FAQ Directory

The PCMH PRIME Certification program launched on January 1, 2016.

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:

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:

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

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:

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:

Yes, this criterion may be met through tele-behavioral health services if the behavioral health care provider has at least partial access to the practice’s systems. To meet this criterion through tele-behavioral health, the off-site BH provider must provide BH treatment to patients. Remote coordination of behavioral health needs is not sufficient to meet this criterion.

This applies to the following Programs and Years:

The PCMH PRIME Standards and Guidelines include a list of qualifying behavioral health providers for these criteria under PP 03 guidance.  To satisfy criteria PP 03 and PP 04, practices must coordinate with or integrate with providers that provide behavioral health treatment to patients. Staff that only identify and coordinate behavioral health needs and do not treat patients are not sufficient for these factors, but may be used to meet criterion PP 01.

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:

The intent of the requirement is that the denial or appeal notice be written in language that can be easily understood by members. Because abbreviations/acronyms may include terms that are not easily understood, even when spelled out, they must be explained. NCQA is updating the explanation under each applicable factor of the referenced elements to read:

NCQA will post an update in December for the 2018 and 2019 HP and UM-CR-PN and 2018 MBHO publications to reflect this change.

This applies to the following Programs and Years: