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.
MBHO 2024
FAQ Directory: Managed Behavioral Healthcare Organization Accreditation
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11.15.2023 Notice of Medicare Non-Coverage (NOMNC) Denials For the UM file review universe, should plans include concurrent denials for Medicare members that involve issuance of a Notice of Medicare Non-Coverage (NOMNC) document?
10.16.2023 UM 12, Element C, factor 2 for mail service delegates Can organizations submit a mail service delegate's timeliness report of mail distribution of UM denials and appeals in lieu of an audit for UM 12, Element C, factor 2?
10.16.2023 Updated: MBHO: Mail Service Organization Delegates Are any delegation oversight factors considered not applicable for organizations that use a mail service organization delegate to meet distribution requirements (per a July 15, 2021 FAQ)?
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
- Factor 3 (semiannual reporting): This factor is NA for mail service organization delegates that only perform annual distribution
- Note: Factor 4 (performance monitoring): Annual distribution must be specified as part of the organization’s process for monitoring delegate performance.
- Factor 3 is not scored NA for distribution that occurs more frequently than annually (e.g., denial and appeal notices).
- Factor 5 (process for providing member experience and clinical performance data to delegates when requested): This factor is NA for mail service organization delegates.
UM 12, Element C: Review of the UM Program
- Factor 1 (annual review of delegate’s UM program): This factor is NA for mail service organization delegates
- Factor 4 (semiannual evaluation of reports): This factor is NA for mail service organization delegates that only perform annual distribution.
- Factor 4 is not scored NA for distribution that occurs more frequently than annually (e.g., denial and appeal notices).
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.
MBHO 2023
10.16.2023 CAQH Application: Illegal drug use question Does the CAQH application question about lack of current illegal drug use meet the intent of NCQA’s requirement in CR 3, Element C, factor 2?
Yes, the following CAQH question meets the intent of the requirement in CR 3, Element C, factor 2:
“Are you currently engaged in the illegal use of drugs?* ("Currently" means sufficiently recent to justify a reasonable belief that the use of drugs may have an ongoing impact on one's ability to practice medicine. It is not limited to the day of, or within a matter of days or weeks before the date of application, rather that it has occurred recently enough to indicate the individual is actively engaged in such conduct. "Illegal use of drugs" refers to drugs whose possession or distribution is unlawful under the Controlled Substances Act, 21 U.S.C. § 812.22. It "does not include the use of a drug taken under supervision by a licensed health care professional, or other uses authorized by the Controlled Substances Act or other provision of Federal law." The term does include, however, the unlawful use of prescription controlled substances.)"
CAQH provides additional information regarding what "currently" means that aligns with language in the explanation of CR 3, Element C, factor 2 that the organization may use more general or extensive language to query practitioners about impairment.
MBHO 2024
10.16.2023 Credentialing application question about present illegal drug use Would the following question on a credentialing application meet the intent of CR 3, Element C, factor 2? “Are you currently using illegal drugs that could affect your ability to practice medicine?”
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.
MBHO 2024
10.16.2023 External organizations providing print services only Does NCQA consider it delegation if an organization contracts with an external organization that provides print services only and does not provide mail services?
8.15.2023 Lack of present illegal drug use Does NCQA require practitioners to attest to their lack of present and past illegal drug use?
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.
MBHO 2024
7.17.2023 Use of software to collect credentialing information (API) May an organization use an application program interface (API) that retrieves data directly from a primary or approved source, even though it is not a web crawler?
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.
MBHO 2023
7.17.2023 UM 5, Element A: Notifying the Practitioner If an organization receives a request from a provider rather than a practitioner (for example, a lab or DME company), may the organization address the UM denial notification to the provider without also notifying the attending or treating practitioner as well?
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.
MBHO 2023
6.15.2023 Use of Delegate's Self-Service Portal for Delegation Reporting Is it acceptable for organizations to pull reports from a delegate’s system for the delegation agreement reporting requirement?
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:
- How often the organization accesses the reports (i.e., must be at least semiannually). The frequency must be specified. Stating “on demand” or “as needed” does not meet the requirement.
- What information is reported by the delegate in the delegate's system about the delegated activities.
- How the organization will access the delegate’s system, and to whom information is reported (i.e., to appropriate committees or individuals in the organization).
MBHO 2023
5.15.2023 MBHO: Applicable Standards for Mail Service Organizations Considered Delegates What standards are considered a delegation relationship if an organization uses a mail service organization to meet the distribution requirements?
NCQA considers the following standards to be a delegation relationship if an organization uses a mail service organization to meet the distribution requirements:
- CC 3, Element A: Notification of Termination
- CC 3, Element B: Continued Access to Practitioners
- UM 5, Element A: Timeliness of UM Decisions
- UM 7, Elements B, C: Denial Notices
- UM 9, Elements B, D: Appropriate Handling of Appeals
MBHO 2023