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FAQ Directory: Health Plan Accreditation

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10.15.2019 CR 2, Element A, Factor 1 What is the required composition of the Credentialing Committee?

NCQA does not require a Credentialing Committee size, composition or quorum beyond that the committee must include practitioners who participate in the network.
Participating practitioners on the credentialing committee must be from a range of specialties or departments that represent the types of practitioners reviewed by the committee. For example, it would not be sufficient for only primary care practitioners to participate on the committee unless the network has only primary care practitioners.

HP 2020

10.15.2019 CR 7, Elements D and E: Assessing Medical and Behavioral Healthcare Providers Does NCQA require a separate tracking mechanism or report for each provider?

No. The organization must provide documentation of a tracking mechanism—or mechanisms (e.g., checklist or spreadsheet)—that encompass the required provider types

HP 2019

10.15.2019 PHM 5: Assessment and Evaluation Does a combined summary of all factors in the assessment meet the requirement for documenting the conclusion of the initial assessment for PHM 5, Elements D and E?

Yes. Assessment and evaluation each require a case manager or a qualified individual to draw and document a conclusion about the data or information collected. Raw data or answers to questions do not meet the requirement; there must be a documented summary of the meaning or implications to the member’s situation, so data can be used in the case management plan.
The organization must draw a conclusion for each factor (unless otherwise stated in the explanation). This may be in separate summaries for each factor or in a combined summary, or in a combination of these.

HP 2019

10.15.2019 2020 HEDIS measures for Accreditation Ratings Is there a resource that outlines the 2020 HPR methodology, including the list of HEDIS and CAHPS measures required for Accreditation?

The structure of Accreditation scoring is changing, beginning with Health Plan Accreditation 2020 and the 2020 HEDIS reporting year, when Accreditation and Health Plan Ratings will align. All organizations undergoing annual reevaluation in 2020 are included in the change to Ratings.
The links below provide information on the Health Plan Ratings, including the measures required for 2020 Accreditation.
Visit https://www.ncqa.org/wp-content/uploads/2019/07/20190731_2020_Health_Plan_Ratings_Methodology.pdf for information on the HPA Methodology document.
Visit https://www.ncqa.org/programs/health-plans/health-plan-accreditation-hpa/current-customers/hpa2020/scoring-updates/ for information on  scoring updates.
Visit https://www.ncqa.org/wp-content/uploads/2019/05/2020-HP-Accreditation_HEDIS-CAHPS-Measures.pdf for the link to the HEDIS and CAHPS measures list for 2020

HP 2020

10.15.2019 Telemedicine Practitioners and Organizations Telemedicine providers are included in the scope of organizational providers in CR 7, Element A, as well as within the scope of credentialing in CR 1–CR 6. If telemedicine practitioners are credentialed under CR 1–CR 6, are they (or the company arranging care they provide) subject to assessment of organizational providers under CR 7?

It depends. If telemedicine practitioners are credentialed under CR 1–CR 6, organizations are not required to also assess the telemedicine organization under CR 7, but if telemedicine practitioners are not credentialed under CR 1–CR 6, the telemedicine organization must be assessed under CR 7.
 

HP 2020

10.15.2019 Survey requirements for PHM 6, Elements A and B What does NCQA review in PHM 6, Elements A and B, for First Surveys and Renewal Surveys?

For Element A

  • For First Surveys, NCQA reviews the organization’s plan for annual comprehensive analysis of its PHM strategy impact or the organization’s most recent annual comprehensive analysis of its PHM strategy impact.
  • For Renewal Surveys, NCQA reviews the organization’s most recent annual comprehensive analysis of its PHM strategy impact.

For Element B

  • Element B is NA for First Surveys.
  • For Renewal Surveys, NCQA reviews the organization’s most recent annual comprehensive analysis of its PHM strategy impact.

NCQA will clarify these requirements in the November Policy Update. 

HP 2020

8.15.2019 Scoring UM 5 Timeliness Requirements The UM 5, Elements A, C, E timeliness requirements were retired in 2020 Health Plan Accreditation. These requirements will be scored NA in HPA 2019. Does that mean that the “Explanation” and the “Related information” sections of these elements regarding notifications no longer apply to UM 5, Elements B, D and F?

No. The “Explanation” and the “Related information” sections of UM 5, Elements A, C and E still apply to UM 5, Elements B, D and F, respectively. All applicable information was moved to the relevant elements for HPA 2020.

HP 2019

8.15.2019 Documentation for ME 5, Element C and ME 6, Element C Will NCQA review an organization’s policies and procedures for ME 5, Element C and ME 6, Element C?

For ME 5, Element C, NCQA reviews the organization’s data collection methodology. This may be in policies and procedures or described as part of the organization’s reports. NCQA also reviews the organization’s most recent assessment and actions reports completed at least once during the look-back period. 

Similarly, for ME 6, Element C, NCQA reviews the organization’s data collection methodology. This may be in policies and procedures or described as part of the organization’s reports. NCQA also reviews the organization’s annual evaluation report and improvement of identified deficiencies.

HP 2020

8.15.2019 Documentation for MEM 2, Element C and MEM 3, Element C Will NCQA review an organization’s policies and procedures for MEM 2, Element C and MEM 3, Element C?

For MEM 2, Element C, NCQA reviews the organization’s data collection methodology. This may be in policies and procedures or described as part of the organization’s reports. NCQA also reviews the organization’s most recent assessment and actions reports completed at least once during the look-back period.
Similarly, for MEM 3, Element C, NCQA reviews the organization’s data collection methodology. This may be in policies and procedures or described as part of the organization’s reports. NCQA also reviews the organization’s annual evaluation report and improvement of identified deficiencies.

HP 2019

8.15.2019 Scoring UM File Review workbook for UM 5 timeliness Requirements Since UM 5, Elements A, C and E decision timeliness requirements were retired for 2020, how will the file review workbook be completed for those elements for 2019?

Because of the complexities of the workbook formulas, we are unable to change the workbook to accept “NA” in time for 2019 Standards Year surveys. To correctly calculate the notification date scoring, a date must be entered in this field.
NCQA will not require organizations to provide documentation of the decision date and will instruct surveyors to enter the earliest of

  1. The written notification date(s), or
  2. The verbal notification date(s) (if applicable).

Regardless of the score calculated for decision date,

  1. Surveyors will not score 30 files for this factor (although if it is necessary to review 30 files for the notification date, surveyors may need to complete this field, as described above for additional files).
  2. Surveyors will score the element NA in IRT.

HP 2019

8.15.2019 UM 5 Timeliness Requirements The UM 5, Elements A, C, E timeliness requirements were retired in 2020 Health Plan Accreditation. These requirements will be scored NA in HPA 2019. How will this affect timeliness reporting in UM 5, Element G?

An “NA” score for UM 5, Elements, A, C and E will not affect the review of UM 5, Element G: UM Timeliness Report. However, NCQA still requires organizations to monitor and submit a report of timeliness of decision making and notification of decisions for UM 5, Element G.

HP 2019

4.15.2019 Value-Based Payment Requirement for PHM 3, Element B If a value-based payment program is new, there may not be payments for all months of the look-back period. How can the program be documented to meet the requirement, and how should this be reflected in the workbook?

The organization does not need to have value-based payments for every month of the look-back period. It reports:

  • As the numerator: The value-based payments made during the look-back period, and
  • As the denominator: All payments (including fee-for-service) made during the entire look-back period.

For example, the denominator is 12 months of all payments, but if there are 3 months of value-based payments in the look-back period, the numerator is the 3 months of value-based payments.

HP 2019