FAQ Directory: Utilization Management, Credentialing and Provider Network

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12.15.2020 Corrective Action Plan Question: What is the corrective action process for organizations that do not meet a must-pass element?

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.

UM_CR 2019

10.15.2020 Inclusion of Dental and Vision Denials and Appeals for UM File Review Should denials and appeals for dental and vision requests be included in the UM denial and appeal file review universes?

For all product lines, dental and vision requests covered under the organization's medical benefit are within the scope of medical necessity review and must be included for UM file review for denials (UM 4-7) and appeals (UM 9), as outlined in the file review instructions.
Dental and vision requests not covered under medical benefits are not within the scope of denial and appeal file review.

UM_CR 2020

8.15.2020 CR 7: Organizational Providers NCQA added language to CR 7 in the 2020 Health Plan Accreditation standards to clarify that Element A applies to all organizational providers (e.g., telemedicine providers, urgent care centers). What does NCQA mean by “all organizational providers”?

NCQA added the word “all” to CR 7 in the 2020 HPA standards and guidelines because it expects organizations to have policies for assessing all providers with which they contract. However, under the 2020 standards and in previous years, NCQA only scores policies for providers listed in CR 7, Elements B and C.
Because the definition may not be sufficient to clearly identify which organizations NCQA considers “providers,” here is a list of provider types in addition to those listed in Elements B and C:

  • Telemedicine providers.
  • Urgent care centers.
  • Hospice.
  • Clinical labs.
  • Comprehensive outpatient rehabilitation facilities.
  • Outpatient physical therapy.
  • Speech pathology providers.
  • End-stage renal disease services.
  • Outpatient diabetes self-management training.
  • Portable x-ray suppliers.
  • Rural health clinics.
  • Federally qualified health centers.

UM_CR 2020

7.15.2020 Updated: CR 1, Element C- Outsourcing Storage of Credentialing Data To External Entities How many contracts does NCQA review for Element C, factor 4 if an organization outsources credentialing data to external entities?

If an organization contracts with external entities to store its own credentialing data or contracts with CR delegates that store data, NCQA also reviews contracts from up to four randomly selected external entities, or reviews all external entities if the organization has fewer than four. If factor 4 is not addressed in a contract, the organization may also present the external entity’s policies and procedures for review. NCQA reviews documentation from the organization and from each external entity against the factor. To be scored “yes,” the organization's and each external entity’s documentation must meet the factor.

Note: The underlined text is an update to the FAQ posted on June 15, 2020. Refer also to the FAQ on the same date regarding cloud storage entities.

UM_CR 2020

7.15.2020 Updated: UM 12- Outsourcing Storage of Utilization Management Data To External Entities How many contracts does NCQA review for Elements A and B, factor 6 if an organization outsources UM data to external entities?

If an organization contracts with external entities to store its own UM data or contracts with UM delegates that store data, NCQA also reviews contracts from up to four randomly selected external entities, or reviews all external entities if the organization has fewer than four. If factor 6 is not addressed in a contract, the organization may also present the external entity’s policies and procedures for review. NCQA reviews documentation from the organization and from each external entity against the factor. To be scored “yes,” the organization's and each external entity’s documentation must meet the factor.

Note: The underlined text is an update to the FAQ posted on June 15, 2020. Refer also to the FAQ on the same date regarding cloud storage entities.

UM_CR 2020

6.15.2020 CR 1C: Outsourcing Storage of Credentialing Data To External Entities Are cloud-services data storage providers included among the external entities for which NCQA reviews contracts for Element C, factor 4?

NCQA includes external entities that store, create, modify or use CR data for any function covered by the CR standards on behalf of the organization in the scope of Element C, factor 4, with the exception of organizations whose only CR service provided for  the organization is to provide cloud-based data storage functions and not services that create, modify or use CR data.
 

UM_CR 2020

6.15.2020 UM 12: Outsourcing Storage of Utilization Management Data To External Entities Are cloud-services data storage providers included among the external entities for which NCQA reviews contracts for Elements A and B, factor 6?

