FAQ Directory: Health Plan Accreditation

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8.17.2018 Where can I find information to help me get started with the LTSS Distinction?

8.15.2018 Updated: Use of Acronyms in UM Denial and Appeal Notices In UM 7, Elements B, E and H and UM 9, Element D, the explanation under Factor 1: states that the reason for denial should not include abbreviations or acronyms that are not defined. Similar language is in UM 8 A.
Does this mean that they must be spelled out (e.g., “We are denying your request for a deoxyribonucleic acid (DNA) test because…”) or explained (“We are denying your request for a DNA test, which is a test that looks at your genetic information in order to…”), or both?

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:

The denial [appeal] notification states the reason for the denial [upholding the denial] in terms specific to the member’s condition or request and in language that is easy to understand, so the member and practitioner understand why the organization denied the request [upheld the denial] and have enough information to file an appeal.
An appropriately written notification includes a complete explanation of the grounds for the denial, in language that a layperson would understand, and does not include abbreviations, acronyms or health care procedure codes that a layperson would not understand. The organization is not required to spell out abbreviations/acronyms if they are clearly explained in lay language. Denial [Appeal] notifications sent only to practitioners may include technical or clinical terms.

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.

HP 2019

7.15.2018 Medical necessity review for personal care services Does NCQA require medical necessity review for personal care services, such as cooking, cleaning and transportation?

No. Medical necessity review is not required for personal care services and other activities of daily living in UM 4–UM 7. However, if these services are covered benefits, any denial decision may be appealed and is included in the scope of appeal file review for UM 9.

HP 2018

5.15.2018 MED standards and the new Medicaid module The previous MED standards are now 15 standards. Can you explain what happened?

In March, NCQA released an expanded Medicaid Module, a voluntary set of 15 standards for organizations with a Medicaid product line. This new module both incorporated the original MED standards (MED 1-MED 6) and added 10 new standards to align with provisions in the federal Medicaid Managed Care Final Rule released by CMS in April 2016.

The new MED module applies to only 2018 HPA; therefore, HPA survey tools for 2017 and earlier are unaffected and do not include the new Medicaid module.

HP 2018

2.15.2018 Identifying a member for Complex Case Management When is a member identified as eligible to receive complex case management services?

A member is identified to receive complex case management services in PHM 2, Element D. The organization’s policies and procedures describes its method for categorizing membership for involvement in complex case management. Once identified, the organization must begin the initial assessment within 30 days and complete within 60 days to meet the PHM 5, Element D requirement.

HP 2018

11.15.2017 DEA or CDS Certificates Is a photocopy of a practitioner's DEA certificate acceptable documentation for CR 3, Element A, factor 2?

Yes. Although photocopies are generally not acceptable documentation for verifying credentialing information, they are accepted for DEA certification because the DEA does not provide phone or written verification.

HP 2018

11.15.2017 Delegation of NET Directories How is NET 7, Element E, factor 1 scored when an organization delegates only the directory functions in NET 6?

The organization is scored NA for factor 1 because the physician and hospital directories do not involve network management procedures.

HP 2018

11.15.2017 The Value-based Payment worksheet What is the Value-Based Payment worksheet for PHM 3B, and where can we find it?

The Value-Based Payment worksheet gives instructions on required reporting to satisfy element PHM 3B: Value-Based Payment Arrangements. It is a workbook that must be completed as part of the survey tool.

HP 2018

11.15.2017 Updated: Timeliness of postservice appeal decisions for Medicare and Medicaid Does the recent change for Medicare and Medicaid postservice appeals from 60 calendar days to 30 calendar days align with Chapter 13 of the Medicare Managed Care Manual?

No. Medicare product lines continue to follow the 60-calendar-day time frame for postservice appeals.

Note: The requirement is correct for Medicare product lines; Medicaid product lines continue to follow the 30-calendar-day time frame for postservice appeals.

HP 2018

9.15.2017 Complex Case Management When does the time frame for completing the initial assessment for complex case management begin?

The time frame for completing the initial assessment begins when the member is determined to be eligible for complex case management. A member is eligible once identified using criteria from Element B, factor 2 and data sources in Element C (e.g., claims/encounter data, hospital discharge data). The initial assessment is not used to determine eligibility, although information gathered in the assessment may make a member ineligible.

Note: There is no “opt-in” option for identifying members.

HP 2017

9.15.2017 Utilization Management and Use of Voicemail When does voicemail meet UM notification requirements?

Voicemail meets UM requirements only when the organization notifies a practitioner about the opportunity to discuss a denial decision. The organization must document who left the message, along with the date and time it was left. Voicemail messages do not meet any other notification requirement.

HP 2018

9.15.2017 Appeals covered in QI 4, Element C What types of appeals are included in QI 4, Element C: Coverage Appeals (e.g., in UM 8-UM 9) or noncoverage appeals (e.g., in RR 2)?

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.


HP 2018