FAQ Directory: Health Plan Accreditation

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12.15.2016 Allowing Automatic Credit for UM 13, (UM 12 in HP 2017) Elements A and B for Interim Surveys Is automatic credit available for Interim Surveys for organizations that delegate UM 13 (UM 12 in HP 2017), Triage and Referral for Behavioral Healthcare, Elements A and B to an NCQA-Accredited/Certified health plan, MBHO or UM-CR?

Yes. Automatic credit is available for an Interim Survey if the organization delegates to an NCQA-Accredited/Certified health plan, MBHO or UM-CR. The delegate’s Accreditation/Certification Survey must include the specific elements or factors for which the organization seeks automatic credit. The organization is responsible for determining if delegated activities are covered in the scope of the delegate’s NCQA review.

HP 2017

12.15.2016 UM 9, Element D: Including Reviewers Names on Appeal Decision Letters Are organizations required to include reviewers’ names on appeal letters or verbally communicate to members that names are available upon request?

No. Organizations are not required to include reviewer names on the decision letter or verbally inform members that the information is available upon request. This language will be removed from UM 9, Element D in the March Policy update.

Please note this requirement remains in UM 8, Element A. 

HP 2017

11.15.2016 Opportunity to discuss a UM request Given CMS appeal regulations (at 42 CFR §422.580), may Medicare organizations give practitioners the opportunity to discuss a UM request prior to a UM decision, to meet the requirements of UM 7, Elements A, D and G?

Yes. For the Medicare product line, the organization may give the treating practitioner an opportunity to discuss a UM request with a physician or other appropriate reviewer prior to the decision. The denial file must contain documentation of this.

HP 2017

10.15.2016 Pharmacists as Same-or-Similar Specialists May pharmacists be considered “same-or-similar” specialists?

No. Because pharmacists do not treat patients, they are not considered same-or-similar specialists.

HP 2017

10.15.2016 UM 7 Denial Notification Under UM 7, Element A, may organizations use a mass communication to notify treating practitioners of the opportunity to discuss a denial?

No. Organizations may not use mass communication for this element. Organizations have three options to notify practitioners of the opportunity to discuss a denial:
1. In the denial notification (included in the denial file).
2. By telephone (time and date of the denial included in the denial file).
3. In materials sent to the treating practitioner, informing the practitioner of the opportunity to discuss a specific denial with a reviewer (evidence that the practitioner was notified that a physician or other reviewer is available to discuss the denial included in the denial file).
 

HP 2017

10.15.2016 Types of pharmacy point of service claims included in UM 4, Element H file review What types of pharmacy point of service claims should be included in the scope of UM 4, Element H (UM 4, Element F in MBHO and UM-CR)?

The following denials (rejections) are included in the scope of UM 4, Element H (UM 4, Element F in MBHO and UM-CR):

  • Claims for prescriptions that were refilled too soon.
  • Claims for prescriptions with the incorrect dosage or quantity.*
  • Claims that were denied because the organization’s reasonable filing procedures were not followed (e.g., lack of prior authorization).

* Inaccurately filed claims that were rejected because of incorrect dosage or quantity may be considered pending until a decision is made. If the request is denied, the claim is included in the scope of UM 4, Element H.

HP 2016