FAQ Directory: Health Plan Accreditation

Terminated arrangements more than 90 calendar days before submission

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.

Mutually Agreed-Upon Dates in the Delegation Contract

NCQA considers the implementation date as the date when the delegate can start performing delegated activities. But because the organization and delegate may have mutually agreed on and implemented delegated activities before signing the delegation agreement, NCQA is changing the policy for evidence of the implementation date.

When reviewing a delegation agreement, NCQA will consider the effective date or start date specified in the agreement as the mutually agreed-upon implementation date, for Element A (of the delegation standards), factor 1. This date may be before or after the signature date on the delegation agreement. If the agreement does not contain an effective date/start date, NCQA considers the date when the agreement was signed as the mutually agreed-upon implementation date.

NCQA may also accept other evidence of the implementation date: a letter, meeting minutes or other form of communication between the organization and the delegate that references their agreement on the delegated activity start date.

If an organization references the effective date/start date of the delegation agreement as the implementation date, NCQA will require submitted evidence for all other delegation factors to conform to that date as the implementation date.

The language in the explanation will be updated in a future Policy Update for applicable 2019 publications.

Where can I find the Medicaid Module Standards and Guidelines?

Submit your request for the 2018 Medicaid Module at My NCQA.

Appeals covered in QI 4, Element C

QI 4 requires organizations to collect data from all sources of member complaints and appeals. This includes UM coverage appeals addressed in UM 8-UM 9 and noncoverage appeals addressed in RR 2.
 

Note: Data collected and analyzed prior to December 15, 2017,will be accepted as meeting the requirement, even if not all types of appeals are included. Data collected and analyzed on or after this date must comply with the requirement stated in the FAQ.

If your organization collected and analyzed data prior to December 15, 2017, and interpreted the requirement as applying to only one type of appeal, notify the surveyor at the start of the survey so the misinterpretation does not affect scoring.

80% must-pass threshold for UM elements

No. To keep scoring simple, NCQA set a threshold of 80% or higher for all UM must-pass elements, rather than setting a specific threshold for each element based on its scoring options. If an element does not have an 80% option, the “or higher” applies. Keep in mind that an organization may miss the requirements for a few files and still score 100% on the element. For additional information on file review scoring, refer to the scoring table in each element or to the file review worksheet in the Interactive Review Tool (IRT).

Revised Look-back Period for UM 7, Elements C, F, I (factors 2 and 3)

The intent of the added language in factors 2 and 3 was to clarify the minimum information required for expedited appeals. NCQA recognizes these are new requirements, and for this reason, has added the following language to the scope of review:

Organizations must implement the changes in factors 2 and 3 for files processed on or after 11/1/18.

NCQA will post an update in December for the 2019 HP publication to reflect this change.

Level of Analysis Required for Appointment Accessibility

No. NCQA does not require the analysis to be stratified by practitioner type.

Data collection for prevention programs for behavioral healthcare for QI 6, Element A, factor 5

No. Element A does not require organizations to implement a preventive behavioral healthcare program. The intent of factor 5 is that organizations collect data to determine if there are behavioral health issues that could be prevented if a program were to be implemented. Organizations collect data to meet Element A. Identifying the opportunity for such a program and implementing it is applicable to Element B.

Updated: Use of Acronyms in UM Denial and Appeal Notices

The intent of the requirement is that the denial or appeal notice be written in language that can be easily understood by members. Because abbreviations/acronyms may include terms that are not easily understood, even when spelled out, they must be explained. NCQA is updating the explanation under each applicable factor of the referenced elements to read:

NCQA will post an update in December for the 2018 and 2019 HP and UM-CR-PN and 2018 MBHO publications to reflect this change.

Life-planning activities for Complex Case Management (CCM) Policies and 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.

NCQA Health Plan Medicaid Module is a complementary program designed to support NCQA-Accredited health plans with a Medicaid product line. The combination of the module standards and NCQA Health Plan Accreditation maximize alignment with the Medicaid Managed Care program requirements. This improves a plan’s opportunity to receive a streamlined state compliance review.

NCQA developed the module by analyzing changes to state and federal requirements for the Medicaid Managed Care programs, as outlined in the Medicaid Managed Care Rule.

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.