monitor and collaborate with relevant medical delivery systems to improve coordination between behavioral health and medical care?
  • Does the organization 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 10)

  • Does the organization identify at least three clinical care issues relevant to its members?
  • Does the organization measure and demonstrate improvement in the quality of clinical care?
11.    Effectiveness of the QI Program (QI 11)

  • Does the organization measure and demonstrate improvement in the quality of service?
  • Does the organization demonstrate meaningful improvements in the quality of clinical care and service it renders to members?
12.    Standards for Treatment Record Documentation (QI 12)

  • Does the organization establish and distribute treatment record policies that address confidentiality, documentation standards, record keeping and availability?
  • Does the organization have methods to improve treatment record keeping where appropriate?
13.    Delegation of QI (QI 13)

  • If the organization 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 organization evaluated whether or not the delegated party can perform the activities?
  • Does the organization approve the delegated party’s QI work plan and review its performance annually?
Utilization Management (UM)

1.    Utilization Management Structure (UM 1)

  • Does the organization have a written description of its program for managing care?
  • Is the program evaluated and approved annually?
  • Does the organization 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 organization review and revise criteria regularly?
  • Can practitioners obtain the criteria upon request?
  • Does the organization evaluate the consistency with which the criteria are applied?
3.    Communication Services (UM 3)

  • Is UM staff accessible to practitioners and members 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 organization 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 organization notify members 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 organization gather sufficient information and consult with the treating physician?
7.    Denial Notices (UM 7)

  • Does the organization clearly communicate the reasons for denials of service?
  • Can a practitioner discuss the reason for the denial with the organization’s physician reviewer?
  • Does the organization state to the member 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 organization have written policies and procedures for the resolution of member appeals?
  • Does the organization have a process in place to respond to expedited appeals within three days?
  • Do members have at least 180 days to appeal denial decisions?
  • Does the organization 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 organization have procedures for allowing an authorized representative to act on behalf of a member?
  • Does the organization 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 organization have a full and fair process for resolving member appeals?
  • Does the organization follow the policies outlined in UM 8?
10.    Evaluation of New Technology (UM 10)

  • Does the organization 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      Satisfaction with the UM Process (UM 11)

  • Does the organization 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 organization cover emergency services without precertification in cases where a prudent layperson, acting reasonably, would have believed that an emergency medical condition existed?
  • Does the organization 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 13)

  • Does the organization 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 14)

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

1.    Credentialing Policies (CR 1)

  • Does the organization have clearly defined and documented procedures for assessing its practitioners’ qualifications and practice history?
  • Does the organization identify which types of practitioners must be credentialed?
  • Does the organization have policies and procedures that define practitioner rights to review and correct credentialing information?
2.    Credentialing Committee (CR 2)

  • Has the organization designated a committee to make recommendations regarding decisions about practitioners’ credentials?
3.    Initial Credentialing Verification (CR 3)

  • Prior to allowing network participation, does the organization 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 organization 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 organization receive and review information from third parties, such as information about any disciplinary actions?
6.    Practitioner Office Site Quality (CR 6)

  • Has the organization set performance standards/thresholds for office site and medical/treatment record keeping criteria?
  • Does the organization take necessary steps when they receive member complaints related to a practitioner’s office site to evaluate and work to improve the problems?
7.    Recredentialing Verification (CR 7)

  • Does the organization reevaluate practitioners’ qualifications every 36 months?
  • Before reevaluating its decision on a practitioner’s qualifications, does the organization receive information from third parties, such as information about disciplinary actions?
8.    Recredentialing Cycle Length (CR 8)

  • Does the organization reevaluate practitioners’ qualifications every 36 months?
9.    Ongoing Monitoring (CR 9)

  • Between recredentialing cycles, does the organization conduct ongoing monitoring of practitioner sanctions, complaints and quality issues?
  • Does the organization take appropriate action when issues are identified?
10.    Notification to Authorities and Practitioner Appeal Rights (CR 10)

  • Does the organization 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 organization’s decision?
  • Does the organization report to appropriate authorities when it suspends or terminates practitioners?
11.    Assessment of Organizational Providers (CR 11)

  • Does the organization 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 organization re-review these standings at least every three years?
12.    Delegation of Credentialing (CR 12)

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

Members' Rights and Responsibilities (RR)

1.    Statement of Member’s Rights and Responsibilities (RR 1)

  • Does the organization have a written policy that states its commitment to treating members in a manner that respects their rights?
  • Does the policy state the organization’s expectations of members’ responsibilities?
2.    Distribution of Rights Statement to Members and Practitioners (RR 2)

  • Does the organization distribute to members and participating practitioners its policy on member’s’ rights and responsibilities?
3.    Policies for Complaints and Appeals (RR 3)

  • Does the organization have written policies and procedures for the timely resolution of member complaints and appeals?
4.    Subscriber Information (RR 4)

  • Does the organization provide written information about benefits and charges for which members are responsible, including co-payments?
  • Does the organization provide written information for members on how to obtain care?
  • Does the organization provide written information for members about how to file a complaint or appeal?
  • When a practitioner leaves the organization, does the organization provide affected members with sufficient notice, and does it help the members choose a new practitioner?
5.    Privacy and Confidentiality (RR 5)

  • Does the organization take steps to protect the privacy of members’ information and records?
  • Does the organization inform members, practitioners and potential members of these policies?
6.    Delegation of RR (RR 6)

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

1.    Implementing Preventive Behavioral Health Programs (PH 1)

  • Has the organization established preventive health programs based on the needs of its covered population, if so; does the program cover at least two groups?
2.    Distributing Preventive Health Information (PH 2)

  • Does the organization distribute and communicate preventive health program information and updates to practitioners and providers?
3.    Promoting Member Health (PH 3)

  • Does the organization ensure that members are aware of available health promotion and preventive health services?
  • Does the organization annually distribute information about preventive health programs to all members?
  •  Does the organization target outreach to at least one specific group of members identified as an at-risk population?
4.     Delegation of PH (PH 4)

  • If the organization delegates behavioral preventive health activity, is the decision-making process—including the responsibilities of the organization and the delegated party—clearly documented?
  • Does the organization evaluate and approve the delegated party’s ability to perform these services beforehand, and on a regular basis?



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