FAQ Directory: Distinction in Multicultural Health Care

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7.28.2015 Are health plans required to report regulatory actions taken against the organization?

Reporting Regulatory Actions

Yes. The Agreement for Health Plan Accreditation Survey (the “Agreement”), specified in the “Organization’s obligations” section of the standards and guidelines, requires the organization to provide NCQA written notice within thirty (30) calendar days of the final determination by a state or federal agency with respect to request for corrective action, imposition of sanctions, changes in licensure or qualification status, if applicable, or violation of any federal or state law that affects the Scope of Review under the Standards and Guidelines. These are termed Reportable Events.

7.28.2015 What specific regulatory actions must be reported?

Specific Regulatory Actions to be Reported

The organization must report the occurrence of any of the following actions by any federal or state regulatory authority:

  • Issuance of Intermediate Sanctions and/or suspension of enrollment by CMS or any other federal or state regulatory authority.
  • Issuance of any fine equal to or exceeding $50,000 related to Organization’s operations by CMS or any other federal or state regulatory authority.
  • Issuance of any request for a corrective action by any federal or state regulatory authority where the substance of such corrective action relates to the Organization’s handling of utilization management decisions, network adequacy, benefit denials, complaints, grievances, appeals or other important patient safety matters. 

The above actions are referred to as the “final determination” within the Agreement.

7.28.2015 How and when must the organization notify NCQA of Reportable Events?

Notifying NCQA of Reportable Events

The organization must notify NCQA, in writing, within thirty (30) calendar days of the issuance of the notice of sanctions, issuance of a fine or issuance of a request for corrective action. 

The organization must also complete an annual attestation signed by an officer, or other authorized signatory of the organization, affirming that it has notified NCQA of all Reportable Events specified within the Agreement. NCQA-accredited health plans that reports HEDIS results include the attestation with its submission of the annual IDSS attestation submission for HEDIS® reporting.  Other health plans submit the completed attestation electronically to NCQA-Accreditation@ncqa.org. 

9.25.2014 When does the "30 calendar-day" response period begin?

NCQA Complaint Review Process

The time period for response begins when the health plan receives the complaint from NCQA.

9.25.2014 Does the Authorization NCQA receives from the complainant permit the organization to release information to NCQA and NCQA to the organization?

NCQA Complaint Review Process

Yes. Release of information to the organization by NCQA and the organizations release of information to NCQA is covered. The organization is not required to seek subsequent release from the member/complainant because the authorization form covers both entities. However, the organization is free to seek their own authorization should they choose to do so.

4.22.2014 Are complaints sent to a specific person at an organization?

NCQA Complaint Review Process

Yes. Complaints are forwarded to the organizations Accreditation contact.

4.22.2014 Does our current Agreement with NCQA permit NCQA to investigate complaints?

NCQA Complaint Review Process

Yes, the current Agreement allows NCQA to investigate complaints relevant to the standards.

4.22.2014 Is the NCQA Complaint Review Process dated March 25, 2013 new?

NCQA Complaint Review Process

No, this is not a new process or policy. NCQA has followed this process for handling complaints for more than a decade. In the interest of transparency, NCQA is sharing its policy with organizations.

4.22.2014 Does NCQA expect the organization to release peer-related information?

NCQA Complaint Review Process

This is up to the organization, in conjunction with their legal counsel, if disclosure is permitted. The organization is expected to provide a copy of the response given to the complainant to NCQA.