FAQ Directory: Health Plan Accreditation

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1.15.2022 UM/CR System Control Delegation Agreement When must the delegation agreement include a description of the delegate’s UM/CR system controls as required in UM 13, Element A and CR 8, Element A?

New delegation agreements implemented on or after January 1, 2022, must include a description of the delegate’s UM/CR system security controls.
 
For delegation agreements in place prior to January 1, 2022, NCQA has extended the time frame for including a description of UM/CR system controls in the delegation agreement. All delegation agreements under the 2024 HPA standards (effective July 1, 2024) must include a description of UM/CR system controls. Prior to July 1, 2024, organizations may alternatively provide a delegation agreement and other mutually agreed upon documentation OR the delegate's system controls policies and procedures in lieu of a delegation agreement with a description of UM/CR System controls.

HP 2022

1.15.2022 Sampling for UM/CR System Controls Monitoring May organizations that use auditing as a method for monitoring system controls use sampling for UM 12 and CR1, Elements C and D?

Yes. NCQA has decided to allow sampling for organizations that use auditing as the method for monitoring in UM 12 and CR 1, Elements C and D. Organizations must use the “5% or 50 files” audit method: Organizations randomly select 5% or 50 files, whichever is less, from each applicable file type, to review against the requirements: 

  • Credentialing and recredentialing. (5% or 50 files total)  
    • At a minimum, the sample includes at least 10 credentialing files and 10 recredentialing files. If fewer than 10 practitioners were credentialed or recredentialed since the last annual audit, the organization audits the universe of files rather than a sample. 
  • UM denials (5% or 50 files). 
  • UM appeals (5% or 50 files). 

HP 2022

11.15.2021 Removal of APM Example In the 2022 NCQA standards for QI 4, Element A, factor 6, the HEDIS measure Metabolic Monitoring for Children and Adolescents on Antipsychotics was removed as an example for the requirement. Why? Can it still be used to fulfill the requirement?

The APM measure may be used if it is relevant to the population. Because it applies to children and adolescents, it was removed from the factor 6 examples to align with the exception (factor 6 is NA if the organization’s membership does not include adult members).

HP 2022

11.15.2021 UM 3, Element A, Notification to Members May notifications sent to members be used as materials to satisfy UM 3, Element A, factors 4 and 5?

Yes. Notifications (e.g. newsletters, member letters) sent to members indicating the TDD/TTY and language assistance services that are available are acceptable materials for factors 4 and 5.

HP 2022

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?

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

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?

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

4.15.2021 Evaluation Options for PHM 6, Element B Does PHM 6, Element B apply to First Surveys?

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

4.15.2021 Provisional Status Triggers In what circumstances will an organization receive Provisional status?

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  

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

HP 2020

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