Where can I find the Medicaid Module Standards and Guidelines?
Submit your request for the 2018 Medicaid Module at My NCQA.
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.
No. To keep scoring simple, NCQA set a threshold of 80% or higher for all UM must-pass elements, rather than setting a specific threshold for each element based on its scoring options. If an element does not have an 80% option, the “or higher” applies. Keep in mind that an organization may miss the requirements for a few files and still score 100% on the element. For additional information on file review scoring, refer to the scoring table in each element or to the file review worksheet in the Interactive Review Tool (IRT).
Yes. If the arrangement was terminated more than 90 calendar days before submission of the completed survey tool, the organization is eligible for automatic credit for the portion of the look-back period when the NCQA-Accredited/Certified/Recognized delegate conducted activities.
The intent of the added language in factors 2 and 3 was to clarify the minimum information required for expedited appeals. NCQA recognizes these are new requirements, and for this reason, has added the following language to the scope of review:
Organizations must implement the changes in factors 2 and 3 for files processed on or after 11/1/18.
NCQA will post an update in December for the 2019 HP publication to reflect this change.
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.
No. After consideration, NCQA removed the requirement for case managers to address life-planning activities at the start of the initial assessment (first contact). This FAQ replaces the previous FAQ issued on October 15, 2017 (which has been deleted) regarding first contact, and the workbook has been adjusted to accommodate the change.
No. Element A does not require organizations to implement a preventive behavioral healthcare program. The intent of factor 5 is that organizations collect data to determine if there are behavioral health issues that could be prevented if a program were to be implemented. Organizations collect data to meet Element A. Identifying the opportunity for such a program and implementing it is applicable to Element B.
NCQA Health Plan Medicaid Module is a complementary program designed to support NCQA-Accredited health plans with a Medicaid product line. The combination of the module standards and NCQA Health Plan Accreditation maximize alignment with the Medicaid Managed Care program requirements. This improves a plan’s opportunity to receive a streamlined state compliance review. NCQA developed the module by analyzing changes to state and federal requirements for the Medicaid Managed Care programs, as outlined in the Medicaid Managed Care Rule.