No. The internal appeal notification must be sent to the member.
The UM 9, Element D stem incorrectly states that both the member and the treating practitioner must be notified. This will be corrected in November’s Policy Updates.
HP 2022
FAQ Directory: Health Plan Accreditation
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9.15.2021 Notification of Internal Appeal to Member or Treating Practitioner Must an internal appeal notification be sent to both the member and the treating practitioner?
7.15.2021 Virtual-Only Practitioners If an organization wants to add virtual-only practitioners to its network for services such as behavioral health, does that affect NET 5 and CR 1?
Yes. If an organization adds virtual-only practitioners to its network, the provider directory must indicate that such practitioners are virtual only (i.e., in lieu of a physical office location) to meet NET 5, Element A. Virtual-only practitioners must also be fully credentialed, per requirements in CR 1, Element A.
HP 2021
7.15.2021 Use of Mail Service Organizations for Distribution Requirements Is it considered delegation if an organization uses a mail service organization to meet distribution requirements?
NCQA considers it to be delegation if the organization uses another organization, including a mail service organization, to perform any function not listed in the “Vendor” section of Appendix 2.
NCQA considers it to be a vendor relationship if the organization uses another organization (e.g., a mail service organization) to perform functions evaluated by the elements or element components listed in the "Vendor" section of Appendix 2.
HP 2021
4.15.2021 Vendor Relationship: ME 2, Element A Are all the requirements in ME 2, Element A considered a vendor relationship if the organization utilizes a mail vendor for distribution?
4.15.2021 Provisional Status Triggers In what circumstances will an organization receive Provisional status?
4.15.2021 Evaluation Options for PHM 6, Element B Does PHM 6, Element B apply to First Surveys?
12.15.2020 Corrective Action Process What is the corrective action process for organizations that do not meet a must-pass element?
A Corrective Action Plan (CAP) is required when an organization does not meet the minimum threshold for one or more must-pass elements. The CAP must be submitted to NCQA within 30 days after receipt of the final Accreditation status and must meet NCQA approval. The organization undergoes a CAP Survey that focuses on the failed must-pass elements (not at the factor level), i.e., all element factors, will be reviewed in addition to the factor(s) that failed the must-pass requirement.
NCQA schedules the CAP Survey for submission 6 months following the organization’s last full survey; the file review is 4 weeks later. The organization’s Accreditation status is noted “Under Corrective Action” status modifier noted on the report card during the corrective action period.
The fees for the CAP Survey can be found in the Pricing Exhibit on My NCQA. The look-back period is from the date of implementation of the corrective action up to the CAP Survey submission date and may be between 3 and 6 months before the CAP Survey submission.
After successful completion of the CAP Survey, the status modifier is removed from the organization’s status on the report card. The expiration date of the Accreditation status remains the same as the date specified in the decision that precipitated the CAP Survey. If a CAP Survey is unsuccessful, the Review Oversight Committee (ROC) may:
- Extend the CAP status modifier, or
- Reduce the organization’s status from Accredited to Provisional or from Provisional to Denied, or
- Issue a Denied Accreditation status.
HP 2019
10.15.2020 Inclusion of Dental and Vision Denials and Appeals for UM File Review Should denials and appeals for dental and vision requests be included in the UM denial and appeal file review universes?
For all product lines, dental and vision requests covered under the organization's medical benefit are within the scope of medical necessity review and must be included for UM file review for denials (UM 4-7) and appeals (UM 9), as outlined in the file review instructions.
Dental and vision requests not covered under medical benefits are not within the scope of denial and appeal file review.
HP 2020
8.15.2020 CR 7: Organizational Providers NCQA added language to CR 7 in the 2020 Health Plan Accreditation standards to clarify that Element A applies to all organizational providers (e.g., telemedicine providers, urgent care centers). What does NCQA mean by “all organizational providers”?
NCQA added the word “all” to CR 7 in the 2020 HPA standards and guidelines because it expects organizations to have policies for assessing all providers with which they contract. However, under the 2020 standards and in previous years, NCQA only scores policies for providers listed in CR 7, Elements B and C.
Because the definition may not be sufficient to clearly identify which organizations NCQA considers “providers,” here is a list of provider types in addition to those listed in Elements B and C:
- Telemedicine providers.
- Urgent care centers.
- Hospice.
- Clinical labs.
- Comprehensive outpatient rehabilitation facilities.
- Outpatient physical therapy.
- Speech pathology providers.
- End-stage renal disease services.
- Outpatient diabetes self-management training.
- Portable x-ray suppliers.
- Rural health clinics.
- Federally qualified health centers.
HP 2020
7.15.2020 Updated: UM 12- Outsourcing Storage of Utilization Management Data To External Entities How many contracts does NCQA review for Elements A and B, factor 6 if an organization outsources UM data to external entities?
If an organization contracts with external entities to store its own UM data or contracts with UM delegates that store data, NCQA also reviews contracts from up to four randomly selected external entities, or reviews all external entities if the organization has fewer than four. If factor 6 is not addressed in a contract, the organization may also present the external entity’s policies and procedures for review. NCQA reviews documentation from the organization and from each external entity against the factor. To be scored “yes,” the organization's and each external entity’s documentation must meet the factor.
Note: The underlined text is an update to the FAQ posted on June 15, 2020. Refer also to the FAQ on the same date regarding cloud storage entities.
HP 2020
7.15.2020 Updated: CR 1, Element C- Outsourcing Storage of Credentialing Data To External Entities How many contracts does NCQA review for Element C, factor 4 if an organization outsources credentialing data to external entities?
If an organization contracts with external entities to store its own credentialing data or contracts with CR delegates that store data, NCQA also reviews contracts from up to four randomly selected external entities, or reviews all external entities if the organization has fewer than four. If factor 4 is not addressed in a contract, the organization may also present the external entity’s policies and procedures for review. NCQA reviews documentation from the organization and from each external entity against the factor. To be scored “yes,” the organization's and each external entity’s documentation must meet the factor.
Note: The underlined text is an update to the FAQ posted on June 15, 2020. Refer also to the FAQ on the same date regarding cloud storage entities.
HP 2020
7.15.2020 Qualitative Analysis If quantitative analysis demonstrates that the organization met its goal or benchmark, must it perform qualitative analysis?
It depends. For initial measurement, the organization conducts quantitative and qualitative analysis of data.
For remeasurement, the organization conducts quantitative analysis and also conducts qualitative analysis if quantitative analysis demonstrates that stated goals were not met.
HP 2020