FAQ Directory: Managed Behavioral Healthcare Organization Accreditation

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5.15.2020 UM 11: Outsourcing Storage of Utilization Management Data To External Entities Question: How many contracts does NCQA review if an organization outsources UM data to external entities?

If an organization contracts with external entities to store its own UM data or contracts with UM delegates that store data, NCQA reviews contracts and documentation from up to four randomly selected external entities, or reviews all external entities if the organization has fewer than four. The score for the element is the average of the scores for all external entities.

MBHO 2020

5.15.2020 CR 1, Element C: Outsourcing Storage of Credentialing Data To External Entities How many contracts does NCQA review if an organization outsources storage of credentialing data to external entities?

If an organization contracts with external entities to store its own credentialing data or contracts with CR delegates that store data, NCQA reviews contracts and documentation from up to four randomly selected external entities, or reviews all external entities if the organization has fewer than four. The score for the element is the average of the scores for all external entities.

MBHO 2020

5.15.2020 UM 5: Medicaid lookback period For Renewal Surveys, the look-back period is specified as 6 months for the Medicaid product line in UM 5, Elements A-C. Is this correct?

No. The look-back period should be specified as 12 months for all product lines, for Renewal Surveys, which is consistent with the other file review standards and elements. NCQA initially changed the scope of review to account for a change made to verbal notification and how it no longer affords organizations an extension.

However, because of this error, if an organization does not meet a factor in UM 5, Elements A-C within the first 6 months of the look-back period, NCQA does not penalize the organization and scores the file “NA” instead of “Not Met” for Medicaid surveys.

MBHO 2020

4.15.2020 Update: Practitioner Involvement and Adoption of UM Criteria For UM 2, Element A, factor 4, when an organization develops or adopts UM criteria, may it limit involvement of practitioners to practitioners who are organization staff, even if they are also network practitioners?

The answer posted in March 2020 unintentionally increased the rigor of the requirement for the 2020 standards year. Therefore, we are updating the answer.
For the 2020 standards year, organizations may limit involvement to practitioners who are staff or participants in the network; NCQA does not require non-staff network practitioners to be involved.

Effective for the 2021 standards year, organizations may not limit involvement to practitioners who are staff. Non-staff network practitioners must also be involved in developing, adopting and reviewing criteria, because they are subject to application of the criteria. If an organization has been unable to involve network practitioners, it must document its attempts and provide the documentation to NCQA during the survey.

This change will be released in the 2021 standards and guidelines.

MBHO 2020

4.15.2020 Distribution of Rights and Responsibility to Existing Members and Practitioners Does distributing the members rights and responsibilities statement to all members and practitioners, whether requested or not, meet the intent of ME 1, Element B, factors 2 and 4 (RR 1, Element B, factors 2 and 4 in MBHO)?

Yes. Distributing the rights and responsibilities statement to all members and practitioners (new and existing) is acceptable. Factors 2 and 4 will be scored yes; organizations are not required to track requests for existing members and practitioners during the look-back period.

MBHO 2020

3.26.2020 Guidance and Exceptions to NCQA Programs Regarding Coronavirus Has NCQA issued guidance about exceptions or modifications to NCQA programs and requirements in response to the coronavirus?

Yes. NCQA posted guidance for HEDIS reporting and Accreditation/Recognition programs at https://www.ncqa.org/covid/. NCQA is monitoring the effects of the coronavirus on our customers; we will adjust requirements as circumstances warrant. Please continue to check this website frequently as the situation continues to evolve.

 

MBHO 2019

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.

MBHO 2019

2.15.2020 UM Timeliness Report (MBHO) Under 2020 MBHO standards, UM 5, Element B requires organizations to monitor UM decision making and notification using UM 5 decision time frames, even though UM 5, Element A was eliminated under the 2020 standards. Is this correct?

Yes, it is correct. The elimination of Element A does not affect the 2020 review of Element B: 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.

MBHO 2020

2.15.2020 Measure Validity (MBHO) The explanation in Element A in CC 1 and CC 2 does not require that data collected results be valid or reliable measures; however, the explanation for Element D in CC 1 and Element C in CC 2 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, C or D?

NCQA does not evaluate the validity or reliability of the measure in Element A, CC 1 and CC 2. In Element D in CC 1 and Element C in CC 2, 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.

MBHO 2019

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.
 

MBHO 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.

MBHO 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.

MBHO 2019