FAQ Directory: Case Management

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12.15.2019 Excluding organization employees and their dependents from complex case management (CCM) file review Should organizations exclude employees and their dependents from the CCM file review universe?

Yes. Employees and their dependents are excluded from the CCM file review universe.

CM 2019

10.15.2019 PHM 5: Assessment and Evaluation Does a combined summary of all factors in the assessment meet the requirement for documenting the conclusion of the initial assessment for PHM 5, Elements D and E?

Yes. Assessment and evaluation each require a case manager or a qualified individual to draw and document a conclusion about the data or information collected. Raw data or answers to questions do not meet the requirement; there must be a documented summary of the meaning or implications to the member’s situation, so data can be used in the case management plan.
The organization must draw a conclusion for each factor (unless otherwise stated in the explanation). This may be in separate summaries for each factor or in a combined summary, or in a combination of these.

CM 2019

3.15.2019 LTSS 4, Element C: Analysis of Unplanned transitions The explanation for LTSS 4, Element C, factor 1 states that analysis includes patterns of unplanned admissions, readmissions, emergency room visits and repeat visits, and admission to participating and nonparticipating facilities.
Is the organization required to include all these areas to meet the intent of the factor?

No. The organization is not required to include all these areas in its analysis, but at a minimum, must evaluate rates of unplanned admissions to facilities and emergency room visits to identify areas for improvement.

CM 2019

9.15.2018 Life-planning activities for Complex Case Management (CCM) Policies and Assessment Are organizations required to address life-planning activities at the first contact and start of the CCM initial assessment?

No. After consideration, NCQA removed the requirement for case managers to address life-planning activities at the start of the initial assessment (first contact). This FAQ replaces the previous FAQ issued on October 15, 2017 (which has been deleted) regarding first contact, and the workbook has been adjusted to accommodate the change.

CM 2019

9.15.2018 Terminated arrangements more than 90 calendar days before submission (CM and CMLTSS 2017) If an organization terminated an arrangement with an NCQA-Accredited/Certified/Recognized delegate more than 90 calendar days before it submitted the completed survey tool, is the organization eligible for automatic credit for the portion of the look-back period when activities were performed by the delegate?

Yes. For non-file review requirements, if the arrangement was terminated more than 90 calendar days before submission of the completed survey tool, the organization is eligible for automatic credit for the portion of the look-back period when the NCQA-Accredited/ Certified/Recognized delegate conducted activities. For file review requirements, automatic credit is applied if the delegate processed (or handled) the file, regardless of when the delegation arrangement was terminated.

CM 2017

8.24.2018 How long does it take to earn LTSS Distinction for Case Management Organizations?

The typical evaluation time frame is 12 months from application submission to decision, depending on an organization’s readiness. Some organizations may already be working within NCQA guidelines.

CM 2017

8.24.2018 How do I get started with LTSS Distinction for Case Management Organizations?

If you are not currently accredited and want to learn more, contact NCQA. If you are currently accredited and want to talk to someone about your status or about renewing or adding accreditations, submit a question through My NCQA.

CM 2017

8.24.2018 What organizations are eligible for the LTSS Distinction?

8.24.2018 What other case management organizations have earned LTSS Distinction?

8.24.2018 Where can I find the LTSS Distinction for Case Management Organizations Standards and Guidelines?

8.24.2018 What is the process for earning LTSS Distinction for Case Management Organizations?

The first step to earning distinction is a discussion with an NCQA program expert. Purchase and review the program resources, conduct a gap analysis and submit your online application.

Align your organization’s processes with the standards. NCQA conducts the survey and determines your distinction status within 30 days of the final review.

See a step-by-step process.

CM 2017

8.24.2018 What is Long-term Services and Supports Distinction for Case Management Organizations?

NCQA LTSS Distinction for Case Management Organizations is a complementary program designed to support organizations that provide comprehensive clinical case management services and coordinate social services for LTSS populations. The program standards provide a framework for organizations to deliver efficient, effective person-centered care that meets people’s needs, helps keep people in their preferred setting and aligns with state requirements.

CM 2017