FAQ Directory

PCMH PRIME adds 13 behavioral health integration criteria to NCQA PCMH Recognition standards. A practice must be NCQA PCMH Recognized (at any level except PCMH 2011 Level 1)) and meet 7 of the 13 behavioral health integration criteria to qualify for PCMH PRIME.

Criteria reflect capabilities primary care providers need to develop in order to identify and manage behavioral health conditions in a timely manner. The criteria include integration of, or collaboration with, behavioral health providers; comprehensive diagnostic screenings; identifying high risk patients; referral tracking and follow-up; and provision of medication-assisted treatment for addiction. 

This applies to the following Programs and Years:

Some practices seeking PCMH PRIME Certification may be designated by the HPC as on the “Pathway to PCMH PRIME.”  Practices qualify for Pathway to PCMH PRIME status if they are currently NCQA PCMH Recognized (at any level except PCMH 2011 Level 1) and commit to applying to NCQA for PCMH PRIME Certification within 18 months of submitting a PCMH PRIME application to the HPC.

This applies to the following Programs and Years:

If your practice has additional questions about PCMH PRIME, you can: 

• Speak to an NCQA representative by calling 617-996-0081.
• Submit questions via NCQA’s Program/Policy Clarification Support (PCS) system at https://my.ncqa.org. 
• E-mail your questions to HPC staff at HPC-Certification@state.ma.us.

This applies to the following Programs and Years:

• Accreditation Process and Timeline: Key steps, timing and resources for a successful accreditation.
• Standards and Guidelines: The complete standards and guidelines, including the intent and scope of review.
• Interactive Survey Tool: Contains the complete standards and guidelines; you can also determine your organization’s survey readiness—the tool calculates your potential survey score.

This applies to the following Programs and Years:

The HPC is committed to engaging payers to support PCMH PRIME practices and their efforts toward behavioral health integration.  The HPC is involved in ongoing discussions with payers about PCMH PRIME, and we encourage practices to speak with their payer contacts about certification incentives or other payments that may be available

This applies to the following Programs and Years:

The PCMH PRIME program standards do not define care manager qualifications; this requirement was intentionally left flexible so that practices could fulfill PP 01 with a care manager that best suits the practice’s patient population needs.

Generally, a care manager must facilitate appropriate behavioral healthcare services by applying specialized knowledge and judgment to support and address behavioral health needs. The practice must define the qualifications and/or training a care manager must have in order to manage patients’ behavioral health conditions. The practice must also demonstrate that at least one member of the staff with care management responsibilities has the necessary qualifications/training to support patients with behavioral health needs.

This applies to the following Programs and Years:

No. For criterion PP 01, the care manager function must be filled by practice staff

This applies to the following Programs and Years:

Behavioral health conditions (mental illnesses and substance use disorders) suffer from both under-diagnosis and delayed diagnosis. This is a serious public health problem nationally and across the Commonwealth. Untreated behavioral health conditions contribute to morbidity and increase the total cost of care. The gap in care and treatment for behavioral health conditions requires action and a coordinated effort by providers and payers to ensure that patients get the care they need, before illness is severe and results in a crisis situation (e.g., avoidable ED visit or inpatient admission). Integrating behavioral health—including appropriate screening for behavioral health conditions (and treatment, when appropriate)—is critical in the primary care setting.

This applies to the following Programs and Years:

No. Care managers must be able to serve any patient within a practice, not just patients from specific payers. The aim of PCMH PRIME Certification is to encourage coordinated, team-based care for all patients, regardless of payer status. To that end, criterion PP 01 can only be satisfied through use of care managers whose services are made available to patients based on need and not payer type.

This applies to the following Programs and Years:

No, the percentage should reflect the screenings that are completed at the primary care practice. Practices, including those that are a part of an integrated system, should still have a process in place to ensure that all patients who have recently given birth have the opportunity to be screened for postpartum depression. Practices are not required to achieve a minimum percentage threshold to meet this factor; therefore, practices may focus on completing postpartum depression screening for patients who have not been screened in another setting, e.g. an OB/GYN appointment.

This applies to the following Programs and Years:

Yes. A care manager may be shared and rotate between affiliated practice sites, as long as the care manager is integrated into the practice’s care team(s) and workflows for providing team-based care. 

This applies to the following Programs and Years:

Yes. A practice may satisfy criterion PP 02 by having a prescribing clinician who is accessible through telehealth,  provided that the clinician is integrated into the practice’s workflow for MAT (e.g., can exchange patient information with the practice site, as appropriate).

This applies to the following Programs and Years: