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

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3.15.2022 Inaccessibility of practitioners’ licensure information from Maryland Department of Health The Maryland Department of Health (MDH) experienced a network security incident on December 4, 2021, that made its network systems and practitioners’ licensing information inaccessible for primary source verification. The MDH reports that all disrupted licensing board systems were restored as of February 4, 2022. The MDH granted a grace period (with no expiration date) on practitioners’ licenses set to expire between November 2021 and February 2022, and issued temporary licenses to affected practitioners whose licenses will expire June 2022.

How will NCQA evaluate affected practitioners’ files?

For Maryland practitioners credentialed between December 2021 and February 2022, NCQA will not penalize organizations on inability to verify licensure due to the MDH network security incident. NCQA accepts the MDH’s grace period on licensure expirations and accepts temporary licenses issued by the MDH and will consider them current and valid. Organizations should adhere to guidance provided by MDH and document the guidance in the affected practitioners’ credentialing files.

HP 2022

2.15.2022 Annual Monitoring of UM System Controls Monitoring for Delegates Have the allowed methods to audit delegate files in UM 13, Element C, factor 5 changed?

No. Delegate files may be audited using one of the following methods as described in the factor explanation and noted below:

  • 5 percent or 50 of its files, whichever is less, to ensure that information is verified appropriately.
  • The NCQA “8/30 methodology” available at https://www.ncqa.org/programs/health-plans/policy-accreditation-and-certification/

Either methodology is allowed, for consistency with other Delegation Oversight requirements for annual file audits.

HP 2022

2.15.2022 Updated: Sampling for UM/CR System Controls Monitoring May organizations that use auditing as a method for monitoring system controls use sampling for UM 12 and CR1, Elements C and D?

Yes. NCQA has decided to allow sampling for organizations that use auditing as the method for monitoring in UM 12, Elements A – D and CR 1, Elements C and D. Organizations must use the “5% or 50 files” audit method: Organizations randomly select 5% or 50 files, whichever is less, from each applicable file type, to review against the requirements: 

  • Credentialing and recredentialing. (5% or 50 files total)  
    • At a minimum, the sample includes at least 10 credentialing files and 10 recredentialing files. If fewer than 10 practitioners were credentialed or recredentialed since the last annual audit, the organization audits the universe of files rather than a sample. 
  • UM denials (5% or 50 files). 
  • UM appeals (5% or 50 files). 

For each applicable file type noted above, the organization must determine the sample size of 5% or 50 files (whichever is less) based on all files in the file universe. The file universe includes all files with or without modifications. The sample that will be audited must include only files with modifications (i.e., modifications that meet and do not meet the organization’s policies and procedures). NCQA does not specify how the organization selects the sample once the sample size is determined using the entire file universe. It may select the sample of modified files from the universe or, if the organization can identify files with modifications, it may randomly select the sample that will be audited from only the modified files.

The organization’s analysis report must include the number or percentage of files that do not meet the organization’s policies and procedures.
Example for UM denials:

  • An organization’s UM denial file universe contains 800 files with and without modifications. Therefore, the minimum required sample for review is 40 files (5% of 800) which is less than 50 files. The organization must randomly select the 40 files for review from the total universe of 800 files or from only files with modifications (if the organization’s system has the capability to identify files with modifications). All 40 files must have a modification and are reviewed against the organization’s policies and procedures to identify noncompliant modifications.

Note: The underlined text is an update to the FAQ posted on January 15, 2022.

HP 2022

2.15.2022 Annual Monitoring of CR System Controls Monitoring for Delegates Have the allowed methods to audit delegate files in CR 8, Element C, factor 5 changed?

