FAQ Directory: Managed Behavioral Healthcare Organization Accreditation

Both the organization and delegate must monitor the delegate’s system security controls as part of the delegation oversight requirements and may choose audit as the monitoring method. If auditing is the chosen method, the delegate provides an audit report of modifications that did not comply with its policies and procedures or with the delegation agreement.

The organization is not required to conduct an audit if it determines that the delegate adequately monitored and reported noncompliant modifications, but must provide documentation (a report, meeting minutes or other evidence) that it reviewed and agreed with the delegate’s findings. If the organization determines that the delegate did not adequately monitor noncompliant modifications, it must conduct its own audit of the delegate’s system controls.

The organization must submit its documentation and the delegate’s documentation as part of the survey.
 

MBHO 2022

For UM 11, Elements A and C:

• Factors 1–5 apply to receipt and notification dates, covered in UM 5 and UM 8–UM 9.
• Factor 6 applies to all UM system data for managing denials and appeals (not only the dates specified in factors 1–5), covered in UM 4–UM 7 and UM 8–UM 9.

MBHO 2022

No. Although the organization may set a monitoring goal, NCQA does not require it for UM 11, Elements B and D, factor 2 and CR 1, Element D, factor 2. The intent is that the organization reviews all instances of modifications that did not meet its policies and procedures.

MBHO 2022

For Maryland practitioners credentialed between December 2021 and February 2022, NCQA will not penalize organizations on inability to verify licensure due to the MDH network security incident. NCQA accepts the MDH’s grace period on licensure expirations and accepts temporary licenses issued by the MDH and will consider them current and valid. Organizations should adhere to guidance provided by MDH and document the guidance in the affected practitioners’ credentialing files.

MBHO 2022

Yes. NCQA has decided to allow sampling for organizations that use auditing as the method for monitoring in UM 11, Elements A – D and CR 1, Elements C and D. Organizations must use the “5% or 50 files” audit method: Organizations randomly select 5% or 50 files, whichever is less, from each applicable file type, to review against the requirements: 

• Credentialing and recredentialing. (5% or 50 files total)  
  • At a minimum, the sample includes at least 10 credentialing files and 10 recredentialing files. If fewer than 10 practitioners were credentialed or recredentialed since the last annual audit, the organization audits the universe of files rather than a sample. 
• UM denials (5% or 50 files). 
• UM appeals (5% or 50 files). 

For each applicable file type noted above, the organization must determine the sample size of 5% or 50 files (whichever is less) based on all files in the file universe. The file universe includes all files with or without modifications. The sample that will be audited must include only files with modifications (i.e., modifications that meet and do not meet the organization’s policies and procedures). NCQA does not specify how the organization selects the sample once the sample size is determined using the entire file universe. It may select the sample of modified files from the universe or, if the organization can identify files with modifications, it may randomly select the sample that will be audited from only the modified files.
The organization’s analysis report must include the number or percentage of files that do not meet the organization’s policies and procedures.
Example for UM denials:

• An organization’s UM denial file universe contains 800 files with and without modifications. Therefore, the minimum required sample for review is 40 files (5% of 800) which is less than 50 files. The organization must randomly select the 40 files for review from the total universe of 800 files or from only files with modifications (if the organization’s system has the capability to identify files with modifications). All 40 files must have a modification and are reviewed against the organization’s policies and procedures to identify noncompliant modifications.

Note: The underlined text is an update to the FAQ posted on January 15, 2022.

MBHO 2022

No. Delegate files may be audited using one of the following methods as described in the factor explanation and noted below:

• 5 percent or 50 of its files, whichever is less, to ensure that information is verified appropriately.
  • At a minimum, the sample includes at least 10 credentialing files and 10 recredentialing files. If fewer than 10 practitioners were credentialed or recredentialed since the last annual audit, the organization audits the universe of files rather than a sample.
• The NCQA “8/30 methodology” available at https://www.ncqa.org/programs/health-plans/policy-accreditation-and-certification/

Either methodology is allowed, for consistency with other Delegation Oversight requirements for annual file audits.

MBHO 2022

No. Delegate files may be audited using one of the following methods as described in the factor explanation and noted below:

• 5 percent or 50 of its files, whichever is less, to ensure that information is verified appropriately.
• The NCQA “8/30 methodology” available at https://www.ncqa.org/programs/health-plans/policy-accreditation-and-certification/

Either methodology is allowed, for consistency with other Delegation Oversight requirements for annual file audits.

MBHO 2022

No. Delegate files may be audited using one of the following methods as described in the factor explanation and noted below:

• 5 percent or 50 of its files, whichever is less, to ensure that information is verified appropriately.
• The NCQA “8/30 methodology” available at https://www.ncqa.org/programs/health-plans/policy-accreditation-and-certification/

Either methodology is allowed, for consistency with other Delegation Oversight requirements for annual file audits.

MBHO 2022

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

An organization will receive Provisional status if it:  
 

1. Has an overall standards score between 60 and 69.99, or  

2. Does not achieve an element score of 80% in three or more must-pass elements.

MBHO 2021

No. For RR 3, Element A, only the distribution component of the requirement is considered a vendor relationship. 

As stated in the explanation, these elements may not be delegated. The organization must create the written information, but may distribute it through a mail vendor.

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:

• Extend the CAP status modifier, or
• Reduce the organization’s status from Accredited to Provisional or from Provisional to Denied, or
• Issue a Denied Accreditation status.

MBHO 2019