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

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3.15.2020 PHM 3, Element B: Value Based Payment Arrangements Does NCQA require organizations to have more than one type (e.g., pay-for-performance, shared savings) of value-based payment arrangement per product line?

No. An organization meets the requirement if it has at least one VBP of any type per product line. Organizations may report more than one VBP arrangement per product line but are not required to do so.

HP 2020

3.15.2020 Using Complaint Data to Supplement Surveys or Self-Reported Information In NET 2, Elements A–C, if an organization collects data using surveys or practitioner self-reported information, it must supplement the data with an analysis of complaints regarding access. Are organizations required to conduct a complete quantitative and qualitative analysis of complaint data?

No. Supplemental complaint data validates survey findings and self-reported information and assists in qualitative analysis of primary data. The organization is not required to conduct complete quantitative and qualitative analysis of supplemental data.

HP 2020

3.15.2020 36-month Recredentialing time frame Does NCQA allow an organization to extend the 36-month recredentialing time frame if it failed to credential a practitioner on time?

No. Except as noted under “Related information: Extending the recredentialing cycle length,” where NCQA makes provisions for situations such as active duty military assignment and medical leave, the organization may not extend the 36-month recredentialing cycle. If the practitioner is not recredentialed within 36 months, the file will be scored down. There is no grace period for recredentialing.
If an organization missed the recredentialing deadline and intends to keep the practitioner in the network, files must be processed as follows:

  • If the organization can complete the credentialing process within 30 days of the original due date, it may recredential the practitioner (e.g., the organization need not verify credentials required only at initial credentialing). The organization must complete the process and make the credentialing decision within 30 days of the original credentialing due date.
  • If the organization cannot complete the credentialing process within 30 calendar days of the original recredentialing due date, it must take the practitioner through the initial credentialing process.

HP 2019

2.15.2020 Measure Validity The explanation in Element A in QI 3 and QI 4 does not require that data collected results be valid or reliable measures; however, the explanation for Element C in QI 3 and QI 4 states that the organization must describe its methodology (numerator, denominator, sampling, measurement periods). Does NCQA review the validity and reliability of measure results in either Element A or C?

NCQA does not evaluate the validity or reliability of the measure in Element A, QI 3 and QI 4. In Element C, QI 3 and QI 4, NCQA evaluates the validity of the remeasurement relative to the initial measurement. For example, NCQA evaluates if sampling, timing or other methodological factors introduces bias or other issues of comparison when determining an intervention’s effectiveness.

HP 2020

2.15.2020 UM Timeliness Report Under 2020 HPA standards, UM 5, Element D requires organizations to monitor UM decision making and notification using UM 5 decision time frames, even though UM 5, Elements A, C and E were eliminated under the 2020 standards. Is this correct?

Yes, it is correct. The elimination of Elements A, C and E does not affect the review of Element D: UM Timeliness Report. The expectation is that the report includes timeliness for both decision making and notification of the decision given that the report includes denials and approvals. NCQA does not require written notification for approvals; therefore, timeliness for approvals is only reported under decisions.

HP 2020

1.15.2020 “Training and Experience” for Same or Similar Specialists Please clarify what is meant by “training and experience” for same or similar specialist in UM 8 and UM 9.

The purpose of same-or-similar specialist review of appeals is to apply specific clinical knowledge and experience when determining if an appeal meets criteria for medical necessity and clinical appropriateness. “Training and experience” refers to the practitioner’s clinical training and experience.
The intent is that the specialist reviewing the appeal would have encountered a patient with this condition who is considering or has received the service or procedure in a clinical setting. NCQA assesses whether the specialist is appropriate for the condition, service or procedure in question, and does not consider the referring practitioner type.

Effective January 1, 2020, NCQA accepts board certification in the same specialty as a proxy for clinical training and experience.
NCQA does not require that the same-or similar specialist reviewer be actively practicing.

Experience with the condition, service or procedure that is limited to UM decision making in cases similar to the appeal in question is not considered sufficient experience, nor do UM decision-making criteria supersede the requirement for same-or-similar specialist review.

HP 2020

1.15.2020 Denial Notifications to members via web portals If an organization uses a member web portal as a means of member written/electronic denial notification (which includes all requirements of UM 4 through UM 7), does this meet the UM denial notification requirements?

No, notification of denials to a member through a web portal does not meet the requirement for member notifications. However, emailing a denial notification directly to a member would be acceptable for electronic notification.

HP 2020

12.15.2019 PHM 1 Element B - Delegation vs Vendor Arrangements PHM 1, Element B is listed in Appendix 2 as an element where a vendor relationship may exist. The “Related information” section also includes information about the use of vendors in this element; however, it is unclear what functions NCQA considers delegation and what it considers a vendor relationship. Please clarify.

For PHM 1, Element B, NCQA evaluates communicating information to members who become eligible for programs that involve interactive contact.

Therefore, for any program that involves interactive contact (e.g., CCM, wellness coaching, web-based tools, disease management, smoking cessation classes), if the organization under review (e.g., a plan) contracts with another organization (e.g., a PHM company) to perform the function and the PHM company is responsible for communicating the information required to meet PHM 1, Element B, the plan has delegated the functions associated with PHM 1, Element B. This is considered delegation and all delegation requirements, including oversight, apply.

If the PHM company provides a technology supported service, such as a web-based tool, this is a vendor relationship for any requirements that directly evaluate the PHM function (e.g., PHM 4).

HP 2020

12.15.2019 Excluding organization employees and their dependents from complex case management (CCM) file review Should organizations exclude employees and their dependents from the CCM file review universe?

Yes. Employees and their dependents are excluded from the CCM file review universe.

HP 2019

10.15.2019 Survey requirements for PHM 6, Elements A and B What does NCQA review in PHM 6, Elements A and B, for First Surveys and Renewal Surveys?

For Element A

  • For First Surveys, NCQA reviews the organization’s plan for annual comprehensive analysis of its PHM strategy impact or the organization’s most recent annual comprehensive analysis of its PHM strategy impact.
  • For Renewal Surveys, NCQA reviews the organization’s most recent annual comprehensive analysis of its PHM strategy impact.

For Element B

  • Element B is NA for First Surveys.
  • For Renewal Surveys, NCQA reviews the organization’s most recent annual comprehensive analysis of its PHM strategy impact.

NCQA will clarify these requirements in the November Policy Update. 

HP 2020

10.15.2019 CR 7, Elements D and E: Assessing Medical and Behavioral Healthcare Providers Does NCQA require a separate tracking mechanism or report for each provider?

No. The organization must provide documentation of a tracking mechanism—or mechanisms (e.g., checklist or spreadsheet)—that encompass the required provider types

HP 2019

10.15.2019 CR 2, Element A, Factor 1 What is the required composition of the Credentialing Committee?

NCQA does not require a Credentialing Committee size, composition or quorum beyond that the committee must include practitioners who participate in the network.
Participating practitioners on the credentialing committee must be from a range of specialties or departments that represent the types of practitioners reviewed by the committee. For example, it would not be sufficient for only primary care practitioners to participate on the committee unless the network has only primary care practitioners.

HP 2020