No. Delegate files may be audited using one of the following methods as described in the factor explanation and noted below:

  • 5 percent or 50 of its files, whichever is less, to ensure that information is verified appropriately.
    • At a minimum, the sample includes at least 10 credentialing files and 10 recredentialing files. If fewer than 10 practitioners were credentialed or recredentialed since the last annual audit, the organization audits the universe of files rather than a sample.
  • The NCQA “8/30 methodology” available at https://www.ncqa.org/programs/health-plans/policy-accreditation-and-certification/

Either methodology is allowed, for consistency with other Delegation Oversight requirements for annual file audits.

HP 2022

1.15.2022 UM/CR System Control Delegation Agreement When must the delegation agreement include a description of the delegate’s UM/CR system controls as required in UM 13, Element A and CR 8, Element A?

New delegation agreements implemented on or after January 1, 2022, must include a description of the delegate’s UM/CR system security controls.
 
For delegation agreements in place prior to January 1, 2022, NCQA has extended the time frame for including a description of UM/CR system controls in the delegation agreement. All delegation agreements under the 2024 HPA standards (effective July 1, 2024) must include a description of UM/CR system controls. Prior to July 1, 2024, organizations may alternatively provide a delegation agreement and other mutually agreed upon documentation OR the delegate's system controls policies and procedures in lieu of a delegation agreement with a description of UM/CR System controls.

HP 2022

11.15.2021 UM 3, Element A, Notification to Members May notifications sent to members be used as materials to satisfy UM 3, Element A, factors 4 and 5?

Yes. Notifications (e.g. newsletters, member letters) sent to members indicating the TDD/TTY and language assistance services that are available are acceptable materials for factors 4 and 5.

HP 2022

11.15.2021 Removal of APM Example In the 2022 NCQA standards for QI 4, Element A, factor 6, the HEDIS measure Metabolic Monitoring for Children and Adolescents on Antipsychotics was removed as an example for the requirement. Why? Can it still be used to fulfill the requirement?

The APM measure may be used if it is relevant to the population. Because it applies to children and adolescents, it was removed from the factor 6 examples to align with the exception (factor 6 is NA if the organization’s membership does not include adult members).

HP 2022

9.15.2021 Notification of Internal Appeal to Member or Treating Practitioner Must an internal appeal notification be sent to both the member and the treating practitioner?

No. The internal appeal notification must be sent to the member.  

The UM 9, Element D stem incorrectly states that both the member and the treating practitioner must be notified. This will be corrected in November’s Policy Updates.

HP 2022

7.15.2021 Virtual-Only Practitioners If an organization wants to add virtual-only practitioners to its network for services such as behavioral health, does that affect NET 5 and CR 1?

Yes. If an organization adds virtual-only practitioners to its network, the provider directory must indicate that such practitioners are virtual only (i.e., in lieu of a physical office location) to meet NET 5, Element A. Virtual-only practitioners must also be fully credentialed, per requirements in CR 1, Element A.

HP 2021

7.15.2021 Use of Mail Service Organizations for Distribution Requirements Is it considered delegation if an organization uses a mail service organization to meet distribution requirements?

NCQA considers it to be delegation if the organization uses another organization, including a mail service organization, to perform any function not listed in the “Vendor” section of Appendix 2. 
NCQA considers it to be a vendor relationship if the organization uses another organization (e.g., a mail service organization) to perform functions evaluated by the elements or element components listed in the "Vendor" section of Appendix 2.

HP 2021

4.15.2021 Vendor Relationship: ME 2, Element A Are all the requirements in ME 2, Element A considered a vendor relationship if the organization utilizes a mail vendor for distribution?

No. For ME 2, Element A, only the distribution component of the requirement is considered a vendor relationship. 

As stated in the explanation, these elements may not be delegated. The organization must create the written information, but may distribute it through a mail vendor.

HP 2021

4.15.2021 Provisional Status Triggers In what circumstances will an organization receive Provisional status?

An organization will receive Provisional status if it:  
 

  1. Scores below 80% and above 55% of the maximum possible points in any Standards Category, or  

  1. Does not achieve an element score of “Met” in three or more must-pass elements.

HP 2020