FAQ Directory: Health Plan Accreditation

An organization will receive Provisional status if it:  
 

1. Scores below 80% and above 55% of the maximum possible points in any Standards Category, or  

2. Does not achieve an element score of “Met” in three or more must-pass elements.

HP 2020

No. For ME 2, Element A, only the distribution component of the requirement is considered a vendor relationship. 

As stated in the explanation, these elements may not be delegated. The organization must create the written information, but may distribute it through a mail vendor.

HP 2021

No. PHM 6, Element B applies only to Renewal Surveys. First Surveys are not required to meet this element and will receive an NA for 2020.

HP 2020

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

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

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

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

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

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

Yes. Distributing the rights and responsibilities statement to all members and practitioners (new upon enrollment and annually to existing) is acceptable, because it is consistent with prior years' and exceeds the standards effective July 1, 2020. Factors 2 and 4 will be scored yes; organizations are not required to track requests for existing members and practitioners during the look-back period.

HP 2020

For elements that are reviewed and scored by product line, NCQA expects to see evidence or documentation for each product line. Each product line is scored separately.

For reports, it is acceptable to have one document if the data or analysis for each product line is clearly separated within the document. If a single documented process or policy and procedure applies to multiple product lines, the documented process must state the product lines to which it applies. For materials, if a single document applies to more than one product line, the organization must demonstrate this.
For elements that are not designated to be reviewed and scored by product line, NCQA reviews one document for the element if the product lines are managed the same. Documentation must demonstrate that it applies to all product lines included in the survey (e.g., data and analysis may be combined for a report, but it must be clear that they represent all included product lines).

Evidence in documentation does not need to be separated by product lines; all product lines receive the same score. However, if product lines are managed differently, the element is treated as if it was designated to be reviewed and scored by product line, as described above.

HP 2020

NCQA includes external entities that store, create, modify or use UM data for any function covered by the UM standards on behalf of the organization in the scope of Elements A and B, factor 6, with the exception of organizations whose only UM service provided for  the organization is to provide cloud-based data storage functions and not services that create, modify or use UM data.

HP 2020