No. After consideration, NCQA removed the requirement for case managers to address life-planning activities at the start of the initial assessment (first contact). This FAQ replaces the previous FAQ issued on October 15, 2017 (which has been deleted) regarding first contact, and the workbook has been adjusted to accommodate the change.
Yes. If the arrangement was terminated more than 90 calendar days before submission of the completed survey tool, the organization is eligible for automatic credit for the portion of the look-back period when the NCQA-Accredited/Certified/Recognized delegate conducted activities.
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.
NCQA Managed Behavioral Healthcare Organization Accreditation is a comprehensive, evidence-based evaluation that reviews organizations to assure they use processes to deliver high-quality care and access. It provides a framework for organizations to align and improve operations in areas of quality improvement, care coordination, utilization management and credentialing and recredentialing and members’ rights.
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.
The first step to earning accreditation is a discussion with an NCQA program expert. Purchase and review the program resources, conduct a gap analysis and submit your online application. Align your organization’s processes with the CR standards. NCQA conducts the survey and determines your accreditation status within 30 days of the final review. See a step-by-step process.
Any organization that provides managed health care services may apply for the NCQA Managed Behavioral Healthcare Organization Accreditation if it meets the following criteria:
Has been in operation for at least six months, andEnrolls or receives enrollment of an identifiable eligible population that is eligible to access the network, andProvides comprehensive behavioral health care services through an organized delivery system across a continuum of care, andPerforms functions addressed in the standards (quality improvement, care coordination, utilization management, credentialing, member rights and responsibilities), either directly or through a service agreement, andHas a process for monitoring, evaluating and improving the quality and safety of care.
The standards, provide a framework for implementing best practices to improve:
Quality Management and Improvement: Monitor, evaluate and improve the quality and safety of care.Care Coordination: Coordinate medical care and behavioral healthcare for its members.Utilization Management: Notifies members and practitioners about coverage decisions within required time frames.Credentialing and Recredentialing: Verifies the credentials of the practitioners in its network.
Members’ Rights and Responsibilities: Written members’ rights and responsibilities policy exist.
To see the program requirement details, get the Standards & Guidelines document.
