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

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9.15.2017 Complex Case Management When does the time frame for completing the initial assessment for complex case management begin?

The time frame for completing the initial assessment begins when the member is determined to be eligible for complex case management. A member is eligible once identified using criteria from Element B, factor 2 and data sources in Element C (e.g., claims/encounter data, hospital discharge data). The initial assessment is not used to determine eligibility, although information gathered in the assessment may make a member ineligible.

Note: There is no “opt-in” option for identifying members.

HP 2017

9.15.2017 Denial Notices—Right to Representation The denial notification must include a statement that members may be represented by anyone they choose, including an attorney. If the notification states that members have the right to be represented by anyone, but does not specify “including an attorney,” is this acceptable?

Yes. If the notification indicates that members may be represented by anyone, this is acceptable because the reference to “anyone” implies “including an attorney.” If the notification lists specific types of individuals, it must also specify “an attorney.”

HP 2018

8.15.2017 Overturned appeals Who can overturn a medical necessity or benefit denial on appeal?

NCQA allows any individual at the organization to overturn a denial on appeal. Upheld denials still require same-or-similar specialist review for medical necessity decisions and review by a nonsubordinate for benefit decisions.

HP 2018

5.15.2017 QI 5 Element G: Complex Case Management Assessment and Evaluation Is collecting information or data only for each factor sufficient to meet the “assessment” or “evaluation” requirements in QI 5, Element G (QI 9, Element G in MBHO)?

No. Presenting data alone is not sufficient. The case manager must draw a conclusion from the data and note it in the member’s file.

Note: Effective for complex case management files that were opened on or after September 1, 2017.

HP 2017

5.15.2017 Updated: Pharmacists as Same-or-Similar Specialists May pharmacists be considered “same-or-similar” specialists?

No. Beginning with files processed on and after February 1, 2017, pharmacists are not considered same-or-similar specialists because they do not treat patients in most instances.
Note: An FAQ communicating that pharmacists are not considered same-or-similar specialists was posted on October 15, 2016, and this policy was applied beginning February 1, 2017 (90 days from notification).

HP 2017

4.15.2017 UM 9B: Timeliness of the Appeal Process for Medicaid Under the new Medicaid Managed Care Final Rule, effective July 1, 2017, Medicaid organizations are required to have only one level of appeal. However, this may not be effective immediately for organizations with contracts prior to this date. How will NCQA evaluate Medicaid organizations coming through under the 2017 standards and guidelines?

Organizations with one level of appeal will be evaluated against the timeliness requirements specified in the current 2017 standard. Medicaid organizations that maintain a two-level appeal process will be evaluated under the 2016 standard requirements; these time frames apply:

  • For preservice first-level appeals: 30 calendar days.
  • For postservice first-level appeals: 60 calendar days.

HP 2017

3.15.2017 UM 9 C: Scoring reviewer for appeals of system-made benefit denials Under UM 9, Element C, for an appeal of an initial benefit denial that was made by an automated system (e.g., claims or POS), where a person makes the appeal decision, should the file be scored “NA” or “Yes”?

The file should be scored "Yes.” A person making the appeal decision is different from, and not subordinate to, an automated system.

HP 2017

1.15.2017 UM 7 B: Specific criterion referenced in a denial decision In UM 7, Element B, factor 2, organizations are required to reference the specific criterion used to make a denial decision. How specific does the criterion need to be?

The criterion referenced must be identifiable by name and must be specific to an organization or source (e.g., ABC PBM’s Criteria for Treatment of Hypothyroidism with Synthroid or CriteriaCompany Inc.’s Guidelines for Wound Treatment). If it is clear that the criterion is attributable to the organization, it is acceptable to state “our Criteria for XXX” (e.g., our Criteria for Treating High Cholesterol with Lipitor).

Note: This also applies to Element E and Element H in HPA and Element E in UM-CR.

HP 2016

12.15.2016 Allowing Automatic Credit for UM 13, (UM 12 in HP 2017) Elements A and B for Interim Surveys Is automatic credit available for Interim Surveys for organizations that delegate UM 13 (UM 12 in HP 2017), Triage and Referral for Behavioral Healthcare, Elements A and B to an NCQA-Accredited/Certified health plan, MBHO or UM-CR?

Yes. Automatic credit is available for an Interim Survey if the organization delegates to an NCQA-Accredited/Certified health plan, MBHO or UM-CR. The delegate’s Accreditation/Certification Survey must include the specific elements or factors for which the organization seeks automatic credit. The organization is responsible for determining if delegated activities are covered in the scope of the delegate’s NCQA review.

HP 2017

12.15.2016 UM 9, Element D: Including Reviewers Names on Appeal Decision Letters Are organizations required to include reviewers’ names on appeal letters or verbally communicate to members that names are available upon request?

No. Organizations are not required to include reviewer names on the decision letter or verbally inform members that the information is available upon request. This language will be removed from UM 9, Element D in the March Policy update.

Please note this requirement remains in UM 8, Element A. 

HP 2017

11.15.2016 Opportunity to discuss a UM request Given CMS appeal regulations (at 42 CFR §422.580), may Medicare organizations give practitioners the opportunity to discuss a UM request prior to a UM decision, to meet the requirements of UM 7, Elements A, D and G?

Yes. For the Medicare product line, the organization may give the treating practitioner an opportunity to discuss a UM request with a physician or other appropriate reviewer prior to the decision. The denial file must contain documentation of this.

HP 2017

10.15.2016 UM 7 Denial Notification Under UM 7, Element A, may organizations use a mass communication to notify treating practitioners of the opportunity to discuss a denial?

No. Organizations may not use mass communication for this element. Organizations have three options to notify practitioners of the opportunity to discuss a denial:
1. In the denial notification (included in the denial file).
2. By telephone (time and date of the denial included in the denial file).
3. In materials sent to the treating practitioner, informing the practitioner of the opportunity to discuss a specific denial with a reviewer (evidence that the practitioner was notified that a physician or other reviewer is available to discuss the denial included in the denial file).

HP 2017