NCQA includes external entities that store, create, modify or use UM data for any function covered by the UM standards on behalf of the organization in the scope of Elements A and B, factor 6, with the exception of organizations whose only UM service provided for  the organization is to provide cloud-based data storage functions and not services that create, modify or use UM data.

UM_CR 2020

5.15.2020 UM 5: Medicaid lookback period For Renewal Surveys, the look-back period is specified as 6 months for the Medicaid product line in UM 5, Elements A-C. Is this correct?

No. The look-back period should be specified as 12 months for all product lines, for Renewal Surveys, which is consistent with the other file review standards and elements. NCQA initially changed the scope of review to account for a change made to verbal notification and how it no longer affords organizations an extension.

However, because of this error, if an organization does not meet a factor in UM 5, Elements A-C within the first 6 months of the look-back period, NCQA does not penalize the organization and scores the file “NA” instead of “Not Met” for Medicaid surveys.

UM_CR 2020

4.15.2020 Update: Practitioner Involvement and Adoption of UM Criteria For UM 2, Element A, factor 4, when an organization develops or adopts UM criteria, may it limit involvement of practitioners to practitioners who are organization staff, even if they are also network practitioners?

The answer posted in March 2020 unintentionally increased the rigor of the requirement for the 2020 standards year. Therefore, we are updating the answer.
For the 2020 standards year, organizations may limit involvement to practitioners who are staff or participants in the network; NCQA does not require non-staff network practitioners to be involved.

Effective for the 2021 standards year, organizations may not limit involvement to practitioners who are staff. Non-staff network practitioners must also be involved in developing, adopting and reviewing criteria, because they are subject to application of the criteria. If an organization has been unable to involve network practitioners, it must document its attempts and provide the documentation to NCQA during the survey.

This change will be released in the 2021 standards and guidelines.

UM_CR 2020

3.26.2020 Guidance and Exceptions to NCQA Programs Regarding Coronavirus Has NCQA issued guidance about exceptions or modifications to NCQA programs and requirements in response to the coronavirus?

Yes. NCQA posted guidance for HEDIS reporting and Accreditation/Recognition programs at https://www.ncqa.org/covid/. NCQA is monitoring the effects of the coronavirus on our customers; we will adjust requirements as circumstances warrant. Please continue to check this website frequently as the situation continues to evolve.

 

UM_CR 2019

3.15.2020 36-month Recredentialing time frame Does NCQA allow an organization to extend the 36-month recredentialing time frame if it failed to credential a practitioner on time?

No. Except as noted under “Related information: Extending the recredentialing cycle length,” where NCQA makes provisions for situations such as active duty military assignment and medical leave, the organization may not extend the 36-month recredentialing cycle. If the practitioner is not recredentialed within 36 months, the file will be scored down. There is no grace period for recredentialing.
If an organization missed the recredentialing deadline and intends to keep the practitioner in the network, files must be processed as follows:

  • If the organization can complete the credentialing process within 30 days of the original due date, it may recredential the practitioner (e.g., the organization need not verify credentials required only at initial credentialing). The organization must complete the process and make the credentialing decision within 30 days of the original credentialing due date.
  • If the organization cannot complete the credentialing process within 30 calendar days of the original recredentialing due date, it must take the practitioner through the initial credentialing process.

UM_CR 2019

2.15.2020 UM Timeliness Report Under 2020 HPA standards, UM 5, Element D requires organizations to monitor UM decision making and notification using UM 5 decision time frames, even though UM 5, Elements A, C and E were eliminated under the 2020 standards. Is this correct?

Yes, it is correct. The elimination of Elements A, C and E does not affect the review of Element D: UM Timeliness Report. The expectation is that the report includes timeliness for both decision making and notification of the decision given that the report includes denials and approvals. NCQA does not require written notification for approvals; therefore, timeliness for approvals is only reported under decisions.

UM_CR 2020