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 3.
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 3.
MBHO 2021
A Corrective Action Plan (CAP) is required when an organization does not meet the minimum threshold for one or more must-pass elements. The CAP must be submitted to NCQA within 30 days after receipt of the final Accreditation status and must meet NCQA approval. The organization undergoes a CAP Survey that focuses on the failed must-pass elements (not at the factor level), i.e., all element factors, will be reviewed in addition to the factor(s) that failed the must-pass requirement.
NCQA schedules the CAP Survey for submission 6 months following the organization’s last full survey; the file review is 4 weeks later. The organization’s Accreditation status is noted “Under Corrective Action” status modifier noted on the report card during the corrective action period.
The fees for the CAP Survey can be found in the Pricing Exhibit on My NCQA. The look-back period is from the date of implementation of the corrective action up to the CAP Survey submission date and may be between 3 and 6 months before the CAP Survey submission.
After successful completion of the CAP Survey, the status modifier is removed from the organization’s status on the report card. The expiration date of the Accreditation status remains the same as the date specified in the decision that precipitated the CAP Survey. If a CAP Survey is unsuccessful, the Review Oversight Committee (ROC) may:
MBHO 2019
For all product lines, dental and vision requests covered under the organization's medical benefit are within the scope of medical necessity review and must be included for UM file review for denials (UM 4-7) and appeals (UM 9), as outlined in the file review instructions.
Dental and vision requests not covered under medical benefits are not within the scope of denial and appeal file review.
MBHO 2020
NCQA added the word “all” to CR 7 in the 2020 HPA standards and guidelines because it expects organizations to have policies for assessing all providers with which they contract. However, under the 2020 standards and in previous years, NCQA only scores policies for providers listed in CR 7, Elements B and C.
Because the definition may not be sufficient to clearly identify which organizations NCQA considers “providers,” here is a list of provider types in addition to those listed in Elements B and C:
MBHO 2020
If an organization contracts with external entities to store its own UM data or contracts with UM delegates that store data, NCQA also reviews contracts from up to four randomly selected external entities, or reviews all external entities if the organization has fewer than four. If factor 6 is not addressed in a contract, the organization may also present the external entity’s policies and procedures for review. NCQA reviews documentation from the organization and from each external entity against the factor. To be scored “yes,” the organization and each external entity’s documentation must meet the factor.
Note: The underlined text is an update to the FAQ posted on June 15, 2020. Refer also to the FAQ on the same date regarding cloud storage entities.
MBHO 2020
If an organization contracts with external entities to store its own credentialing data or contracts with CR delegates that store data, NCQA also reviews contracts from up to four randomly selected external entities, or reviews all external entities if the organization has fewer than four. If factor 4 is not addressed in a contract, the organization may also present the external entity’s policies and procedures for review. NCQA reviews documentation from the organization and from each external entity against the factor. To be scored “yes,” the organization's and each external entity’s documentation must meet the factor.
Note: The underlined text is an update to the FAQ posted on June 15, 2020. Refer also to the FAQ on the same date regarding cloud storage entities.
MBHO 2020
NCQA includes external entities that store, create, modify or use CR data for any function covered by the CR standards on behalf of the organization in the scope of Element C, factor 4, with the exception of organizations whose only CR service provided for the organization is to provide cloud-based data storage functions and not services that create, modify or use CR data.
MBHO 2020
NCQA includes external entities that store, create, modify or use UM data for any function covered by the UM standards on behalf of the organization in the scope of Elements A and B, factor 6, with the exception of organizations whose only UM service provided for the organization is to provide cloud-based data storage functions and not services that create, modify or use UM data.
MBHO 2020
Yes. Distributing the rights and responsibilities statement to all members and practitioners (new upon enrollment and annually to existing) is acceptable, because it is consistent with prior years' and exceeds the standards effective July 1, 2020. 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
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
