FAQ Directory

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, 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 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. 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:

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:

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 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:

Use of flow sheets, demonstration of EHR prompts or other evidence of guideline implementation with which the provider is alerted when a specific service or action is needed at the point of care, based on evidence-based guidelines, would meet the intent of PP 12. In addition to the evidence, practices must also provide information on the condition addressed by the clinical decision support and the source of the evidence-based guideline on which the clinical decision support is based.

Flow charts, copies of guidelines or empty templates do not demonstrate implementation of clinical decision support. These items show the guideline, but do not demonstrate its use at the point of care.

This applies to the following Programs and Years:

Yes. Use of PHQ-2/PHQ-9 meets the requirement if practices demonstrate its use in monitoring depression treatment and provide an example of the tool’s implementation in clinical care and decision making at the point of care. The intent of KM 20 A is to implement clinical decision support during treatment, not for screening or diagnosis of a mental health condition. Practices that use an evidence-based tool built into the EHR or as part of a workflow in accordance with clinical guidelines can meet the requirements if they demonstrate the guideline and an example of the guidelines implementation (i.e., the tool’s use).

This applies to the following Programs and Years:

NCQA is not prescriptive regarding which depression screening tool is used as long as it’s a standardized tool. Some depression screening tool examples that would be appropriate for adolescents include but are not limited to PHQ2, PHQ9, PHQ-A, PSC, PSC-Y, RAAPS, or HEADSS. 

This applies to the following Programs and Years:

The U.S. Preventive Services Task Force (USPSTF) states that adults and adolescents should be screened for depression when a practice has access to services that can be used for follow-up, if there is a positive result (i.e., mental health providers within the practice or external to the practice to whom the practice can refer patients). To meet KM 03, practices are expected to have an approach to follow up and act on results.

This applies to the following Programs and Years:

The intent of PP 08 is for the practice to implement universal screening for depression based on guidelines, so all adult and adolescent patients must be included. The practice should have a process to routinely screen patients and the frequency at which the screening is conducted should be based on evidence-based guidelines. The documented process should also include what follow-up occurs for positive screens.

This applies to the following Programs and Years: