FAQ Directory: Long-Term Services and Supports Distinction for Health Plans

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10.15.2019 PHM 5: Assessment and Evaluation Does a combined summary of all factors in the assessment meet the requirement for documenting the conclusion of the initial assessment for PHM 5, Elements D and E?

Yes. Assessment and evaluation each require a case manager or a qualified individual to draw and document a conclusion about the data or information collected. Raw data or answers to questions do not meet the requirement; there must be a documented summary of the meaning or implications to the member’s situation, so data can be used in the case management plan.
The organization must draw a conclusion for each factor (unless otherwise stated in the explanation). This may be in separate summaries for each factor or in a combined summary, or in a combination of these.

HP 2019

8.15.2019 UM 5 Timeliness Requirements The UM 5, Elements A, C, E timeliness requirements were retired in 2020 Health Plan Accreditation. These requirements will be scored NA in HPA 2019. How will this affect timeliness reporting in UM 5, Element G?

An “NA” score for UM 5, Elements, A, C and E will not affect the review of UM 5, Element G: UM Timeliness Report. However, NCQA still requires organizations to monitor and submit a report of timeliness of decision making and notification of decisions for UM 5, Element G.

HP 2019

8.15.2019 Documentation for MEM 2, Element C and MEM 3, Element C Will NCQA review an organization’s policies and procedures for MEM 2, Element C and MEM 3, Element C?

For MEM 2, Element C, NCQA reviews the organization’s data collection methodology. This may be in policies and procedures or described as part of the organization’s reports. NCQA also reviews the organization’s most recent assessment and actions reports completed at least once during the look-back period.
Similarly, for MEM 3, Element C, NCQA reviews the organization’s data collection methodology. This may be in policies and procedures or described as part of the organization’s reports. NCQA also reviews the organization’s annual evaluation report and improvement of identified deficiencies.

HP 2019

8.15.2019 Scoring UM 5 Timeliness Requirements The UM 5, Elements A, C, E timeliness requirements were retired in 2020 Health Plan Accreditation. These requirements will be scored NA in HPA 2019. Does that mean that the “Explanation” and the “Related information” sections of these elements regarding notifications no longer apply to UM 5, Elements B, D and F?

No. The “Explanation” and the “Related information” sections of UM 5, Elements A, C and E still apply to UM 5, Elements B, D and F, respectively. All applicable information was moved to the relevant elements for HPA 2020.

HP 2019

8.15.2019 Scoring UM File Review workbook for UM 5 timeliness Requirements Since UM 5, Elements A, C and E decision timeliness requirements were retired for 2020, how will the file review workbook be completed for those elements for 2019?

Because of the complexities of the workbook formulas, we are unable to change the workbook to accept “NA” in time for 2019 Standards Year surveys. To correctly calculate the notification date scoring, a date must be entered in this field.
NCQA will not require organizations to provide documentation of the decision date and will instruct surveyors to enter the earliest of

  1. The written notification date(s), or
  2. The verbal notification date(s) (if applicable).

Regardless of the score calculated for decision date,

  1. Surveyors will not score 30 files for this factor (although if it is necessary to review 30 files for the notification date, surveyors may need to complete this field, as described above for additional files).
  2. Surveyors will score the element NA in IRT.

HP 2019

8.15.2019 Documentation for ME 5, Element C and ME 6, Element C Will NCQA review an organization’s policies and procedures for ME 5, Element C and ME 6, Element C?

For ME 5, Element C, NCQA reviews the organization’s data collection methodology. This may be in policies and procedures or described as part of the organization’s reports. NCQA also reviews the organization’s most recent assessment and actions reports completed at least once during the look-back period. 

Similarly, for ME 6, Element C, NCQA reviews the organization’s data collection methodology. This may be in policies and procedures or described as part of the organization’s reports. NCQA also reviews the organization’s annual evaluation report and improvement of identified deficiencies.

HP 2020

4.15.2019 Value-Based Payment Requirement for PHM 3, Element B If a value-based payment program is new, there may not be payments for all months of the look-back period. How can the program be documented to meet the requirement, and how should this be reflected in the workbook?

The organization does not need to have value-based payments for every month of the look-back period. It reports:

  • As the numerator: The value-based payments made during the look-back period, and
  • As the denominator: All payments (including fee-for-service) made during the entire look-back period.

For example, the denominator is 12 months of all payments, but if there are 3 months of value-based payments in the look-back period, the numerator is the 3 months of value-based payments.

HP 2019

3.15.2019 Citing a benefit provision If a benefit provision is used as the basis for the denial, how must it be cited in the notification?

Referencing benefit documents such as the member handbook or Certificate of Coverage by title alone is not specific enough to meet the requirement. Because benefit documents are often large and complex, the organization must direct members to the specific location of the information, either by section title or page number.

The reference must still support the organization’s decision and relate to the reason for the request

HP 2019

3.15.2019 LTSS 4, Element C: Analysis of Unplanned transitions The explanation for LTSS 4, Element C, factor 1 states that analysis includes patterns of unplanned admissions, readmissions, emergency room visits and repeat visits, and admission to participating and nonparticipating facilities.
Is the organization required to include all these areas to meet the intent of the factor?

No. The organization is not required to include all these areas in its analysis, but at a minimum, must evaluate rates of unplanned admissions to facilities and emergency room visits to identify areas for improvement.

HP 2019

3.15.2019 PHM 5, Element F: Aligning the examples with the factor explanation Are the examples in PHM 5, Element F all-inclusive? Does using only the listed questions meet the requirement?

No. As a general rule, examples should be used as a guide. Examples of questions for PHM 5, Element F that are not prescriptive, but address each requirement listed in the Explanation, include:

1.  How satisfied are you with the information provided about the overall case management program?

2.  How would you rate your experience with the case manager overall? With the program staff?

3.  Did the case manager and other program staff treat you with courtesy and respect?

4. Was the information provided to you useful?

5. How well were you able to follow the recommendations provided to you by the case manager?

6. Were you able to achieve your health goals in your case management plan?

HP 2019

3.15.2019 UM 8, Element A MAXIMUS What factors are scored “Met” for UM 8, Element A if an upheld denial was sent to MAXIMUS?

Factors 7-13 should be scored as “Met” for upheld denials sent to MAXIMUS.

HP 2018

2.15.2019 Language in denial letters May an organization send a single denial letter to a member and a practitioner that contains the reason for the denial in both layman terms (for the member) and clinical terms (for the practitioner)?

Yes. The organization may send a single letter to the member and practitioner that includes the specific reason for the denial, in language that would be easily understood by the member. The letter may also include, in a separate section, additional clinical or technical language directed toward a practitioner.

When NCQA reviews the letter to ascertain if the reason for the denial would be easy for the member to understand, it considers both the written reason and the context of the language and whether the information can be understood in context.
 

HP 2019