Submit your request for the 2018 Medicaid Module at My NCQA.
FAQ Directory: Long-Term Services and Supports Distinction for Health Plans
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8.24.2018 Where can I find the Medicaid Module Standards and Guidelines? How can I obtain the Medicaid Module Standards and Guidelines?
8.24.2018 What organizations are eligible for the Medicaid Module?
An organization is eligible for the NCQA Health Plan Medicaid Module if:
- Its Medicaid product line has a current NCQA Accreditation status as a First or Renewal Survey, or
- It is seeking accreditation for its Medicaid product line under NCQA HP Accreditation as an Interim, First or Renewal Survey.
This applies to the following Programs and Years:
HP 2018, 2019, 20208.24.2018 Where can I find information to help me get started with Health Plan Accreditation?
- Accreditation Process and Timeline:Key steps, timing and resources for a successful accreditation.
- Standards and Guidelines: The complete standards and guidelines, including the intent and scope of review.
- Interactive Survey Tool: Contains the complete standards and guidelines; you can also determine your organization’s survey readiness—the tool calculates your potential survey score.
This applies to the following Programs and Years:
HP 2017, 2018, 2019, 20208.24.2018 Are there additional resources for health plans seeking LTSS Distinction?
- LTSS Best Practices Academy: Interactive forum for professionals to discuss strategies for coordinating quality long-term services and supports (LTSS) programs.
- LTSS Roadmap: A compilation of resources to guide organizations through meeting Case Management and Health Plan Standards for LTSS.
This applies to the following Programs and Years:
HP 2017, 2018, 2019, 20208.24.2018 Where can I find the Health Plan Accreditation Standards and Guidelines?
Find the Standards and Guidelines document in the NCQA eStore.
This applies to the following Programs and Years:
HP 2017, 2018, 2019, 20208.24.2018 Where can I find information to help me get started with the Medicaid Module?
- Accreditation Process and Timeline: Key steps, timing and resources for a successful accreditation.
- Standards and Guidelines: The complete standards and guidelines, including the intent and scope of review.
- Interactive Survey Tool: Contains the complete standards and guidelines; you can also determine your organization’s survey readiness—the tool calculates your potential survey score.
This applies to the following Programs and Years:
HP 2018, 2019, 20208.24.2018 What are Health Plan Accreditation requirements?
NCQA standards are a roadmap for improvement—organizations use them to perform a gap analysis and align improvement activities with areas that are most important to states and employers, such as network adequacy and consumer protection. Standards help plans in:
- Quality Management and Improvement.
- Population Health Management.
- Network Management.
- Utilization Management.
- Credentialing and Recredentialing.
- Members’ Rights and Responsibilities.
- Member Connections.
- Medicaid Benefits and Services.
This applies to the following Programs and Years:
HP 2018, 2019, 20208.24.2018 How do I get started with LTSS Distinction for Health Plans?
If you are not currently accredited and want to learn more, contact NCQA. If you are currently accredited and want to talk to someone about your status or about renewing or adding accreditations, submit a question through My NCQA.
This applies to the following Programs and Years:
HP 2017, 2018, 2019, 20208.24.2018 What other organizations have earned Health Plan Accreditation?
Over 1,000 health plan products have earned NCQA Health Plan Accreditation. See the NCQA Report Card for a directory of accredited organizations.
This applies to the following Programs and Years:
HP 2017, 2018, 2019, 20208.17.2018 Where can I find information to help me get started with the LTSS Distinction?
- Accreditation Process and Timeline: Key steps, timing and resources for a successful accreditation.
- Standards and Guidelines: The complete standards and guidelines, including the intent and scope of review.
- Interactive Survey Tool: Contains the complete standards and guidelines; you can also determine your organization’s survey readiness—the tool calculates your potential survey score.
This applies to the following Programs and Years:
HP 2017, 2018, 2019, 2020
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.
This applies to the following Programs and Years:
HP 2018, 2019|MBHO 2018|UM-CR-PN 2018, 20197.15.2018 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.