No. Notice of Medicare Non-Coverage (NOMNC) denial files are out of NCQA’s scope of review and should be excluded from the UM file universe.
Yes. NCQA uses language in the Explanation that organizations may use more general or extensive language to query practitioners about impairment.
Note: This question was previously posted on August 15, 2023 and reevaluated by NCQA. This FAQ answer replaces the previously posted response.
Yes, the following CAQH question meets the intent of the requirement in CR 3, Element C, factor 2:
Yes. Using UM 12: Delegation of UM as an example, the following describes factors that would be considered NA:
UM 12, Element A: Delegation Agreement
UM 12, Element C: Review of the UM Program
Note: Factor 2 (annual audits): This factor is not scored NA, but the organization may submit the delegate’s timeliness report of mail distribution in lieu of an audit.
This must be specified in the delegation agreement.
Update: The strikethrough text is an update to the FAQ posted on October 15, 2022.
NCQA requires practitioners to attest to their lack of present illegal drug use, but not to past drug use or history of drug use.
Organizations are not required to refer exclusively to the present; therefore, an organization may choose to ask about both present and past drug use.
No. Only addressing the UM denial notification to the provider does not meet the intent of the requirement. The UM denial notification must also be addressed to the attending/treating practitioner.
If information on the attending/treating practitioner was not provided with the request, the organization attempts to identify the practitioner and documents its efforts to identify the practitioner. If the organization is not able to obtain the name of the attending/treating practitioner, the practitioner’s name is not required. In such a case, the organization must address the notification "To the Attention of the Attending/Treating Practitioner.”
For urgent concurrent decisions, the organization may inform the hospital Utilization Review department staff without attempting to identify the attending/treating practitioner, with the understanding that staff will inform the practitioner.
In all cases, if the practitioner is not known, the organization must address the notification “To the Attention of the Attending/Treating Practitioner”; the practitioner’s name is not required.
Yes. Organizations may use an API to access data from a primary or approved source, and must provide documentation that the API collects information only from primary or approved sources.
Organizations that use an API must still meet the “Appropriate documentation” requirements in CR 1, Element A, including documentation that the organization's staff reviewed the information.
As noted in an FAQ from February 15, 2023, use of another entity’s software to collect credentialing information is not considered delegation unless the entity also reviews the information on the organization’s behalf.
Yes, if the delegation agreement addresses the required information in the Explanation (e.g., CR 8, Element A, factor 3 for credentialing). The delegation agreement must specify:
NCQA considers the following standards to be a delegation relationship if an organization uses a mail service organization to meet the distribution requirements: