FAQ Directory

No. A third paragraph should have been added that reads, “For factor 2, NCQA reviews a documented process, reports or materials, depending on the action taken to address identified opportunities.”
 
The update was intended to give organizations the option of presenting its updated policies and procedures, materials or a report showing revisions, if the intervention was revision of policies and procedures or materials.
 
NCQA will correct the scope of review for both elements in the November release of the NCQA Corrections, Clarifications and Policy Changes to the 2016 HP Standards.
 
 

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years:

Yes. NCQA posted an example HAI SIR table to the HEDIS 2017 Web site at http://www.ncqa.org/hedis-quality-measurement/hedis-measures/hedis-2017. The final HAI SIR table (Table HSIR) will be posted to the NCQA Web site by January 2, 2017.

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years:

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.
 

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years:

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

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years:

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years: