FAQ Directory: Case Management

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8.20.2018 What is Case Management Accreditation?

NCQA Case Management Accreditation is a comprehensive, evidence-based program dedicated to quality improvement that evaluates the operations of case management programs in provider, payer or community-based organizations. NCQA-Accredited organizations demonstrate they have the internal processes and service delivery structure to cost-effectively meet the complex patient needs to improve health or functional capability.

CM 2013

8.20.2018 How does Case Management Accreditation help my organization?

Use the NCQA Case Management Accreditation standards to perform a gap analysis and determine improvement areas. They provide a framework for implementing evidence-based best practices to ensure:

  • Efficient and cost-effective case management processes and service delivery.
  • Apply a QI process to improve operations.
  • Maintain security of personal health information.
  • Ensure patient access to well-qualified case management staff.
  • Develop personalized, patient-centered care plans.
  • Manage patients between care settings.
  • Conduct systematic patient-centered assessments.
  • Monitor patient to care goals progress.

CM 2013

8.20.2018 How do I get started?

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 2014

8.20.2018 Where can I find the Case Management Standards and Guidelines?

8.20.2018 What is the price for Case Management Accreditation?

Pricing is based on multiple factors. Obtain full pricing information by submitting a request through My NCQA.

CM 2014

8.20.2018 How long does it take to earn Case Management Accreditation?

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 2014

2.15.2017 Effective date for Case Management Accreditation 2017 and Termination date of Case Management Accreditation 2014 When will the 2017 CM standards be effective and when will the 2014 CM standards year end?

The 2017 CM standards are effective on or after January 30, 2017. For organizations that have already scheduled a survey through June 30, the 2014 CM standards year will end on June 30, 2017. 

CM 2014

5.01.2015 Reporting Regulatory Actions Are health plans required to report regulatory actions taken against the organization?

Yes. The Agreement for Health Plan Accreditation Survey (the “Agreement”), specified in the “Organization’s obligations” section of the standards and guidelines, requires the organization to provide NCQA written notice within thirty (30) calendar days of the final determination by a state or federal agency with respect to request for corrective action, imposition of sanctions, changes in licensure or qualification status, if applicable, or violation of any federal or state law that affects the Scope of Review under the Standards and Guidelines. These are termed Reportable Events.

CM 2013

5.01.2015 Notifying NCQA of Reportable Events How and when must the organization notify NCQA of Reportable Events?

The organization must notify NCQA, in writing, within thirty (30) calendar days of the issuance of the notice of sanctions, issuance of a fine or issuance of a request for corrective action. 

The organization must also complete an annual attestation signed by an officer, or other authorized signatory of the organization, affirming that it has notified NCQA of all Reportable Events specified within the Agreement. NCQA-accredited health plans that reports HEDIS results include the attestation with its submission of the annual IDSS attestation submission for HEDIS® reporting.  Other health plans submit the completed attestation electronically to NCQA-Accreditation@ncqa.org. 

CM 2013

5.01.2015 Specific Regulatory Actions to be Reported What specific regulatory actions must be reported?

The organization must report the occurrence of any of the following actions by any federal or state regulatory authority:

  • Issuance of Intermediate Sanctions and/or suspension of enrollment by CMS or any other federal or state regulatory authority.
  • Issuance of any fine equal to or exceeding $50,000 related to Organization’s operations by CMS or any other federal or state regulatory authority.
  • Issuance of any request for a corrective action by any federal or state regulatory authority where the substance of such corrective action relates to the Organization’s handling of utilization management decisions, network adequacy, benefit denials, complaints, grievances, appeals or other important patient safety matters. 

The above actions are referred to as the “final determination” within the Agreement.

CM 2010

11.15.2012 Eligibility for Case Management (CM) What organizations are eligible to pursue Case Management Accreditation?

NCQA considers entities that perform relevant functions to be eligible for NCQA CM Accreditation, including, but not limited to: CM organizations, population health management organizations, health plans (HP), managed behavioral healthcare organizations (MBHO), provider-based organizations– including medical groups, hospitals, integrated delivery systems, patient-centered medical homes (PCMH) and accountable care organizations (ACO), community care teams.

CM 2014

11.15.2012 Applicable factors for CM program If some factors are not applicable for our case management program, how would we address it to meet the requirements in CM 2, Element E: Initial Assessment?

For CM 2, Element E, which is a file review element, NCQA is looking for documentation of whether or not you completed the applicable activities listed in CM 2, Element D: Initial Assessment Process. For your program, you would note in your documentation that certain factors are not applicable for that particular patient population.

CM 2014