FAQ Directory

Here are some of the most frequently asked questions about NCQA’s various programs. If you don’t see what you are looking for in one of the entries below, you can  ask a question through My NCQA.

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8.04.2016 Updated: Documentation for structural requirements when delegating to an NCQA-Accredited health plan What are the documentation requirements for a health plan delegating a structural requirement to an NCQA-Accredited health plan?

Organizations that delegate the following structural requirements to an NCQA-Accredited health plan are eligible to receive automatic credit, as stated in Appendix 5, Table 2, if they meet the criteria for automatic credit. The organization does not need to provide its own documentation.

·    QI 4, Element B: Behavioral Healthcare Telephone Access Standards.

·    QI 5, Element F: Case Management Process.

·    NET 1, Element B: Practitioners Providing Primary Care, factors 1 and 2.

·    NET 1, Element C: Practitioners Providing Specialty Care, factors 1–4.

·    NET 1, Element D: Practitioners Providing Behavioral Healthcare, factors 1–3.

·    NET 2, Element A: Access to Primary Care. 

·    NET 2, Element B: Access to Behavioral Healthcare.

 

8.04.2016 Updated: Documentation for structural requirements when delegating to an NCQA-Accredited MBHO What are the documentation requirements for a health plan delegating a structural requirement to an NCQA-Accredited MBHO?

Health plans that delegate the following structural requirements to an NCQA-Accredited MBHO are eligible to receive automatic credit, as stated in Appendix 5, Table 3 (this is Appendix 3, Table 21 in the MBHO standards and guidelines), if they meet the criteria for automatic credit. The organization does not need to provide its own documentation.

  • QI 1, Element A: Program Structure, factor 2 (MBHO QI 1, Element A, factor 3).
  • QI 4, Element B: Behavioral Healthcare Telephone Access Standards (MBHO QI 5, Element B).
  • NET 1, Element D: Practitioners Providing Behavioral Healthcare, factors 1–3 (MBHO QI 4, Element B, factors 1–3).
  • NET 2, Element B: Access to Behavioral Healthcare, factors 1–3 (MBHO QI 5, Element A, factors 1 and 2).
  • UM 1, Element A: Utilization Management Structure, factors 2 and 4 (MBHO UM 1, Element A, factors 1 and 2).
  • UM 1, Element C: Behavioral Healthcare Practitioner Involvement (UM 1, Elements A and B).

 
1MBHO equivalent standard/element is in parentheses.

7.15.2016 Standardized Healthcare-Associated Infection Ratio Will NCQA post an example HAI Standardized Infection Ratio (SIR) table to be used when reporting the Hospital Acquired Infection (HAI) measure?

6.15.2016 Collecting data by practitioner prescribers and non-prescribers Must an organization collect access data by practitioners who prescribe and those who do not prescribe to meet all factors in NET 2, Element B?

Yes. This was a change from the 2015 Standards and Guidelines. Organizations must collect and analyze access data for behavioral healthcare practitioners who prescribe and who do not prescribe, for all factors in the element.

5.20.2016 UM 4, Element H File Review and Medical Necessity Denials Are medical necessity denials included in the UM 4, Element H file review?

No. If an organization inadvertently includes a medical necessity denial in the UM 4H benefit denial file review, NCQA verifies that the file is appropriately classified as a medical necessity denial. If so, NCQA scores the file NA. If not, NCQA reviews the files under the benefit denial requirements of UM 4H.
 

UM-CR 2016

5.20.2016 UM 4, Element H File Review Does UM 4, Element H file review include benefit denials that resulted from the UM medical necessity review process?

Yes. If an organization inadvertently includes a benefit denial in the UM 4–UM 7 medical necessity denial file reviews, NCQA verifies that the file is appropriately classified as a benefit denial. If so, NCQA scores the file NA. If not, NCQA reviews the files under the medical necessity denial requirements of UM 4–UM 7.

UM-CR 2016

4.15.2016 Exchange Benchmarking Data We are looking for external benchmarks for Exchange results. When will they be available?

NCQA collects clinical data for the Quality Rating System (QRS) under contract for CMS, but does not collect or report Exchange data for any other purpose.

Published CMS guidance (https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/Downloads/2019-QRS-and-QHP-Enrollee-Survey-Technical-Guidance_FINAL_20181016_508.pdf) states (page 19, Section 8, Quality Rating Information Preview Process), “The proof sheets will include benchmark information for measure results and an associated definition/rationale for any invalid/non-numeric results (e.g., NR).”

You can e-mail the Exchange Operations Support Center Help Desk at CMS_FEPS@cms.hhs.gov or phone 855-267-1515 if you have questions about benchmarks for Exchange QRS data. Reference “Exhange Quality Initiatives (MQI)-QRS” in the subject line.

Exchange 2016

4.15.2016 State restrictions on information provided to prospective members and RR 5 If an organization can provide only certain information to prospective members, due to regulatory restrictions, and that information does not cover some requirements in RR 5, how does NCQA score the unmet requirements?

NCQA holds the organization harmless (scores the impacted requirement NA) if restrictions prevent it from meeting NCQA requirements. The organization must provide documentation of the regulatory restriction.

4.15.2016 Organization-level timeliness reports Is a corporate level report acceptable for UM 5, Element G?

No. Reports on timeliness of UM decision making may not be at the corporate level. Reports must be at the accreditable-entity level.

4.15.2016 Product line requirement for QI 4, Element E What evidence must organizations present to meet QI 4E?

For factor 1, organizations present a report of complaints and appeals by product line.
For factor 2, organizations present a report showing member experience results by product line. Organizations are not required to conduct a separate survey for each product line brought forward. If organizations conduct one behavioral healthcare survey across all product lines, results must be presented by product line, even if response rates are low.

4.15.2016 Off-label medication use denials in UM 4H Are denials for “off-label” medication use included in the file review for UM 4, Element H (UM 4F in UM-CR and MBHO)?

Yes. Denials for off-label medication use are included in the scope of UM 4, Element H (UM 4F in UM-CR and MBHO) if the organization covers medications only for “on-label” use.

UM-CR 2016

4.15.2016 Experimental/investigational procedure denials in UM 4H Are denials of requests for experimental or investigational procedures included in the file review for UM 4, Element H (UM 4F in UM-CR and MBHO)?

Yes. If an experimental or investigational procedure is explicitly excluded from the benefits or medical policy, this is a benefit denial and is included in the scope of UM 4, Element H (UM 4F in UM-CR and MBHO).

UM-CR 2016