FAQ Directory: Health Plan Accreditation

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.

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years:

NCQA does not evaluate the validity or reliability of the measure in Element A, QI 3 and QI 4. In Element C, QI 3 and QI 4, NCQA evaluates the validity of the remeasurement relative to the initial measurement. For example, NCQA evaluates if sampling, timing or other methodological factors introduces bias or other issues of comparison when determining an intervention’s effectiveness.

This applies to the following Programs and Years:

Yes, it is correct. The elimination of Elements A, C and E does not affect the review of Element D: UM Timeliness Report. The expectation is that the report includes timeliness for both decision making and notification of the decision given that the report includes denials and approvals. NCQA does not require written notification for approvals; therefore, timeliness for approvals is only reported under decisions.

This applies to the following Programs and Years:

No, notification of denials to a member through a web portal does not meet the requirement for member notifications. However, emailing a denial notification directly to a member would be acceptable for electronic notification.

This applies to the following Programs and Years:

The purpose of same-or-similar specialist review of appeals is to apply specific clinical knowledge and experience when determining if an appeal meets criteria for medical necessity and clinical appropriateness. “Training and experience” refers to the practitioner’s clinical training and experience.
The intent is that the specialist reviewing the appeal would have encountered a patient with this condition who is considering or has received the service or procedure in a clinical setting. NCQA assesses whether the specialist is appropriate for the condition, service or procedure in question, and does not consider the referring practitioner type.

Effective January 1, 2020, NCQA accepts board certification in the same specialty as a proxy for clinical training and experience.
NCQA does not require that the same-or similar specialist reviewer be actively practicing.

Experience with the condition, service or procedure that is limited to UM decision making in cases similar to the appeal in question is not considered sufficient experience, nor do UM decision-making criteria supersede the requirement for same-or-similar specialist review.
 

This applies to the following Programs and Years:

For PHM 1, Element B, NCQA evaluates communicating information to members who become eligible for programs that involve interactive contact.

Therefore, for any program that involves interactive contact (e.g., CCM, wellness coaching, web-based tools, disease management, smoking cessation classes), if the organization under review (e.g., a plan) contracts with another organization (e.g., a PHM company) to perform the function and the PHM company is responsible for communicating the information required to meet PHM 1, Element B, the plan has delegated the functions associated with PHM 1, Element B. This is considered delegation and all delegation requirements, including oversight, apply.

If the PHM company provides a technology supported service, such as a web-based tool, this is a vendor relationship for any requirements that directly evaluate the PHM function (e.g., PHM 4).

This applies to the following Programs and Years:

Yes. Employees and their dependents are excluded from the CCM file review universe.

This applies to the following Programs and Years:

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.
 

This applies to the following Programs and Years:

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. 

This applies to the following Programs and Years: