No. The Exchange product line is only for the public (ACA-related) exchanges. Private commercial exchanges come under the commercial product line and Medicare exchanges come under the Medicare product line.
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10.15.2013 Commercial and Medicare Exchanges. Do private commercial and Medicare exchanges come under the Exchange product line?
10.15.2013 Meeting UM 7C and 7F using the Notice of Denial of Medical Prescription Drug Coverage. Does the Notice of Denial of Medicare Prescription Drug Coverage meet the same factors in UM 7, Elements C and F as the Notice of Denial of Medical Coverage (NDMC)?
10.15.2013 Use of a vendor or delegate for HIP and WHP Certifications. May an organization coming through for HIP or WHP certification use a vendor or delegate for any functions or activities required by the standards and guidelines?
10.15.2013 Identification of Alcohol and Other Drug Services On page 298 of HEDIS 2014 Volume 2, in the Outpatient and ED section, the 5th bullet states "where the organization can confirm that the visit was in an intensive outpatient or partial hospitalization setting (POS 53 is not specific to setting)." Should the language be changed to reference an "outpatient" setting?
Yes. The language should read, "where the organization can confirm that the visit was in an outpatient setting (POS 53 is not specific to setting)." The intent is to include only codes where the organization can confirm that the visit was in an outpatient setting.
This applies to the following Programs and Years:
HEDIS 201410.15.2013 Core and Structural elements. What is the difference between core elements and structural elements?
Core elements are requirements that an organization must meet even if it has no clients.
Structural elements are requirements that the organization must meet even if it delegates 100% of the function. If an organization delegates the functions associated with a structural requirement, it must provide NCQA with its own programs or policies and procedures and evidence of approval of the delegates documentation.
This applies to the following Programs and Years:
UM-CR 201310.15.2013 Clarification that MED elements are NA for Exchange Product Line. Is the Exchange product line NA for the Medicaid standard and elements?
10.15.2013 Scoring and implementation of new Medicaid language in HP 2014. The 2014 HP standards state that beginning July 1, 2014, Medicaid plans will be reviewed and scored on MEM standards, but may submit a plan for implementing the MEM standards by July 1, 2015 (if the functions are not already in place). What is required of organizations that have surveys before July 1, 2015? What documentation is required of these organizations? Similarly, what is required of organizations that have surveys on or after July 1, 2015?
For Medicare, Medicaid and Exchange surveys beginning on or before June 30, 2015, NCQA will review and score the organization on their submitted implementation plan. The implementation plan must address all requirements of the applicable elements and factors, during the first year of review (July 1, 2014-June 30, 2015). NCQA will not resurvey or reevaluate organizations in 2015 to determine if MEM functions are operational. For Medicare, Medicaid and Exchange surveys beginning on or after July 1, 2015, the organization must demonstrate that MEM functions are operational in order to receive the associated points. We do not expect organizations to submit additional documentation between surveys.
This applies to the following Programs and Years:
8.29.2013 Lack of expiration date for board certification What is NCQA's documentation requirement if a medical board does not provide an expiration date?
If the medical board does not provide the expiration date for a practitioner's board certification, the organization must verify and document that the board certification is current within 180 calendar days of the credentialing decision date.
This applies to the following Programs and Years:
8.29.2013 Documentation requirements using NPDB-PDS Databank What are the documentation expectations for CVOs that use the NPDB-PDS Databank's Continuous Query for collecting and reporting malpractice history?
The CVO must provide NCQA with evidence of a practitioners current or continuous enrollment in the NPDB-PDS Databank, and of review and reporting of databank activity to the organizations client within 120 calendar days.
If no malpractice history is reported by the databank, the CVO must document this in the file and must report to clients that no malpractice settlements were reported. NCQA does not prescribe how the organization documents this information.
This applies to the following Programs and Years:
8.29.2013 Expiration date for board certification not provided by ABMS member board American Board of Pediatrics How should organizations handle NCQA's expiration date and timeliness requirements if the Medical Board does not provide an expiration date for a practitioner's board certification?
If the medical board does not provide the expiration date for a practitioner's board certification, the organization must verify that the board certification is current. Verification must be documented 180 calendar days prior to the recredentialing decision date.
This applies to the following Programs and Years:
8.29.2013 Use of Web crawlers for collection of credentialing information Does NCQA accept automated verifications obtained by a Web crawler or Internet grabber used in credentialing software?
Yes, if such mechanisms can legitimately access, retrieve and share the data from approved/recognized sources. All credentialing documentation requirements must be met, and there must be clear documentation that the organizations staff reviewed the credentialing information.