FAQ Directory: Health Plan Accreditation

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5.15.2020 UM 12: Outsourcing Storage of Utilization Management Data To External Entities How many contracts does NCQA review 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 reviews contracts and documentation from up to four randomly selected external entities, or reviews all external entities if the organization has fewer than four. The score for the element is the average of the scores for all external entities.

HP 2020

5.15.2020 UM 5: Medicaid lookback period For Renewal Surveys, the look-back period is specified as 6 months for the Medicaid product line in UM 5, Elements A-C. Is this correct?

No. The look-back period should be specified as 12 months for all product lines, for Renewal Surveys, which is consistent with the other file review standards and elements. NCQA initially changed the scope of review to account for a change made to verbal notification and how it no longer affords organizations an extension.

However, because of this error, if an organization does not meet a factor in UM 5, Elements A-C within the first 6 months of the look-back period, NCQA does not penalize the organization and scores the file “NA” instead of “Not Met” for Medicaid surveys.

HP 2020

5.15.2020 CR 1, Element C: Outsourcing Storage of Credentialing Data To External Entities How many contracts does NCQA review if an organization outsources storage of 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 reviews contracts and documentation from up to four randomly selected external entities, or reviews all external entities if the organization has fewer than four. The score for the element is the average of the scores for all external entities.

HP 2020

4.15.2020 LTSS 1, Element G: HEDIS Measure The November 2019 Policy Update change to LTSS 1, Element G specifies that the Comprehensive Assessment and Update (LTSS-CAU) measure may be used instead of completing the file review. Is this correct?

No. Replace “LTSS-CAU” with “LTSS-CPU“ (Comprehensive Care Plan and Update). Performance results of LTSS-CPU may be used instead of completing the file review.

HP 2020

4.15.2020 Update: Practitioner Involvement and Adoption of UM Criteria For UM 2, Element A, factor 4, when an organization develops or adopts UM criteria, may it limit involvement of practitioners to practitioners who are organization staff, even if they are also network practitioners?

The answer posted in March 2020 unintentionally increased the rigor of the requirement for the 2020 standards year. Therefore, we are updating the answer.
For the 2020 standards year, organizations may limit involvement to practitioners who are staff or participants in the network; NCQA does not require non-staff network practitioners to be involved.

Effective for the 2021 standards year, organizations may not limit involvement to practitioners who are staff. Non-staff network practitioners must also be involved in developing, adopting and reviewing criteria, because they are subject to application of the criteria. If an organization has been unable to involve network practitioners, it must document its attempts and provide the documentation to NCQA during the survey.

This change will be released in the 2021 standards and guidelines.

HP 2020

4.15.2020 Distribution of Rights and Responsibility to Existing Members and Practitioners Does distributing the members rights and responsibilities statement to all members and practitioners, whether requested or not, meet the intent of ME 1, Element B, factors 2 and 4 (RR 1, Element B, factors 2 and 4 in MBHO)?

Yes. Distributing the rights and responsibilities statement to all members and practitioners (new and existing) is acceptable. 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

3.26.2020 Guidance and Exceptions to NCQA Programs Regarding Coronavirus Has NCQA issued guidance about exceptions or modifications to NCQA programs and requirements in response to the coronavirus?

Yes. NCQA posted guidance for HEDIS reporting and Accreditation/Recognition programs at https://www.ncqa.org/covid/. NCQA is monitoring the effects of the coronavirus on our customers; we will adjust requirements as circumstances warrant. Please continue to check this website frequently as the situation continues to evolve.

 

HP 2019

3.15.2020 Clarifying HPA 2020 Scoring with File Review Scoring Question Please explain “PARTIALLY MET” for scoring that reads “High (90-100%) or medium (60-89%) on file review for X factors” in file review elements (e.g., PHM 5, Element D)?

Interpret that text to mean any combination of high and medium other than the scoring thresholds specified for “MET.”
For example, an organization must earn “high” on 7 factors to score MET on PHM 5, Element D; therefore, to score “PARTIALLY MET” for that element, it may earn “high” on 0–6 factors and “medium” on the remaining factors.

HP 2020

3.15.2020 36-month Recredentialing time frame Does NCQA allow an organization to extend the 36-month recredentialing time frame if it failed to credential a practitioner on time?

No. Except as noted under “Related information: Extending the recredentialing cycle length,” where NCQA makes provisions for situations such as active duty military assignment and medical leave, the organization may not extend the 36-month recredentialing cycle. If the practitioner is not recredentialed within 36 months, the file will be scored down. There is no grace period for recredentialing.
If an organization missed the recredentialing deadline and intends to keep the practitioner in the network, files must be processed as follows:

  • If the organization can complete the credentialing process within 30 days of the original due date, it may recredential the practitioner (e.g., the organization need not verify credentials required only at initial credentialing). The organization must complete the process and make the credentialing decision within 30 days of the original credentialing due date.
  • If the organization cannot complete the credentialing process within 30 calendar days of the original recredentialing due date, it must take the practitioner through the initial credentialing process.

HP 2019

3.15.2020 PHM 3, Element B: Value Based Payment Arrangements Does NCQA require organizations to have more than one type (e.g., pay-for-performance, shared savings) of value-based payment arrangement per product line?

No. An organization meets the requirement if it has at least one VBP of any type per product line. Organizations may report more than one VBP arrangement per product line but are not required to do so.

HP 2020

3.15.2020 Using Complaint Data to Supplement Surveys or Self-Reported Information In NET 2, Elements A–C, if an organization collects data using surveys or practitioner self-reported information, it must supplement the data with an analysis of complaints regarding access. Are organizations required to conduct a complete quantitative and qualitative analysis of complaint data?

No. Supplemental complaint data validates survey findings and self-reported information and assists in qualitative analysis of primary data. The organization is not required to conduct complete quantitative and qualitative analysis of supplemental data.

HP 2020

3.15.2020 PHM 3, Element A, Factor 3: Practice transformation support Does reporting a physician’s designation or status as “integrated or advanced” practice in a web-based physician directory meet the requirement to support practice transformation?

No. Publicly reporting a practice’s designation or status does not constitute “active support.” Organizations may actively support transformation through financial incentives, learning collaboratives, MOC credits and other methods.

HP 2020