Factors 7-13 should be scored as “Met” for upheld denials sent to MAXIMUS.
MBHO 2018
FAQ Directory: Managed Behavioral Healthcare Organization Accreditation
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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?
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
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?
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
9.15.2018 Life-planning activities for Complex Case Management (CCM) Policies and Assessment Are organizations required to address life-planning activities at the first contact and start of the CCM initial assessment?
No. After consideration, NCQA removed the requirement for case managers to address life-planning activities at the start of the initial assessment (first contact). This FAQ replaces the previous FAQ issued on October 15, 2017 (which has been deleted) regarding first contact, and the workbook has been adjusted to accommodate the change.
MBHO 2019
9.15.2018 Terminated arrangements more than 90 calendar days before submission If an organization terminated an arrangement with an NCQA-Accredited/Certified/Recognized delegate more than 90 calendar days before it submitted the completed survey tool, is the organization eligible for automatic credit for the portion of the look-back period when activities were performed by the delegate?
Yes. For non-file review requirements, if the arrangement was terminated more than 90 calendar days before submission of the completed survey tool, the organization is eligible for automatic credit for the portion of the look-back period when the NCQA-Accredited/ Certified/Recognized delegate conducted activities. For file review requirements, automatic credit is applied if the delegate processed (or handled) the file, regardless of when the delegation arrangement was terminated.
MBHO 2019
8.24.2018 Where can I find information to help me get started with MBHO Accreditation?
- Accreditation Process and Timeline: Key steps, timing and resources for a successful accreditation.
- Standards and Guidelines: The complete standards and guidelines, including the intent and scope of review.
- Interactive Survey Tool: Contains the complete standards and guidelines; you can also determine your organization’s survey readiness—the tool calculates your potential survey score.
MBHO 2019
8.24.2018 How do I get started with MBHO Accreditation?
If you are not currently accredited and want to learn more, contact NCQA. If you are currently accredited and want to talk to someone about your status or about renewing or adding accreditations, submit a question through My NCQA.
MBHO 2019
8.24.2018 What other organizations have earned Managed Behavioral Healthcare Accreditation?
More than 30 organizations have earned NCQA Health Plan Accreditation. See the NCQA Report Card for a directory of accredited organizations.
MBHO 2019