FAQ Directory: Managed Behavioral Healthcare Organization Accreditation

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10.15.2019 CR 7, Elements D and E: Assessing Medical and Behavioral Healthcare Providers Does NCQA require a separate tracking mechanism or report for each provider?

No. The organization must provide documentation of a tracking mechanism—or mechanisms (e.g., checklist or spreadsheet)—that encompass the required provider types

MBHO 2019

10.15.2019 PHM 5: Assessment and Evaluation Does a combined summary of all factors in the assessment meet the requirement for documenting the conclusion of the initial assessment for PHM 5, Elements D and E?

Yes. Assessment and evaluation each require a case manager or a qualified individual to draw and document a conclusion about the data or information collected. Raw data or answers to questions do not meet the requirement; there must be a documented summary of the meaning or implications to the member’s situation, so data can be used in the case management plan.
The organization must draw a conclusion for each factor (unless otherwise stated in the explanation). This may be in separate summaries for each factor or in a combined summary, or in a combination of these.

MBHO 2019

8.15.2019 UM 5 Timeliness Requirements The UM 5, Elements A, C, E timeliness requirements were retired in 2020 Health Plan Accreditation. These requirements will be scored NA in HPA 2019. How will this affect timeliness reporting in UM 5, Element G?

An “NA” score for UM 5, Elements, A, C and E will not affect the review of UM 5, Element G: UM Timeliness Report. However, NCQA still requires organizations to monitor and submit a report of timeliness of decision making and notification of decisions for UM 5, Element G.

MBHO 2019

8.15.2019 Scoring UM 5 Timeliness Requirements The UM 5, Elements A, C, E timeliness requirements were retired in 2020 Health Plan Accreditation. These requirements will be scored NA in HPA 2019. Does that mean that the “Explanation” and the “Related information” sections of these elements regarding notifications no longer apply to UM 5, Elements B, D and F?

No. The “Explanation” and the “Related information” sections of UM 5, Elements A, C and E still apply to UM 5, Elements B, D and F, respectively. All applicable information was moved to the relevant elements for HPA 2020.

MBHO 2019

8.15.2019 Scoring UM File Review workbook for UM 5 timeliness Requirements Since UM 5, Elements A, C and E decision timeliness requirements were retired for 2020, how will the file review workbook be completed for those elements for 2019?

Because of the complexities of the workbook formulas, we are unable to change the workbook to accept “NA” in time for 2019 Standards Year surveys. To correctly calculate the notification date scoring, a date must be entered in this field.
NCQA will not require organizations to provide documentation of the decision date and will instruct surveyors to enter the earliest of

  1. The written notification date(s), or
  2. The verbal notification date(s) (if applicable).

Regardless of the score calculated for decision date,

  1. Surveyors will not score 30 files for this factor (although if it is necessary to review 30 files for the notification date, surveyors may need to complete this field, as described above for additional files).
  2. Surveyors will score the element NA in IRT.

MBHO 2019

3.15.2019 LTSS 4, Element C: Analysis of Unplanned transitions The explanation for LTSS 4, Element C, factor 1 states that analysis includes patterns of unplanned admissions, readmissions, emergency room visits and repeat visits, and admission to participating and nonparticipating facilities. Is the organization required to include all these areas to meet the intent of the factor?

No. The organization is not required to include all these areas in its analysis, but at a minimum, must evaluate rates of unplanned admissions to facilities and emergency room visits to identify areas for improvement.

MBHO 2019

3.15.2019 UM 8, Element A MAXIMUS What factors are scored “Met” for UM 8, Element A if an upheld denial was sent to MAXIMUS?

Factors 7-13 should be scored as “Met” for upheld denials sent to MAXIMUS.

MBHO 2018

3.15.2019 Citing a benefit provision If a benefit provision is used as the basis for the denial, how must it be cited in the notification?

Referencing benefit documents such as the member handbook or Certificate of Coverage by title alone is not specific enough to meet the requirement. Because benefit documents are often large and complex, the organization must direct members to the specific location of the information, either by section title or page number.

The reference must still support the organization’s decision and relate to the reason for the request

MBHO 2019

2.15.2019 Language in denial letters May an organization send a single denial letter to a member and a practitioner that contains the reason for the denial in both layman terms (for the member) and clinical terms (for the practitioner)?

Yes. The organization may send a single letter to the member and practitioner that includes the specific reason for the denial, in language that would be easily understood by the member. The letter may also include, in a separate section, additional clinical or technical language directed toward a practitioner.

When NCQA reviews the letter to ascertain if the reason for the denial would be easy for the member to understand, it considers both the written reason and the context of the language and whether the information can be understood in context.

MBHO 2019

12.15.2018 Mutually Agreed-Upon Dates in the Delegation Contract What date on the delegation agreement is considered the “mutually agreed-upon” date?

NCQA considers the implementation date as the date when the delegate can start performing delegated activities. But because the organization and delegate may have mutually agreed on and implemented delegated activities before signing the delegation agreement, NCQA is changing the policy for evidence of the implementation date.

When reviewing a delegation agreement, NCQA will consider the effective date or start date specified in the agreement as the mutually agreed-upon implementation date, for Element A (of the delegation standards), factor 1. This date may be before or after the signature date on the delegation agreement. If the agreement does not contain an effective date/start date, NCQA considers the date when the agreement was signed as the mutually agreed-upon implementation date.

NCQA may also accept other evidence of the implementation date: a letter, meeting minutes or other form of communication between the organization and the delegate that references their agreement on the delegated activity start date.

If an organization references the effective date/start date of the delegation agreement as the implementation date, NCQA will require submitted evidence for all other delegation factors to conform to that date as the implementation date.

The language in the explanation will be updated in a future Policy Update for applicable 2019 publications.

MBHO 2019

11.15.2018 Appeals covered in QI 6 What types of appeals are included in QI 6, coverage appeals (e.g., in UM 8–UM 9) or noncoverage appeals (e.g., in RR 2)?

QI 6 requires organizations to collect data from all sources of member complaints and appeals, including UM coverage appeals addressed in UM 8–UM 9 and noncoverage appeals addressed in RR 2.
Note: Data collected and analyzed before February 15, 2019, will be accepted as meeting the requirement even if not all types of appeals are included. Data collected and analyzed on or after this date must comply with the requirement stated in the FAQ.
If your organization collected and analyzed data before February 15, 2019, and interpreted the requirement as applying to only one type of appeal, notify the surveyor at the start of the survey so the misinterpretation does not affect scoring.


MBHO 2018

10.15.2018 80% must-pass threshold for UM elements Because NCQA raised the UM must-pass threshold from 50% to 80%, will NCQA create an 80% scoring option for requirements without such a scoring option?

No. To keep scoring simple, NCQA set a threshold of 80% or higher for all UM must-pass elements, rather than setting a specific threshold for each element based on its scoring options. If an element does not have an 80% option, the “or higher” applies. Keep in mind that an organization may miss the requirements for a few files and still score 100% on the element. For additional information on file review scoring, refer to the scoring table in each element or to the file review worksheet in the Interactive Review Tool (IRT).

MBHO 2019